In this ever-changing world of health-care reform, limited resources, and reduced reimbursement, as well as increased demands for quality performance measures, clinicians are experiencing less autonomy in their scope of practice due to these growing restrictions (1,2,3,4,5,6,7,8,9). Health-care providers, particularly physicians, are reporting more job-related stressors, including employee dissatisfaction and mental exhaustion (10,11), over the last several decades, as the availability of their human resources (time and emotion/empathy) to invest in their clientele/patients is diminishing; however, consumer demand, partly due to increased complexity and severity of illness, is not (12).

This is particularly true in the disciplines of oncology and palliative care, examples of subspecialties in which clinicians care for individuals with chronic, progressive, often life-limiting diseases, with whom they develop deep, meaningful doctor-patient relationships. The well-being and job satisfaction of individuals practicing in these fields should be tantamount to the wellness that they expect from the delivery of their services to their patients (1). It has been noted that the wellness of a care provider has direct negative effects on important outcomes, including quality of patient care, efficiency, and productivity, as well as increased resource utilization. These stressors often lead to problems with substance abuse and psychiatric or medical illnesses. They can affect interpersonal relationships, subsequently causing compassion fatigue before culminating later in burnout or even early retirement (1,6,9,10,13,14,15,16,17,18,19,20). This rippling effect has the potential to decrease clinical workforce substantially, creating gaps in the ability to provide expert care (1).

Research over the last several decades, however, consistently elucidates that no significant advances have been made to improve upon these factors, reducing stress, burnout, and compassion fatigue (21,22,23,24). Therefore, it is imperative that workers in the human service industry incorporate measures into their daily routine to effectuate professional sustainability and find tenable ways to ensure adequate and frequent maintenance of their mind, body, and soul so that delivery of quality care may persist.

The aim of this chapter is to describe job-related stressors in the field of oncology and palliative care and to delineate its impact on provider performance as it relates to burnout and compassion fatigue. It has been noted that higher levels of burnout exist in oncologists (82). Although, there has been a paucity of major advances in mitigating burnout and compassion fatigue over the last decades, we will provide a recent selective review of the literature to further understand and attempt to improve upon this potentially career destructive syndrome. Finally, we provide an overview of strategies for sustained self-care.

One is often bewildered as to the differences between burnout and compassion fatigue. These terms are frequently used interchangeably in our profession. Commonalities between the two experiences do exist; however, there are striking distinguishing features. These are perhaps two distinct entities on a spectrum of job satisfaction.

Much attention has been given to the concept of burnout or burnout syndrome over the last 40 years, more so from an organizational business model, but of late from a healthcare perspective (21,22,23,24). Less is known, however, about the entity of compassion fatigue. Historically, most of the existing literature on burnout and compassion fatigue has stemmed from studies conducted in the nursing population. In recent years, however, increasing attention has focused on physician experiences of burnout and compassion fatigue. The literature that does exist on physicians deals primarily with physician job satisfaction (13,25,26,27,28,29). It is possible, though, to see how this topic might be extrapolated further to theorize about physician burnout and compassion fatigue.

Burnout is a term first described in the 1970s by psychologist and psychoanalyst Herbert Freudenberger, Ph.D. (6,30,31,32), endowed with quantifiable measures two decades later by Christina Maslach, Ph.D., at the University of California, Berkley, CA, United States. Burnout is felt to be a “stress-induced occupational disease” affecting many healthcare professionals (33,34,35). The Maslach Burnout Inventory-Human Services Survey (MBI-HSS) is now considered the gold standard in measuring the burnout syndrome, in which the domain metrics are emotional exhaustion, depersonalization, and personal accomplishment (6,33,35). The MBI consists of a 22-item questionnaire assessing the frequency with which clinicians experience certain feelings related to their jobs in the three aforementioned subscales where scores are rated low, moderate, and high (Table 56.1) (35). One is said to have burnout when emotional exhaustion or depersonalization scores are high (52).

Emotional exhaustion encompasses the feelings of being overextended with loss of emotional and physical resources
and reserve. Depersonalization refers to “negative, callous, or excessively detached responses” to various aspects of the job. Both of these entities, which are deemed high in burnout syndrome, are mechanisms by which one distances himself/herself from the job. Sense of personal accomplishment, which is low in burnout, refers to the feelings of incompetence and underachievement at work (36,37,38). In a 1991 study of oncologists by Whippen et al., 56% of members surveyed from the American Society of Clinical Oncology met the criteria for burnout syndrome. These individuals displayed increased emotional exhaustion, increased levels of depersonalization, and low levels of personal accomplishment. Researching burnout in oncology and palliative care has yielded mixed, but striking, statistics. According to two studies using the MBI scale, 53.3% and 69% of oncologists, respectively, documented high rates of emotional exhaustion compared with only 37.1% of allied health professionals caring for their patients (23,36,39). Additional studies illustrate rates of depersonalization ranging from 10% to 25%, both in the United States and internationally, where oncology physicians scored higher in this domain, suggesting they may be more vulnerable to burnout than their oncology nurse colleagues. Compared with Canadian and Japanese oncologists and palliative care physicians (33% to 50%) and allied health professionals, American oncologists were less likely (9%) to exhibit feelings of low personal accomplishment (23,36,40,41).

Burnout has been described as “an individual experience that is specific to the work context” (6). It might be best for one to conceptualize burnout in terms of individual job fit. In other words, one may be more prone to experiencing feelings of “being burned out,” if one’s work conditions are not congruent with one’s work goals. Maslach et al. noted that burnout occurs when there is a mismatch of the person and the job, as it relates to workload, control, reward, community, fairness, and values (32,42,43). This is not to say that one will find perfection in each of the aforementioned domains—rather that there will be acceptable or substantial levels of satisfaction in them such that one remains satisfied and committed to his/her job. This commitment or job engagement may help mitigate job burnout.

For all intents and purposes, these domains reflect organizational, often modifiable elements, more so than personal, perhaps less modifiable traits. Therefore, burnout, in its deconstruction, seems to stem from external influences that are beyond the care provider’s own locus of control. Potter cites Gentry and Baranowsky who describe burnout as “the chronic psychological syndrome of perceived demands from work outweighing perceived resources in the work environment” (10). Thus, this imbalance produces a stress reaction in the individual; if such stress persists unaddressed, it manifests fertile conditions for burnout.

By contrast, where burnout relates to extrinsic issues of the workplace environment, the basis of compassion fatigue seems due to internal qualities of the care provider: giving high levels of energy and compassion over a prolonged period to those who are suffering, often without experiencing the positive outcomes of seeing patients improve (44,45). Joinson initially described the phenomenon of compassion fatigue in 1992, a concept derived from research on burnout in emergency department nurses (10). She suggested that compassion fatigue was “a unique form of burnout that affects people in care giving profession” (10,44,46). She noted particular behaviors characteristic of compassion fatigue in “cancer-care providers,” which included the following: chronic fatigue, irritability, dread going to work, aggravation of physical ailments, and a lack of joy in life (44).

Some investigators purport that the “cost of caring” (47) for patients with cancer and other chronic life-limiting diseases in which deep emotional, empathic investment is made undergirds the concept of compassion fatigue. They suggest that repeated exposure to highly emotional care, often with frequent losses, is akin to post-traumatic stress disorder (PTSD). Compassion fatigue has also been described as secondary trauma or vicarious trauma—a consequence of trauma of another rather than trauma to oneself (36,47,48). It is characterized by classic symptomatology of PTSD, including recurring and intrusive thoughts, avoidance, and emotional hyper-arousal. Compassion fatigue can lead to burnout (36,48).

Orlovsky (44,49) helped to differentiate compassion fatigue from job dissatisfaction or frustration with the organizational mechanics of the workplace. Compassion fatigue may be considered a loss of the continued “ability to nurture” (46) as it relates to loss of empathic restoration due to repeated encounters with those dying from their chronic diseases. Although one may be unable to nurture anymore and is suffering from compassion fatigue or perhaps is even burned out, there can still exist a degree of compassion satisfaction. Compassion satisfaction, as noted by Stamm in 2002 (50), is defined as “the positive benefits that helping professionals derive from working with traumatized or suffering persons and the degree to which they feel successful in their jobs.” Therefore, it is appears possible to experience compassion fatigue concomitantly with compassion satisfaction. Furthermore, research conducted by Costa (51) postulates that compassion satisfaction subdues compassion fatigue and burnout.

Reviewing the limited, but growing, body of literature on the phenomenon of compassion fatigue has yielded many descriptions of the caregiver’s experience. Emotions include discontentment, depression, and loss of self-worth, in addition to feelings of mental and physical exhaustion (10,33,36,79). Although none of these emotions is wholly unique to compassion fatigue per se, it is in a context of simultaneous expression of such characteristics that compassion fatigue manifests itself. It is normal for a health-care provider to feel exhausted, both physically and emotionally, at times during one’s career. However, it is the loss of the caregiver’s ability to be an empathic witness for one’s patients and their families that constitutes compassion fatigue. Colloquially, compassion fatigue has been characterized as when “the well runs dry” or when one’s “cup is empty” and is unable to be replenished (44). For our purposes, we consider compassion fatigue to be a unique form of burnout that occurs earlier on the “trajectory” of job burnout where there is the loss of “ability to nurture” (46). It is a phenomenon where timely and upstream intervention can ameliorate its vastly devastating effects. Interventions are listed in Table 56.2.