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Gynecologic Oncology 94 (2004) 134 – 139 www.elsevier.com/locate/ygyno

Job satisfaction, stress, and burnout among Canadian gynecologic oncologists L. Elit, a,* K. Trim, b I.H. Mand-Bains, a J. Sussman, c and E. Grunfeld d in conjunction with the Society of Gynecologic Oncology Canada a

Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, McMaster University, Canada b Department of Education, McMaster University, Canada c Supportive Cancer Care Research Unit at Hamilton Regional Cancer Centre, Hamilton, ON, Canada L8V 5C2 d Cancer Care Nova Scotia, Canada Received 26 November 2003 Available online 19 May 2004

Abstract Objectives. (1) To provide a job description of Canadian gynecologic oncologists. (2) To assess job satisfaction and job stress, and measure the prevalence of burnout and psychological morbidity. Methods. A cross-sectional survey was mailed to all Canadian gynecologic oncologists in September 2002. Results. The job profile on Canadian gynecologic oncologists is predominantly clinical with a minor component of administration and to a less extent education or research. Clinically, 80% of the activity is focused on gynecologic cancer care. The majority of physicians (92%) are satisfied with their job, but there are clear concerns raised concerning systems issues in health care delivery. Approximately 26% of physicians are experiencing high stress, and this is strongly associated with emotional exhaustion and high depersonalization. Fourteen percent of Canadian gynecologic oncologists are actively looking for alternative jobs and 45% are trying to decrease the number of hours worked per week. When considering an alternate job, the most important factors are location, colleagues, and potential for personal growth. Conclusion. High stress and low personal accomplishment were seen in Canadian gynecologic oncologists. Organizations (i.e., hospitals) and health care funders have the opportunity to incorporate preventative strategies to keep this physician resource healthy. D 2004 Elsevier Inc. All rights reserved. Keywords: Job satisfaction; Stress; Burnout

Introduction In 1991, the Royal College of Surgeons Canada accredited subspecialty training in gynecologic oncology. At its core, gynecologic oncology is a subspecialty that involves cancer surgery as it relates to the gynecologic tract and surgery for complicated benign gynecologic conditions such as endometriosis. In some instances, the subspecialists provide chemotherapy for these cancers. The subspecialists are involved in ongoing surveillance of women who have completed primary therapy. They are involved in the management of complications that are related to treatment or

* Corresponding author. Hamilton Regional Cancer Centre, 699 Concession Street, Hamilton, ON, Canada L8V 5C2. Fax: +1-905-5756343. E-mail address: [email protected] (L. Elit). 0090-8258/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2004.04.014

recurrent disease. Gynecologic oncologists are physicians who have 5 years of specialty training in Obstetrics and Gynecology and then a further 2 – 4 years of subspecialty training in gynecologic cancer surgery, principals of radiation oncology, delivery of chemotherapy, pathology, and often basic science or clinical research methods. Most Canadian gynecologic oncologists work within a university environment. In the last decade, there have been stresses on the medical system in Canada with cutbacks of federal funding to the provinces for the delivery of health care. This comes at a time when costs for novel treatment strategies (laparoscopically assisted radical surgery and chemotherapeutic agents) are soaring. This has resulted in an era of hospital restructuring. Currently, there is a loss of control on one’s workplace [1] and lack of adequate resources [2]. At the same time, the population is expanding. In addition, there is a population bulge in the number of senior citizens.

L. Elit et al. / Gynecologic Oncology 94 (2004) 134–139

Cancer is more common in the aging population, thus the health care system is attempting to cope with increasing numbers of patients with cancer. All of these factors impact the day-to-day work environment of the gynecologic oncologist who is one component of the system. There are reports in the laypress of physician burnout, decreased morale, high levels of stress, and staff leaving or decreasing their work hours [3]. We have conducted a survey to determine whether there is evidence to support or refute these reports in the Canadian gynecologic oncology community. The specific objectives of this study were to outline the current job description of gynecologic oncologists in Canada and define any trends between the oncologist’s initial and current job. This study will assess job satisfaction and job stress. We will measure the prevalence of burnout and psychological morbidity using validated instruments.

Methods In the autumn of 2002, we conducted a confidential cross-sectional mailed survey of all gynecologic oncologists in Canada. The respondents were identified from the Society of Gynecologic Oncologists Canada, and input from key provincial sources. A total of 50 questionnaires were mailed. To maximize the response rate, a second survey was sent to non-respondents approximately 1 month after the initial mailing. The study questionnaire consisted of the following: A section addressing demographic factors such as job characteristics, financial, and benefit packages [4]. The Maslach Burnout Inventory (MBI) that is a standardized measure of burnout addressing emotional exhaustion, depersonalization, and personal accomplishment [5]. The General Health Questionnaire (GHQ-12) that is used to assess psychological morbidity [6,7]. A questionnaire designed by Ramirez et al. [8,9] to measure job stress and satisfaction. It assesses 25 specific sources of stress and 17 sources of satisfaction; in addition, it asks for a global rating of stress and satisfaction. A section of four questions to measure a person’s consideration of alternative work situations [4]. Respondents were asked whether they had seriously considered leaving their current job for a job outside the cancer care system, leaving their job for a job outside the province, reduce the number of hours they work, or taking early retirement. The questionnaire was reviewed by three Canadian experts in questionnaire development and members of the executive committee of the Society of Gynecologic Oncol-

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ogists Canada. The initial version was felt to be too long and was amended. In keeping with the work by Grunfeld et al. [10], burnout was defined as high levels of emotional exhaustion, high levels of depersonalization, or low levels of personal accomplishment. Psychological morbidity was defined as a score of 4 or more on the GHQ-12 (this approach is recommended by the developer of the scale and is consistent with other research). High levels of overall satisfaction and overall stress were defined as a score of 3 or more on the respective global satisfaction and stress questions.

Results Demographics Of the 50 gynecologic oncologists, 39 returned the questionnaire, and 35 questionnaires were complete and could be analyzed. Responses came from across Canada (British Columbia 1, Alberta 5, Winnipeg 3, Ontario 14, Quebec 8, Nova Scotia 2, and Newfoundland 1). Table 1 shows that the majority of gynecologic oncologists are in their fifth decade and are married. Job description Setting Gynecologic oncologists practice in either hospital or cancer clinic (Table 2). There is a shift over time toward an increased number of partners (when gynecologists oncologists first began working, 17.6% of practitioners had more than two partners, and currently, 75.8% have more than two partners). Table 1 Characteristics of the respondents No. Age (year) 21 – 30 1 31 – 40 7 41 – 50 16 51 – 60 8 61 – 70 3 Gender Female 12 Male 22 Current marital status Single 3 Married 29 Divorced 1 Widowed 1 Year the gynecologic oncology fellowship was completed After 1995 7 1986 – 1995 14 1976 – 1985 10 1966 – 1975 3

Percent 2.9 20 45.7 22.9 8.6 35.3 64.7 8.8 85.3 2.9 2.9 20 40 28.6 8.6

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Table 2 Practice characteristics Location of their main office Hospital 19 51% Cancer center 16 44% University 1 2.7% Private 1 2.7% Majority of outpatient cancer patients are seen in: Hospital-based clinics 9 24.3% Cancer center-based clinics 27 73.0% Private office 1 2.7% Does your center have a gynecologic oncology fellowship program? Yes 16 45.7% Is this your first position? Yes 24 68.6%

Clinical oncology practice Each week the gynecologic oncologist sees approximately 6 –8 new (range 2– 12) and 26– 40 follow-up (range 10– 80) oncology patients. The gynecologic oncologist performs three operations of more than 2-h duration per week (range 1 –5) and 82% provide chemotherapy. Spectrum of practice About 80% of the respondent’s time is focused on oncology with 10% on colposcopy and 10% on benign complex cases. In terms of volume of patients seen per week, about 40 patients have cancer, 20 undergo colposcopy assessment, and less than 10 have benign disease. There has been a slight shift over time to increasing educational and research endeavors. There is a larger shift toward administrative activities, and this comes at the expense of time devoted to direct patient care (Table 3). Reimbursement and benefits Most practitioners are paid by a combination of base salary and fee for service (42.9%), with some physicians on an alternative payment plan (37.1%). Although physicians have 2 weeks of conference leave and 4 – 6 weeks of vacation time, it appears that most physicians are not using all this time (vacation available: 44.8%, 4 weeks; 3.4%, 5 weeks; 48.3%, 6 weeks; vacation taken: 5.7%, 1 week; 11.4%, 2 weeks; 8.6%, 3 weeks, 31.4%, 4 weeks; 14.3%, 5 weeks; 20%, 6 weeks). Job satisfaction and job stress Burnout inventory On the MBI, 34% of gynecologic oncologists show high emotional exhaustion, 14.3% showed high depersonalization, and 32.4% showed low personal accomplishment. Emotional exhaustion is the strongest component of burnout and is associated with high stress. None of the demographic or practice factors correlate with emotional exhaustion. High depersonalization scores positively correlate with age, proportion of time in direct patient contact, interest in leaving

one’s current job, considering reducing one’s hours, and planning for retirement; and negatively correlated with number of weeks of vacation. Low personal accomplishment correlates with few partners, high numbers of followup and colposcopy patients, high proportion of time with gynecologic oncology patients, in administration, and low amount of time in education or research, high number of calls per month. Job satisfaction This was assessed using a 10-point linear analogue scale with anchors of ‘‘not satisfied’’ to ‘‘extremely satisfied’’. Ninety-two percent of gynecologic oncologists are satisfied with their job (scores of 5 –10). Job satisfaction was further evaluated using the Ramirez question. Low job satisfaction correlated with high emotional exhaustion and depersonalization. Table 4 outlines the many factors that gynecologic oncologists felt negatively influence job satisfaction like loss of ability to positively change the institution and lack of staff. Job stress The General Health Questionnaire shows that 26% of gynecologic oncologists experience high stress. There was a very high correlation with the Ramirez job stress question. High stress is associated with high personal accomplishment, depersonalization, and emotional exhaustion. Table 5 outlines the factors that correlated with high stress including organizational factors, which contribute to high emotional

Table 3 Spectrum of Practice Direct patient care (%)

Administration (%)

Research (%)

Education (%)

In your first position, what percent of time was devoted to the above activities? 0 25 9.4 3.1 < 10% 62.5 78.2 62.5 11 – 20% 9.4 9.4 25 21 – 30% 3.1 3.1 6.3 31 – 40% 41 – 50% 6.2 51 – 60% 18.8 61 – 70% 21.9 3.1 71 – 80% 46.9 81 – 90% 3.1 91 – 100% 3.1 Currently, what percentage of your time is devoted to the above activities? 0 18.8 12.5 < 10% 40.7 68.8 59.4 11 – 20% 25.1 12.5 28.2 21 – 30% 3.1 3.1 6.2 9.4 31 – 40% 6.2 6.3 3.1 41 – 50% 21.9 6.3 51 – 60% 21.9 61 – 70% 18.8 71 – 80% 21.9 81 – 90% 3.1 91 – 100% 3.1

L. Elit et al. / Gynecologic Oncology 94 (2004) 134–139 Table 4 Factors that influence job satisfaction Correlation Emotional exhaustion (high)

Depersonalization Personal (high) accomplishment (low)

Positive

level of responsibility colleagues indicate that I do my job well, job variety intellectual stimulation, dealing with relatives

Negative

level of responsibility, ability to bring positive change in the institution, institution has the staff needed to do the job, intellectual stimulation from my job, high level of autonomy, opportunities for personal learning, institution is adequately financed, intellectual stimulation from teaching learners, adequate facilities, feeling used to my optimum, dealing with relatives

job variety, job security

level of responsibility, intellectual stimulation

A high level of responsibility leads to job satisfaction but it contributed toward emotional exhaustion, low personal accomplishment but not so critically to depersonalization.

exhaustion; patient and job specific factors, which contribute to high depersonalization; and home and financial stresses, which contribute to low personal accomplishment.

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When considering a new job, the respondents indicate that the three leading factors that influence a decision to move are job location, colleagues, and potential for professional growth.

Discussion In this paper, we have described the job profile of Canadian gynecologic oncologists. Their role is predominantly clinical with a minor component of administration and to a lesser extent, education or research. In the clinical role, 80% of the activity is focused on gynecologic cancer patients either in new patient assessment, surgery, chemotherapy, or follow-up. Although vacation and conference time is technically available, this appears to be under utilized. We can only speculate on explanations such as a sense of responsibility to colleagues and patients. The majority of physicians are satisfied with their job, but there are clear concerns in terms of system issues. Approximately 26% of physicians are experiencing high stress, and this was strongly associated with emotional exhaustion and somewhat associated with depersonalization. The emotional exhaustion factors are clearly related to system issues (i.e., inadequate work facilities, too great a patient volume, inadequate numbers of staff). The depersonalization factors involved relationships with colleagues, staff, and patient’s family. Approximately 14% of Canadian gynecologic oncologists are actively looking for alternative jobs and 45% are actively trying to decrease the number of hours worked per week. When looking for a job, the three priorities are location, colleagues, and potential for personal growth. Practice

Looking to the future There are a significant number of physicians who are considering decreasing the number of hours they work (45.7%) or planning to leave their current job (13.8%).

There is little information available in the published literature describing the specific clinical and non-clinical activities of specialist or subspecialty practice. The gynecologic oncologist’s workweek of 58 h is in keeping with that

Table 5 Factors that influence job stress Correlation

Emotional exhaustion (high)

Depersonalization (high)

Personal accomplishment (low)

Positive

insufficient input into my unit, inadequate facilities, dealing with relatives, taking on managerial responsibilities, relations with colleagues, administration, and supervisors, responsible for the work of others, too great a volume, conflict with time, inadequate staff numbers, one’s expertise is not being put to good use, conflicting responsibilities, responsible for the welfare of other staff

disrupted home life, inadequate facilities, deal with relatives, difficult relations with colleagues, administrative staff, and supervisors, conflicting demands on time, inadequate staff to do a proper job

disruption of home life, keep up to date with current research, inequitable pay, conflicting demands on my time

Negative

difficulties with junior staff, responsible for the welfare of other staff

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published by New Zealand subspecialists in pediatrics and internal medicine [11]. Slightly more of the Canadian gynecologic oncologists’ time is devoted to teaching and administration (26%) compared to the New Zealand pediatric or internal medicine specialists (9– 19%). Job stress The GHQ has been used in other physician groups. In New Zealand, job stress was seen in 18% of general pediatricians, 26% of pediatric subspecialists, 25% of general internal medicine specialists, and 23% of internal medicine subspecialists [11]. Our finding that 26% of Canadian gynecologic oncologists have high stress is in keeping with these published rates. The differences and similarities in the Canadian and New Zealand system of health care provision cannot be commented on from the published reports. Burnout Burnout is a response to stressors at work. Emotional exhaustion is considered the first stage in burnout. Using the same instrument, we have information on burnout from four physician groups (medical oncologists from United Kingdom and Ontario, Canada, medical specialists from Holland, emergency physicians from Canada) (Table 6). The patterns of burnout scores for Canadian gynecologic oncologists were in keeping with our medical oncology colleagues in the United Kingdom [10] and Ontario [10]. The Canadian gynecologic oncologists had a higher burnout score than the Dutch medical specialists [12]. Gynecologic oncologists did not experience the high depersonalization pattern described by the Canadian emergency physicians [13]; however, where depersonalization was high, both physician groups responded by planning to change their job or decrease their hours. Job change Approximately 14% of gynecologic oncologists are very interested in a job change. This rate is in keeping with that reported by other groups with similar work profiles (15.7 – 19.6%) [11]. Of concern is that any change in manpower in

such a small subspecialty group has major ramifications for that region. This study has demonstrated a significant level of job stress and burnout among responding gynecologic oncologists in Canada. This study has several limitations. We used self-reporting which may lead to bias from recall and social desirability. As well, by using a structured questionnaire, we may have missed important factors associated with our observations. These could have been better delineated from personal interviews. There was no attempt to validate workload reports against annual cancer clinic or hospital statistics, or physician billings. We did not probe the respondent’s potential stress outlets. Although generalizability is an issue, using the same instrument, our findings in gynecologic oncologists are similar to those reported in other countries with different medical specialty groups. We had an excellent response rate (80%), however, despite our small community, not all practitioners responded. Of note, demographic characteristics were similar between responders and non-responders. Our numbers are small and may or may not represent the levels of stress in gynecologic oncologists in other countries. We identified high rates of burnout and low rates of personal accomplishment in Canadian gynecologic oncologists, and these mirrored the profile of our Ontario medical oncology colleagues. It is not clear if this finding reflects working in a similar system (i.e., socialized health care system) or is a function of the job description (i.e., oncology). This is the first study assessing burnout and stress in a group of surgical subspecialists. Although these individuals chose the specialty based on personality type and passion, it is also likely that the types of stressors experienced by a surgeon are different than those experience by a medical subspecialist (i.e., physical stamina for long operations). Thus, how the two disciplines react to the same stress factor may or may not be different. This concept has not been evaluated in this study. What we have shown is that despite different job profiles, the gynecologic oncologists display similar levels of stress and burnout. Secondly, this finding is concerning as gynecologic oncologists are the ultimate resource for gynecologic cancer care and complicated benign gynecologic surgery. If this small subspecialty group is unable to work optimally, there is no other resource to deliver appropriate medical care for these women.

Table 6 Comparison of burnout scores across specialists Burnout subscale

UK medical oncologists [10]

Canadian emergency physicians [13]

Ontario medical oncologists [10]

Dutch medical specialists [12]

Canadian gynecologic oncologists

High emotional exhaustion High depersonalization Low personal accomplishment

25

13

54.6

15.5

35.3

15 34

61 44

24.7 50.5

27.3 7.4

14.7 32.4


To decrease stress and burnout, the Ramirez questionnaire showed that three areas must be addressed: physician well being, job description, and environment. Physician well being appears to be inversely correlated to number of hours on call, number of hours in direct patient contact, and lack of vacation time. Many studies have been published over the past 25 years on the effects of fatigue and long work hours on physician well being [14 – 17]. Possibly upper limits on hours of exposure of a physician to patients and mandatory time away from the workplace could be considered. Repercussions of such a model include the need for stable salary support that is not linked to patient or procedural volumes. The Canadian socialized health care system provides medical care for the whole population and gynecologic cancer care is provided in specialized cancer centers affiliated with a host hospital and university. Thus, an adequate number of gynecologic oncologists per center are required to cover the workload, as this system does not allow the opportunity to decant patients to other units. The gynecologic oncologist job description needs to change from being entirely patient focused to a scenario where more time is devoted to university caliber pursuits. Gynecologic oncologist must focus on leadership roles in preinvasive disease (i.e., colposcopy). Thus, appropriate training of gynecologists or family doctors to assume responsibility for colposcopy is required. Given that all Ontario gynecologic oncologists are university professors, the system must allow professional time to be designated to education, research, or administrative pursuits. The gynecologic oncologists felt this would also improve their overall sense of accomplishment. Academic departments should thus invest in training subspecialists so that they have the skill sets to contribute in one of these three areas. Subsequent mentorship, ongoing career planning, accountability, and evaluation are needed. Hospital environmental issues need to focus on enhancing ease of patient care with ready access to diagnostic procedures, minimize waiting times for surgery, access to minimally invasive surgery, and funding strategies that account for changes in volume and work complexity (i.e., promote liquid-based cytology for cervical disease in hospital-based labs). University environmental issues include better aligning service and education with the number of house staff [17]. Lack of physician personnel to deal with patient needs means that bedside-based education will suffer. Firth-Cozens [14] and Jones et al. [15] have suggested that organizations must promote preventative strategies. They propose an organization-wide stress management model that includes improved management style, systems to enhance team development, and

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counseling of physicians to tackle pressures (i.e., by cognitive restructuring, encourage coping skills, improve communications skills, and understand ones reaction to stress). Jones et al. [15] have shown that this can lead to a decrease rate in errors and malpractice claims. These interventions should be considered to prevent further deterioration in the working life of Canadian Gynecologic Oncologists. It is important for the specialty and policymakers to continue to monitor stress and burnout among gynecologic oncologists in Canada to ensure that a crisis situation does not develop.

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