2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

midcareer physician; in one cross-sectional study, more than
three-fourths of internal medicine residents exhibited burnout.
10
Risk factors for physician burnout have been described
across medical disciplines. Demographic factors associated
with increased risk of burnout include younger age and
junior status, female sex, and unmarried status. 11 Personality
factors predisposing physicians to burnout include high
level of motivation and intense investment in one’s profession
12 ; personality traits, such as intensity, impulsivity, and
compulsiveness; previous mental health problems, particularly
depression; and wishful thinking as one’s coping style.
Environmental or contextual risk factors include work overload;
perception of a lack of control over one’s workload,
when that workload exceeds capacity; lack of social support
from colleagues; dissatisfaction with resources at work;
practice within a high-risk medical specialty (such as oncology);
work stressors, including reimbursement issues,
complex regulations, and interactions with insurers; organizational
concerns and management style; and family stress.
The risk of burnout increases proportionally with time spent
in direct patient care; time away and a mix of job responsibilities
are protective. 8 Care for people who are dying and
disease that is not responsive to aggressive treatment, both
prominent in oncology, are sources of burnout that accumulate
over time, especially when the physician feels illequipped
to provide expert end-of-life care or experiences
a sense of failure when disease progresses. Spirituality and
religiosity have been found to exert a protective effect
against burnout.
Multiple dire consequences result from physician burnout
and from inadequate care of the self more generally. Among
physicians, substance abuse rates of 10% to 15% have been
reported, 13 although physicians tend to use alcohol and
prescription medications rather than illicit substances. 14
Physician fatigue is cited in the Institute of Medicine’s
seminal report, To Err is Human, as a factor contributing to
the tens of thousands of medical errors occurring in the
United States each year. 15 A prospective, longitudinal study
found increased burnout and reduced empathy to be associated
with increased likelihood of committing a self-perceived
KEY POINTS
● Self-care encompasses all strategies implemented to
support one’s own optimal health and well-being.
● Because failure to attend to self-care negatively affects
patients both directly and indirectly (e.g., depersonalization
leading to lower empathy or physician
exit from the profession), self-care is a vital responsibility
of every oncologist.
● Self-care can be conceptualized as a set of activities
that one uses on a regular basis to promote fulfillment
and wellness in the professional, personal, and
interpersonal domains of life.
● A vast array of options for self-care, and supporting
facilitators, are available in each domain.
● Self-care strategies must be personalized, with sensitivity
to cultural nuances and other individuallyspecific
determinants of best approach.
e10
medical error in the subsequent 3 months. 16 Failure of
physician self-care to establish well-being is evidenced in
high suicide rates. A meta-analysis that included 25 studies
reported that male physicians commit suicide at a rate 40%
higher than that of men in the general public, and female
physicians do so at 130% the rate of women in general. 17
Among physicians 55 years and younger, higher perceived
stress is associated with (1) lower satisfaction levels, which
in turn are related to intention to quit, decrease work hours,
change specialty, or leave direct patient care, and (2) poorer
mental health, which in turn is related to intention to leave
direct patient care. 18 Other potential consequences of
inadequate physician self-care include impaired job performance,
poor physical health (e.g., headaches, sleep disturbance,
hypertension, and cardiac events), poor emotional
health and well-being (e.g., irritability, fatigue, anxiety, and
depression), and relational and marital difficulties.
Ultimately, it is not only the oncologist’s self that is
affected. Physically, emotionally, mentally, or spiritually
depleted physicians can neither take good care of patients
nor model good health or a lifestyle conducive to health for
their patients. Physicians tend to counsel patients in ways
that are consistent with their own health habits, 19 and if
these habits are not sound, patients receive bad advice.
Furthermore, as oncologists, we are not just caretakers of
people with cancer, we are also members of our own families
and circles of care; physicians experiencing burnout cannot
contribute as well to family life and other valued relationships,
and consequences can be disastrous for all involved.
Professional Recognition of Physician Burnout and
Need for Self-Care
The American Medical Association (AMA) Code of Medical
Ethics, Opinion 9.0305, states, “To preserve the quality of
their performance, physicians have a responsibility to maintain
their health and wellness, construed broadly as preventing
or treating acute or chronic diseases, including
mental illness, disabilities, and occupational stress.” A variety
of resources are available to support physicians’ attention
to their own health. The AMA produces the Physician’s
Guide to Personal Health Toolkit, which covers healthy
eating, physical activity, reduced alcohol consumption, and
smoking cessation, as well as the AMA Physician Health
e-Letter. The biennial International Conference on Physician
Health, sponsored by the AMA, Canadian Medical Association,
and British Medical Association, presents research and
original presentations on topics such as burnout and peer
support, physician health as linked to quality and patient
safety, resilience and work-life balance, and physical and
mental health.
Despite the availability of supportive resources, backed by
injunctions from respected agencies, many oncologists remain
unclear about, neglect, or postpone active strategies to
take optimal care of themselves. In a 2009 survey of California
physicians (n � 1,875), 53% reported moderate to
severe stress, 35% reported no or occasional exercise, 34%
reported getting 6 hours or less of sleep per night, and 27%
never or occasionally ate breakfast. 20
Conceptual Framework
AMY P. ABERNETHY
Clarity in conceptualizing what, specifically, is entailed in
physician self-care may facilitate individuals’ responsible