Feature: Up in Flames: Burnout in Oncology Pharmacy

Allison P. Golbach, PharmD, BCPS
Clinical Oncology Pharmacist
The University of Kansas Health System
Kansas City, KS

Burnout has gained significant attention in recent years, but it is not a new concept. In fact, this phenomenon was originally described by American psychologist, Dr. Herbert J. Freudenberger, in 1974 after he experienced the feeling while working in a free clinic.1 He identified “the dedicated and the committed” as those most at risk for developing burnout. Dr. Freudenberger suggested that burnout in these individuals is secondary to an internal need to give their time and efforts beyond exhaustion, external pressures from leadership to push forward, combined with boredom of a routine job.¹

More than four decades later, we have learned the physical and behavioral signs of burnout, developed methods to measure its severity, and identified significant consequences associated with burnout. However, burnout remains highly prevalent. The development of meaningful interventions is imperative to alleviate the negative effects of burnout on individual professionals; institutional performance; and most importantly, quality patient care.

Defining Burnout
The World Health Organization identifies burnout as a “syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”.² It is characterized by feelings of energy depletion or exhaustion, increased mental distance from one’s job, feelings of cynicism related to one’s job and reduced professional efficacy. The “gold standard” for measuring the extent of burnout is the Maslach Burnout Inventory (MBI).³ This validated, 22-item questionnaire allows respondents to score each statement on a Likert scale (0 to 6, Never to Every Day) to assess burnout on three scales including emotional exhaustion, depersonalization, and personal accomplishment.

Higher scores on the emotional exhaustion and depersonalization scales represent higher levels of burnout, whereas lower scores on the personal accomplishment scale represent higher burnout. Additionally, the Well-Being Index (WBI) was designed to measure multiple dimensions of distress, including anxiety, stress, depression, and fatigue, and assess the risk of burnout.⁴ This nine-item questionnaire is advantageous given its shorter length and it has been validated across many professions, including pharmacists.⁵

Consequences of Burnout
The consequences of burnout in hematology/oncology pharmacy should not be taken lightly. Hematology/oncology pharmacists help to manage critically ill patients receiving highly toxic chemotherapy with a high burden of adverse effects. The longitudinal relationships with patients, coupled with the terminal nature of many disease states may be emotionally challenging. Additionally, the pressure of maintaining competency in a field with the highest rate of new drug approvals among specialties and a proliferative body of literature may confer additional stress.^6,7

The emotional exhaustion felt by someone suffering from burnout can lead to feelings of workplace apathy. This disinterest may progress to negative feelings about their job, detachment from their responsibilities, decreased efficacy in their position, and may even affect coworkers. At its worst, burnout can result in an individual leaving their position. In hematology/oncology pharmacy, the loss of a highly trained and expert pharmacist can be financially detrimental to an organization as the cost of recruiting, hiring, and training a new pharmacist can be significant.

Healthcare professionals spend a large portion of their lives caring for others, but those with burnout are at increased risk of developing their own mental and physical health conditions.

Studies have correlated high levels of burnout with depression, anxiety, insomnia, and use of psychotropic and antidepressant medications.⁸ Additionally, those suffering from burnout may be at higher risk for hypercholesterolemia, coronary heart disease, headaches, and gastrointestinal disorders.⁹ While it is important to continue caring for patients, it is crucial for healthcare professionals to take care of themselves.

Healthcare professional burnout affects not only the individual and their institution, but also the patients.¹⁰ A recent study of 2,231 pharmacists found nearly a quarter of pharmacists reported concern for having made a major medication error within the past three months.⁵ Pharmacists who were concerned about making an error reported higher scores on the WBI, which is associated with an increased risk of burnout. Other studies in pharmacists have demonstrated that increased workload, external job demands and work stress negatively impact medication safety and self-reported medication errors.^11,12

Seventy percent of studies included in a systematic review of burnout literature demonstrated a significant association with medical errors and potential errors.¹³ Similarly, a meta-analysis highlighted physicians with burnout were twice as likely to be involved in a patient safety incident.¹⁰ Even small errors in hematology/oncology pharmacy, such as a miscalculation of body surface area, or missing a decimal point, could result in significant morbidity or even mortality for patients.

Burnout Among HOPA Membership
Given the uptick in discussion around burnout, potential for serious consequences associated with burnout in hematology/oncology pharmacy, and lack of current literature regarding burnout in this population, our team decided to assess burnout among hematology/oncology pharmacists. As the largest organization of hematology/oncology pharmacists, HOPA was chosen as the study population. We developed a survey comprised of the MBI, WBI, and several items assessing sociodemographic and occupational factors to assess the prevalence and risk factors associated with burnout. This survey was validated by the Mayo Clinic Survey Research Center and sent out to HOPA members in October 2020.

Of the 3,024 pharmacist members of HOPA contacted via email, 550 (18.2%) surveys were able to be scored for burnout and were included in our analysis. Pharmacists who responded worked in a wide variety of settings, including ambulatory clinics (55.2%), hospital/inpatient (47.9%), infusion clinics (41.5%), academic medical center (38.0%), specialty pharmacy (5.9%), administration (5.7%), and academia (5.1%). Respondents had worked on average 12 years as a licensed pharmacist, 8.3 years as a hematology/oncology pharmacist, and five years in their current role.

High Levels of Burnout Among our Colleagues
Overall, our study found that 61.8% of pharmacists were experiencing high levels of burnout based on their emotional exhaustion (≥27) and depersonalization (≥10) scores of the MBI. This rate was consistent with previous studies assessing burnout in pharmacists. It is clear from this data that a majority of our colleagues are struggling with significant symptoms from burnout and mitigating actions are required.

As part of the study, we wanted to assess potential consequences associated with burnout in hematology/oncology pharmacists. One of the most jarring findings was that pharmacists with high burnout were more likely than their counterparts without high burnout to report concern for having made a major medication error in the past three months (27.6% vs 8.1%, P < 0.001). Again, it is important to underline the significance of this statistic as even minor errors when working with chemotherapy and other high-risk medications can result in significant, if not fatal, consequences for our already at-risk patients.

Those with Burnout Likely to Leave their Positions
Another potential consequence of burnout we noted was the likelihood of an individual leaving their current position. Of the pharmacists with high burnout based on the MBI, 26.8% responded they were likely or definitely leaving their current position within the next two years for reasons other than retirement compared with 8.1% of pharmacists without high burnout (P < 0.001). This correlates with approximately 90 hematology/oncology pharmacists leaving their current position in our cohort of 550 pharmacists. When taking into consideration the incredible amount of expertise and training that could be lost, efforts to minimize the risk of burnout would be valuable to organizations seeking to minimize overhead costs for replacing such a highly trained individual including recruitment and onboarding.

In our multivariable analysis, we identified several factors associated with an increased risk of high burnout. These factors could be used to develop targeted interventions to help mitigate the risk of burnout. First, we found that individuals who were unaware of any wellness programs were over two times as likely to have high burnout. Of those with high burnout, 62.7% felt they would benefit from a wellness program but 30.5% were unaware of any programs available to them. Additionally, pharmacists working more hours overall (per four hours worked, OR 1.22; 95% CI 1.10-1.35) and more administrative hours (≥4 hours versus <4 hours, OR 2.40; 95% CI 1.52-3.78) were at an increased risk of high burnout. We also found that those with decreased wellness secondary to the COVID-19 pandemic were at higher risk for high burnout (OR 1.89; 95% CI 1.24-2.89).

Where Do We Go From Here?
In February 2021, the American Society of Clinical Oncology (ASCO) published a five-year roadmap to address oncology provider burnout.14 ASCO’s framework is threefold: (1) to engage in well-being initiatives across the organization, (2) develop and improve upon well-being resources, and (3) promote research on well-being amongst clinicians. This comprehensive initiative further emphasizes that burnout is a significant problem in oncology. While this plan is intended for our physician and advanced practice provider colleagues, these concepts can be utilized in hematology/oncology pharmacy to develop a framework to tackle this important issue.

Our study identified that pharmacists who were unaware of wellness programs were at an increased risk of burnout. A logical first step would be to ensure institutional wellness programs are open to pharmacists, advertise availability, and educate on resource options. This would ensure equitable access for all provider levels within an institution and may also be emphasized through a national platform such as HOPA with newsletters, email communication, or postings throughout the workplace so the information is readily accessible to those who need it. Hopefully by increasing awareness and access to programs that already exist, more individuals would utilize these resources and the risk and severity of burnout would decrease.

After providing increased awareness, it is important to collect information about the root cause of the problem. A starting point for administrators and organizations would be to identify pharmacists working more hours and those with more administrative responsibilities since we found those were associated with increased risk of burnout. By identifying these pharmacists, we can have open conversations about what they are experiencing, interventions that may be beneficial, and additional resources that are needed to alleviate workplace stress.¹⁵ Hopefully, by starting with those experiencing the most burnout—resources and programs that are initiated would trickle down to those who are experiencing less severe burnout as well.

While these suggestions may serve as a starting point, there is still much to be done to help reduce the incidence and severity of burnout with interventions that are targeted to the needs of hematology/oncology pharmacists. Once interventions are put into place, it will be important to collect follow-up data and determine what types are the most beneficial so efforts can be focused in these areas. In the meantime, it is critical to maintain open dialogue with colleagues, friends, and mentors because simply knowing there is support can alleviate some symptoms of burnout.

Acknowledgement: Thank you to my research team Kristen B. McCullough, PharmD, BCPS, BCOP (Mayo Clinic Cancer Center); Scott A. Soefje, PharmD, BCOP, FCCP, FHOPA (Mayo Clinic Cancer Center); Kristin C. Mara, M.S. (Mayo Clinic); Tait D. Shanafelt, MD (Stanford Medicine Hospital and Clinics); and Julianna A. Merten, PharmD, BCPS, BCOP (Mayo Clinic Cancer Center).

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