Objective
Burnout is specific to the work domain and in physicians is indicative of emotional exhaustion, depersonalization in relationships with coworkers and detachment from patients, and a sense of inadequacy or low personal accomplishment. The purpose of this study was to determine the burnout rate among gynecologic oncologists and evaluate other personal, professional, and psychosocial factors associated with this condition.
Study Design
This study used a cross-sectional design. Current members of the Society of Gynecologic Oncology were sent an anonymous email survey including 76 items measuring burnout, psychosocial distress, career satisfaction, and quality of life.
Results
A total of 1086 members were invited, 436 (40.1%) responded, and 369 (84.6%) of those completed the survey. Of physicians, 30% scored high for emotional exhaustion, 10% high for depersonalization, and 11% low for personal accomplishment. Overall, 32% of physicians scored above clinical cutoffs indicating burnout. In all, 33% screened positive for depression, 13% endorsed a history of suicidal ideation, 15% screened positive for alcohol abuse, and 34% reported impaired quality of life. Nonetheless, 70% reported high levels of personal accomplishment, and results suggested most were satisfied with their careers, as 89% would enter medicine again and 61% would encourage their child to enter medicine. Respondents with high burnout scores were less likely to report they would become a physician again ( P = .002) or encourage a child to enter medicine ( P < .001), and more likely to screen positive for depression ( P < .001), alcohol abuse ( P = .006), history of suicidal ideation ( P < .001), and impaired quality of life ( P < .001).
Conclusion
Burnout is a significant problem associated with psychosocial distress and lower levels of career satisfaction in gynecologic oncologists. Burnout in obstetrics-gynecology and gynecologic oncology is of particular concern as young age and female gender are often identified as risk factors for this significant problem. Interventions targeted at improving quality of life, treatment of depression, or alcohol abuse may have an impact on burnout. However, significant barriers may exist as 44.5% of respondents in this study reported that they would be reluctant to seek medical care for depression, substance use, or other mental health issues due to concerns about their medical license.
Burnout is a prolonged response to chronic emotional and interpersonal stressors on the job, and is not equivalent to stress or depression. It is defined by the triad of emotional exhaustion; development of a negative, cynical attitude towards patients (depersonalization); and a sense that one’s work is not meaningful or important (personal accomplishment). Workers in the caring and service professions are at high risk of burnout. Over the past few decades burnout has been recognized as endemic among all medical specialties and directly associated with poor physician well-being. Burnout in physicians negatively impacts patient care and health care systems as it is associated with poor patient satisfaction, medical errors, leaving ones current practice, and/or early retirement from the practice of medicine.
Burnout is endemic among physicians although there are substantial differences observed by specialty. The burnout rate in a large study of US physicians was recently noted to be 46%, ranging from 30% to >60%, with the highest rates seen in those at the front line of care access. The American College of Surgeons conducted the largest and most comprehensive study on this topic, revealing that 40% of its members experience burnout. Independent risk factors for burnout included younger age, increased work hours per week, call, type of practice setting, type of compensation, and type of surgical subspecialty. Burnout in surgeons was associated with a higher incidence of medical errors, depression, suicidal ideation, alcohol abuse, low quality of life, and low career satisfaction. Very few data exist on this topic within the field of obstetrics and gynecology.
Burnout among gynecologic oncologists has not been well described as only a few small studies exist. It is difficult to extrapolate data on this topic from other specialties as the practice of a gynecologic oncologist encompasses both the medical and surgical aspects of oncology and is characterized by continuity of care throughout the spectrum of the patient’s diagnosis, therapy, and surveillance. Burnout has significant implications for physicians, but also significantly impacts their patients, families, associates, and health care systems. Therefore, we set out to better understand burnout in gynecologic oncologists.
Our objective was to determine the rate of burnout among full and candidate members of the Society of Gynecologic Oncology (SGO) and to evaluate variables that might be associated with burnout. Specifically, we examined sociodemographic variables (eg, age, relationship status, number of children), professional characteristics (eg, practice setting, compensation, hours spent in operating room), as well as indices of psychological well-being (eg, overall mental health, depressive symptoms, substance use).
Materials and Methods
Participants
All physicians who were senior, full, or candidate members of the SGO and had a working email address listed in the SGO member directory were eligible to participate in the study. Participation was elective and all responses were anonymous. Institutional review board approval was awarded at the Ohio State University Wexner Medical Center prior to beginning the study.
Data collection
An anonymous electronic survey was sent to SGO members via email between February and March 2013. A cover letter stated that the purpose of the study was to evaluate career satisfaction and practice characteristics among gynecologic oncologists. The study participants were asked 76 questions that assessed sociodemographic variables, professional characteristics, physical and psychological well-being, and level of burnout. Validated survey tools were used where appropriate. Two additional reminder emails were sent to SGO members to complete the survey.
Sociodemographic variables
Participants were asked to report age, gender, martial/partnership status, spouse/partner employment status and type, age and number of children, and type of child care.
Professional characteristics
Questions regarding years of practice, hours worked per week, hours spent in the operating room each week, call, practice setting, compensation model, time spent in nonpatient care activities, administration of chemotherapy, number of manuscripts published in the last year, and amount of vacation time available and used were asked. Additional questions were developed to evaluate personal and professional characteristics. Two questions were used to evaluate career satisfaction. One asked gynecologic oncologists if given the opportunity to revisit their career choice, they would choose to become a physician again. The second question asked if they would become a gynecologic oncologist again. Furthermore, we asked if our study participants would encourage their children to pursue a career in medicine. Physicians were also asked about medical errors that occurred in the last 3 months and contributing factors to the error.
Physical and psychological well-being
The Medical Outcomes Study Short Form (SF-12) was used to evaluate mental and physical functioning and overall health-related quality of life. The US population average scores were used for comparison. Depression symptoms were evaluated using the 2-item PRIME MD/PHQ2, a brief screen for depression that has been shown to perform as well psychometrically as more comprehensive screening tools. Items assessing suicidal ideation, feelings of anxiety or stress, the use of antidepressant medication, formal psychiatric evaluation in the past year, and reluctance to seek psychiatric help were included to gauge access and engagement in psychiatric care. Alcohol abuse was evaluated using the CAGE questionnaire.
The Maslach Burnout Inventory (MBI) was used to measure burnout. It is a 22-item survey designed to measure 3 aspects of burnout: emotional exhaustion, depersonalization, and lack of personal accomplishment. As in other studies of burnout in health care professionals a high score in either emotional exhaustion or depersonalization was considered positive for burnout syndrome.
Statistical analysis
Descriptive statistics were used to characterize sample demographics, level of burnout, career satisfaction, mental health characteristics, and quality of life. Continuous variables are presented as medians and interquartile range, while categorical variables are presented as frequencies and percentages. Quality-of-life summaries are presented as means and SD. Fisher exact method was used to test associations between categorical variables and burnout while Wilcoxon rank sum method was used to test continuous variables across burnout. The Holm procedure adjusted P values to conserve the overall type I error at .05 due to the multiple testing in the study. All analyses were done using software (Stata 12.1; StataCorp, College Station, TX).
Results
In all, 1086 SGO members were invited and 436 (40.1%) responded; of these, 369 (34%) completed the burnout portion of the survey. Sociodemographic and professional characteristics are summarized in Tables 1 and 2 . Median age was 48 years old, 62.4% were male, 88% were married/partnered, and over half had a partner who worked outside the home. Most had at least 1 child. Over 60% had been practicing >10 years, >80% worked >50 hours per week, the median number of operating room hours was 15 per week, and nights call was 3 per week. Over 70% managed patients’ chemotherapy, 79% were compensated by salary or salary with bonus, and about 60% practice in an academic setting. These demographic data are similar to that obtained in the 2010 State of the Subspecialty survey published by the SGO.
| Personal characteristics | n (%) |
|---|---|
| No. surveys sent | 1086 |
| No. surveys with response | 436 (40.1) |
| No. surveys completed | 369 (34.0) |
| Age (y), median (IQR) | 48 (40–57) |
| Gender | n = 418 |
| Male | 261 (62.4) |
| Female | 157 (37.6) |
| Relationship status | n = 421 |
| Single | 50 (11.9) |
| Married/partnered | 371 (88.1) |
| Ever divorced | 79 (18.8) |
| Partner or spouse works outside home? | n = 369 |
| Yes | 218 (59.1) |
| No | 151 (40.9) |
| Partner or spouse’s current profession? | n = 218 |
| Physician | 105 (48.2) |
| Health care provider, nonphysician | 51 (23.4) |
| Non health care | 62 (28.4) |
| No. of children | n = 419 |
| 0 | 70 (16.7) |
| 1 | 40 (9.6) |
| 2 | 164 (39.1) |
| 3 | 96 (22.9) |
| ≥4 | 49 (11.7) |
| Form of child care | n = 187 |
| Parent | 80 (42.8) |
| Nanny | 72 (38.5) |
| Daycare | 23 (12.3) |
| Other family member | 12 (6.4) |
| Professional characteristics | n (%) |
|---|---|
| SGO membership | n = 414 |
| Candidate | 63 (15.4) |
| Full member | 351 (84.6) |
| Years in practice | n = 414 |
| <10 | 141 (34) |
| 10–19 | 112 (27.1) |
| 20–30 | 98 (23.7) |
| >30 | 63 (15.2) |
| Hours worked per week | n = 403 |
| <50 | 70 (16.9) |
| 50–59 | 100 (24.2) |
| 60–69 | 131 (31.7) |
| 70–79 | 64 (15.5) |
| ≥80 | 48 (11.6) |
| Hours per week in operating room, median (IQR) | 15 (10–20) |
| No. of nights on call per week, median (IQR) | 3 (1–5) |
| Percentage of time spent on nonpatient | |
| care activities, median (IQR) | 20 (10–100) |
| Give chemotherapy | n = 414 |
| Yes | 320 (77.3) |
| No | 94 (22.7) |
| Practice setting | n = 375 |
| Private practice | 74 (19.7) |
| Private practice with teaching | 79 (21.1) |
| Academic | 222 (59.2) |
| Academic rank | n = 321 |
| Assistant professor | 117 (36.4) |
| Associate professor | 84 (26.2) |
| Full professor | 120 (37.4) |
| Primary method of compensation | n = 403 |
| Salary | 129 (32) |
| Salary with bonus | 192 (47.6) |
| Incentive based on productivity | 48 (11.9) |
| Other | 34 (8.5) |
| Manuscripts in last year, median (IQR) | |
| Primary author | 0 (0–2) |
| Coauthor | 2 (0–4) |
Responses to questions regarding physical and psychological well-being are summarized in Table 3 . Median scores for physical and mental quality of life (SF-12) are reported with 33% positive for depression (PRIME MD/PHQ2), 13% reported a history of suicidal ideation, 11% took medication for depression or anxiety in the last 12 months, 14% experienced panic attacks, and 15% screened positive for alcohol abuse. When asked about feeling overwhelmed or that life was unmanageable, >40% responded affirmatively. In spite of these results only 9% sought psychiatric care in the last 12 months, and 45% reported they would be reluctant to seek formal psychiatric care for depression, substance use (alcohol, drugs, other), or other mental health issues due to concerns regarding their medical license.
| Physical and psychological characteristics | n (%) |
|---|---|
| Quality of life (SF-12) | n = 397 |
| Mean physical score (SD) | 52.4 (7.22) |
| Percent 1 SD below population norm | 14 |
| Mean mental score (SD) | 51.1 (8.85) |
| Percent 1 SD below population norm | 23 |
| Overall health | n = 409 |
| Excellent | 189 (46.2) |
| Very good | 151 (36.9) |
| Good | 54 (13.2) |
| Fair | 14 (3.4) |
| Poor | 0 |
| Cardiovascular exercise per week | n = 403 |
| 0–2 | 208 (52) |
| >3 | 195 (48) |
| Mental health | n = 398 |
| Positive depression screen (PRIME MD/PHQ2) | 133 (33) |
| Suicidal ideation (ever) | 49 (13) |
| CAGE screen positive | 60 (15) |
| In last 12 mo | |
| Felt stressed, overwhelmed | 168 (42) |
| Sought psychiatric help | 34 (9) |
| Taken psychiatric medications | 42 (11) |
| Experienced panic attacks | 54 (14) |
| Reluctant to seek professional mental health assistance | 178 (45) |
Table 4 describes burnout and career satisfaction. Of gynecologic oncologists, 32% scored above clinical cutoffs for burnout with high emotional exhaustion and/or depersonalization scores. Nonetheless, 70% reported high levels of personal accomplishment, and results suggest that most were satisfied with their careers, as 89% would enter medicine and practice gynecologic oncology again, and 61% would encourage their child to pursue a career in medicine.
| Maslach Burnout Inventory Scores | n = 369 |
|---|---|
| Emotional exhaustion | |
| Low | 46% |
| Moderate | 25% |
| High (burnout) | 30% |
| Depersonalization | |
| Low | 66% |
| Moderate | 24% |
| High (burnout) | 10% |
| Personal accomplishment | |
| High | 70% |
| Moderate | 19% |
| Low (poor score) | 11% |
| Overall burnout positive | 32% |
| Career satisfaction | |
| Physician again | 361/406 (89%) |
| Gynecologic oncologist again | 360/405 (89%) |
| Encourage child to enter medicine | 244/401 (61%) |
Table 5 lists factors associated with burnout and the burnout odds ratios (ORs) based on univariate logistic regression analysis of personal and professional characteristics. Female gender, low mental quality-of-life score, positive depression screen, feeling stressed and/or overwhelmed, history of suicidal ideation, reluctance to seek mental health care, and high CAGE score were associated with increased odds of burnout while older age and career satisfaction were protective. Burnout was not associated with number of children, marital status, practice type, spouse working outside the home, amount of vacation taken per year, recent medical error, or number of hours worked. Multivariable logistic regression analysis indicates that physicians with low mental quality of life (OR, 3.23; 95% confidence interval [CI], 1.82–5.72; P < .001), depression screen positive (OR, 2.81; 95% CI, 1.56–5.07; P .001), feeling stressed and overwhelmed (OR, 2.81; 95% CI, 1.58–4.98; P < .001), and reluctance to seek care (OR, 2.72; 95% CI, 1.56–4.74; P < .001) were associated with a higher odds of burnout, while physicians who would encourage a child to enter medicine were associated with lower odds of burnout (OR, 0.42; 95% CI, 0.24–0.73; P .002). Personal accomplishment scores were not significantly correlated with career satisfaction ( P < .225), depression ( P > .99), alcohol abuse ( P > .99), or suicidal ideation ( P > .99).
| Factors | Burnout (%) | Burnout odds ratio (95% CI) | P value |
|---|---|---|---|
| Female | 41 | 1.86 (1.18–2.91) | .007 |
| Male | 27 | ||
| Age >50 y | 25 | 0.48 (0.29–0.81) | .006 |
| Age ≤50 y | 41 | ||
| Become physician again | |||
| Yes | 29 | 0.30 (0.16–0.59) | .002 |
| No | 57 | ||
| Encourage child to become physician | |||
| Yes | 21 | 0.30 (0.19–0.49) | < .001 |
| No | 48 | ||
| Work ≥60 h/wk | |||
| Yes | 34 | 1.20 (0.77–1.88) | .420 |
| No | 30 | ||
| Low SF-mental score | |||
| Yes | 69 | 8.58 (4.96–14.83) | < .001 |
| No | 21 | ||
| Depression screen | |||
| Positive | 61 | 7.34 (4.50–11.98) | < .001 |
| Negative | 18 | ||
| Stressed and overwhelmed | |||
| Yes | 54 | 5.60 (3.47–9.03) | < .001 |
| No | 17 | ||
| Suicidal ideation | |||
| Yes | 65 | 4.92 (2.59–9.34) | < .001 |
| No | 27 | ||
| Reluctant to seek care | |||
| Yes | 48 | 3.65 (2.30–5.80) | < .001 |
| No | 20 | ||
| High CAGE score (alcohol) | |||
| Yes | 55 | 2.93 (1.63–5.28) | .006 |
| No | 28 |
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