mental health and occupational wellbeing of australian gynaecologic oncologists
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Gynecologic Oncology 116 (2010) 526–532
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Gynecologic Oncology
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Mental health and occupational wellbeing of Australian gynaecologic oncologists
Lesley Stafford ⁎, Fiona JuddCentre for Women's Mental Health, Royal Women's Hospital, Locked Bag 300, Parkville, Victoria 3052, AustraliaDepartment of Psychiatry, University of Melbourne, Victoria 3010, AustraliaDepartment of Psychology, School of Behavioural Sciences, University of Melbourne, Victoria 3010, Australia
⁎ Corresponding author. Fax: +61 3 8345 2076.E-mail address: [email protected] (
0090-8258/$ – see front matter © 2009 Elsevier Inc. Adoi:10.1016/j.ygyno.2009.10.080
a b s t r a c t
a r t i c l e i n f oArticle history:
Received 24 August 2009Available online 24 November 2009Keywords:BurnoutJob satisfactionJob stressPsychological morbidity
Objective. To investigate the prevalence of psychiatric morbidity and occupational burnout amongAustralian gynaecologic oncologists and to assess job stress and job satisfaction in this group.
Method. Anonymous, self-report questionnaires containing validated measures were sent to all practicingAustralian gynaecologic oncologists in October 2008.
Results. The response rate was 78.4% (N=29). More than one-third (35.7%) had high levels of emotionalexhaustion, the central component of burnout. In the past 6 months, 42.9%, 57.1%, and 28.6% had seriouslyconsidered leaving for another position, reducing the number of hours worked, and taking early retirement,respectively. The most commonly reported source of stress (80.8%) was home-life disruption due to work.
Compared to general population data and recommended national guidelines, rates of alcohol consumptionwere high. Psychological morbidity, global job stress and burnout were significantly correlated and each wasassociated with harmful alcohol use. Other factors associated with burnout were administrative/organizational demands and patient volume. More than half of respondents (58.6%) had high levels of jobsatisfaction and most had high levels of personal accomplishment (70.4%). Perceived adequacy of thetraining curriculum and proposed changes to the curriculum are reported.Conclusion. Australian gynaecologic oncologists experience considerable occupational distress whilepossessing high levels of personal accomplishment and job satisfaction. To maintain a healthy workforce, it isimportant to build on existing supports while conducting further research to identify suitable evidence-based strategies for improving the mental health of these surgeons.
© 2009 Elsevier Inc. All rights reserved.
Introduction
Approximately 65,000 new cases of cancer are diagnosed eachyear in Australia [1]. With an increase in the age of thepopulation, the overall number of new cases of gynaecologiccancers is projected to rise by almost 15% from 3886 in 2001 to4487 in 2011 [2]. Consequently, the next few decades are likely tobe a time of higher demand for gynaecologic oncologists. As arelatively new subspeciality that demands lengthy formal training,there are currently only a small number of certified gynaecologiconcologists in Australia. To maintain an adequate workforce, itwill be critical to not only train enough gynaecologic oncologistsbut also to guard against the premature attrition of those alreadyin practice.
It is well known that medical practitioners experience high levelsof stress in their profession with an estimated 15% unable to meettheir professional responsibilities at some time in their careers due todepression or substance dependency [3]. While most doctors would
L. Stafford).
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be familiar with the symptoms and sequelae of these psychiatricconditions, they may be less aware of personal distress in the form ofburnout. Burnout is a clinical syndrome characterized by emotionalexhaustion, depersonalization and diminished personal accomplish-ment [4]. Unlike depression, burnout is specific to the workplace [5].Typical symptoms include feelings of ineffectiveness, physicalexhaustion, cynicism, emotional depletion and a sense of detachmentfrom patients and colleagues.
The personal and professional consequences of burnout can beserious. Burnout is associated with higher levels of absenteeism andturnover [6, 7] and evidence suggests a deleterious effect on patientsafety and quality of care [8], including a dose-response relationshipbetween the magnitude of burnout and medical error [9,10]. There isalso accumulating evidence of an association with health problemssuch as cardiovascular disease [11].
Previous studies have found high rates of psychiatric morbidityand burnout in a range of medical specialists [6,12-17] includingsurgical oncologists [18], but only one prior study has investigatedthese outcomes in gynaecologic oncologists [19]. The purpose of thisstudy was to examine these outcomes among Australian gynaecologiconcologists. We also investigated job satisfaction and methods ofcoping with job stress as well as perceptions of the adequacy of the
Table 1Sample characteristics.
n (%)
Demographic characteristicAge (years) 31–40 3 (10.1)
41–50 13 (44.8)51–60 12 (41.4)61–70 1 (3.4)
Gender Male 24 (82.8)Female 5 (17.2)
Marital status Married/de facto 29 (100)Year fellowshipcompleted
1968–1977 1 (3.4)1978–1987 4 (13.8)1988–1997 12 (41.4)After 1997 12 (41.4)
Practice characteristicPrimary consultationsetting
Private practice 15 (51.7)Hospital basedclinic
10 (34.5)
Equal split 4 (13.8)Currently providechemotherapy
3 (10.7)
Currently in first position 17 (60.7)
Mean (SD) Range Median
Nights on call per 28 days 15 (9.04) 5–28 12Hours worked per week 56.5 (9.32) 30–70 57.5Major surgeriesperformed per month
24 (10.84) 0–40 23.5
Patients seen per week New 9 (4.96) 3–25 8Follow-up 29 (17.9) 10–80 27.5Colposcopy 12 (10.9) 0–30 8Benigngynaecology
9 (8.85) 1–40 5
Malignantgynaecology
18 (11.48) 0–45 15.5
Distribution of time (%) Direct patient care 77 (14.38) 40–95 80Research 5 (6.10) 0–30 5Education 5 (4.29) 0–20 5Administration 13 (12.67) 1–50 10
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fellowship curriculum in terms of preparation for independentpractice. Practice characteristics and the spectrum of practice amongstour sample are described.
Method
Sample and procedure
Respondents were identified via the Australian Society ofGynaecologic Oncologists (ASGO) membership list. A total of 37certified gynaecologic oncologists are currently practicing in Australia.Anonymous questionnaires were mailed to all respondents in October2008. A second questionnaire was mailed to all respondents 1 monthlater in order to maximize the response rate. Institutional ethicalapproval was obtained for the study.
Measures
The study questionnaire was modelled after those used inprevious studies [14,19-21] to allow for consistency and comparison.The questionnaire was reviewed by two members of ASGO to ensurelocal relevance. The questionnaire comprised a section on demo-graphic factors, practice characteristics, and spectrumof clinical oncologypractice.
The Maslach Burnout Inventory [4] was used to measure burnout.This 22-item instrument comprises subscales of emotional exhaustion(feeling emotionally over-extended by work), depersonalization (anunfeeling response towards people) and personal accomplishment(feelings of competence at work). Scores are categorized as low,average or high according to predetermined cut-off scores based onnormative data [4]. A high degree of burnout is indicated by highscores on the emotional exhaustion and depersonalization subscalesand low scores on the personal accomplishment scale [4]. Psycholog-ical morbidity was assessed with the 12-item General HealthQuestionnaire (GHQ-12) [22], a validated screen for morbidity incommunity samples and occupational settings. Scores range from 0 to12. In accordance with the recommendations of the scale authors,morbidity was defined as a score ≥4. Alcohol use was assessed usingan abbreviated version of the Alcohol Use Disorders Identification Test(AUDIT) [23]. Respondents were asked about the frequency andquantity of alcohol consumption and whether it had been suggestedthat they reduce their intake.
Job satisfaction was measured with a questionnaire designed byRamirez [15,16] which asks respondents to endorse the extent towhich they derive satisfaction from 25 specific sources. A global ratingof satisfaction is also included. The questionnaire included 3 questionsto measure respondents' consideration of alternative work situationsincluding serious consideration of leaving their current job, reducingthe number of hours worked, and taking early retirement.
Sources of stress were measured with a questionnaire designed byRamirez [15,16]. Additional questions based on previous studies ofstress among medical practitioners [10,24], including oncologists [25]were included. Respondents were also asked whether they had beenadequately prepared for these stressors during their training.Recommendations for changes to future fellowship curricula to bettermeet the needs of future clinicians were assessed with 8 questionsderived from previous studies of oncologists [21].
Strategies for dealing with stress were measured by askingrespondents to rate the importance of 21 different strategies on ascale ranging from “not important” (0) to “essential” (10). Althoughthese questions have not been formally validated, they weredeveloped based on common wellness promotion and stressmanagement strategies reported in previous studies of medicalpractitioners [24,26], including oncologists [25]. Respondents werealso asked to indicate how likely they would be to attend a range ofsmall group meetings to manage stress.
Analysis
Data were analysed using SPSS version 16. Alpha was set at 0.05.Descriptive statistics were used to describe the data. Percentagesreported are valid percentages and refer to the proportion of all validresponses. Relationships between variables were assessed usingsimple bivariate correlations and ANOVA analyses, as appropriate.
Results
Sample characteristics
A total of 29 respondents returned questionnaires (78.4%). Thedemographic and practice characteristics of these respondents areshown in Table 1. Respondents in their first position performed, onaverage, 9 major surgical cases more per month than those no longerin their first position (p=0.02) and devoted approximately 12% moretime to direct patient care (p=0.04) than their counterparts.
Occupational well-being
Job satisfactionSeventeen (58.6%) respondents reported high job satisfaction.
Individual sources of job satisfaction that correlated with global jobsatisfaction were a high level of responsibility (r=0.41, p=0.03),adequate institutional financial resources (r=0.51, p=0.005), a highlevel of job security (r=0.46, p=0.01), and involvement in activitiesthat contribute to the development of the profession (r=0.37,p=0.04). Job satisfaction was inversely associated with number of
Table 2Use of stress management techniques.
Technique Australian gynaecologic oncologists UK medical oncologists [25]
Mean (SD) Range Mean (SD)
Find meaning in my work 8.41 (1.59) 5–10 8.0 (1.87)A positive outlook on things 8.31 (1.76) 3–10 7.4 (2.22)Developed an approach/philosophy todealing with death/end-of-life care
8.10 (1.66) 4–10 8.0 (1.90)
Recreation/hobbies or exercise 7.93 (2.20) 2–10 7.4 (2.41)Regular holidays 7.69 (2.57) 2–10 7.6 (2.44)Protect time away from work with my partner/family 7.34 (2.58) 2–10 7.9 (2.12)Discussions with family or significant others 6.83 (3.10) 1–10 7.8 (2.30)Incorporate a life philosophy stressing balance inmy personal and professional life
6.28 (3.13) 1–10 6.9 (2.44)
Discuss stressful aspects of work with colleagues 6.04 (3.02) 1–10 6.3 (2.56)Look forward to my retirement 5.66 (3.36) 1–10 5.9 (3.25)Involved in research activities 4.28 (2.67) 1–10 5.3 (3.01)Drink alcohol 3.72 (2.56) 1–10 NDNurture the spiritual or religious aspects of myself 3.59 (3.05) 1–10 6.10 (3.10)Regular small group meetings for debriefing/sharing 2.66 (2.64) 1–10 NDWork part time 2.38 (2.62) 1–10 1.7 (2.84)Regular individual meetings with a psychologist to discuss stress 2.14 (2.49) 1–10 1.0 (2.09)Regular small group meetings to discuss patient death/suffering 1.76 (1.68) 1–7 NDRecreational or prescription drugs 1.52 (1.83) 1–9 NDRegular small group meetings with a psychologist to discuss stress 1.41 (1.26) 1–6 NDGamble 1.10 (.31) 1–2 NDSmoke cigarettes 1.03 (.19) 1–2 ND
ND=no data available.
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follow-up patients (r=−0.46, p=0.02), and benign gynaecologypatients (r=−0.43, p=0.03) seen each week. There was an inverserelationship between job satisfaction and thoughts of retiring (r=−0.49, p=0.01). Respondents over 50 years (44.8%) had significantlylower job satisfaction (p=0.04).
Job changeIn the past 6 months, 12 (42.9%), 16 (57.1%), and 8 (28.6%)
respondents had seriously considered leaving for another position,reducing the number of hours worked, and taking early retirement,respectively. Respondents over 50 years of age were more likely tohave considered cutting down the number of hours (p=0.002) andretiring (pb0.001) in the past 6 months.
Job stressRespondents with higher overall levels of stress were more likely
to have considered leaving their current position (r=0.74, p=0.01)and to have considered retiring in the last 6 months (r=0.41,p=0.03). There was a positive association between job stress andnumber of benign gynaecology patients seen per week (r=0.50,p=0.01). Overall job stress was inversely correlated with overall jobsatisfaction (r=−0.43, p=0.02).
The three most commonly reported sources of stress weredisruption of home life (n=21, 80.8%), conflicting demands on time(n=18; 69.2%), and patient load (n=16, 59.3%). A small majority of
Table 3Maslach Burnout Inventory scores.
Subscale Categorization n (%)
Emotional exhaustion High 10 (35.7)Average 6 (21.4)
Low 12 (42.9)Depersonalization High 3 (10.7)
Average 5 (17.9)Low 20 (71.4)
Personal accomplishment High 19 (70.4)Average 7 (25.9)
Low 1 (3.7)
EE=emotional exhaustion; PA=personal accomplishment; DP=depersonalization.
respondents (n=15, 57.7%) endorsed the following factors as majorsources of stress: inadequate facilities, insufficient input into themanagement of the unit, pressure to meet deadlines, inadequatestaffing, and poor payment (n=14, 53.8%).
Coping with job stressFinding meaning in work received the highest overall mean rating
as a way of managing stress (mean=8.41, SD=1.59, range=5–10).Having a positive outlook (mean=8.31, SD=1.76, range=3–10)and a philosophy for dealing with end of life care/death (mean=8.10, SD=1.65, range=4–10) were the second and third most highlyendorsed stress management techniques, respectively. Endorsementsof stress management and wellness promotion techniques are shownin Table 2 alongside comparable data from a study of UK medicaloncologists [25].
In response to whether clinicians would participate in small groupmeetings of oncologists to manage stress if these were available, 10(35.7%)wouldmeet ingroupswithapsychologist, 11 (40.7%)wouldmeetto discuss patient death/suffering, and 16 (57.1%) respondents indicatedthat they would meet for debriefing and sharing with other oncologists.
BurnoutResults from the Maslach Inventory are presented in Table 3.
More than one third of respondents had clinically significantemotional exhaustion and 10.7% would be considered pathologically
Mean (SD) Range
21.25 (10.00) 4–41Possible range 0–54
5.07 (5.31) 0–22Possible range 0–30
41.48 (4.54) 32–48Possible range 0–48
Table 4Significant correlations between practice characteristics, stress and satisfaction and dimensions of burnout.
Variable Emotional exhaustion Depersonalization Personal accomplishment
Practice characteristicsNumber of gynaecologic oncology patients/week −0.41⁎Hours worked 0.45⁎Nr follow-up patients/week 0.40⁎
Sources of stressInsufficient input into unit 0.44⁎Disruption of home life due to long hours 0.53⁎⁎ 0.63⁎⁎⁎Difficulties with hospital administration 0.44⁎Poorly paid 0.44⁎Difficult relationships with managers 0.43⁎Administrative duties 0.41⁎ 0.39⁎Finding meaning 0.40⁎ 0.38⁎Inadequate staffing 0.62⁎⁎⁎Conflicting demands on time 0.46⁎Difficulties with administrative staff 0.56⁎⁎Inadequate facilities 0.49⁎⁎Responsibility for welfare of other staff 0.46⁎Difficulties with colleagues 0.42⁎Taking paperwork home 0.39⁎Keeping up to date with research −0.43⁎Applying for grant support −0.41⁎
Sources of job satisfactionOpportunities for personal learning −0.44⁎Good relationships with patients −0.42⁎
Stress management techniquesSmoking cigarettes 0.55⁎⁎Attending regular small group meetings −0.50⁎⁎ −0.50⁎⁎Regular holidays 0.40⁎Work-home life balance −0.50⁎⁎
⁎ pb0.05.⁎⁎ pb0.01.⁎⁎⁎ pb0.001.
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detached from their patients and work colleagues. The majority(70.4%) report a high level of personal accomplishment associatedwith their work. Emotional exhaustion was positively associatedwith global ratings of job stress (r=0.45, p=0.02), and psycholog-ical morbidity (r=0.61, pb0.001). Respondents with increasinglevels of emotional exhaustion were more likely to have consideredleaving their position in the last 6 months (r=0.45, p=0.02).Significant associations between practice characteristics, stress and
Table 5Occupational burnout and psychological morbidity by medical speciality.
Speciality Country n
Gynaecologic oncology Australia 29Gynaecologic oncology [19] Canada 35Surgical oncology [18] USA 549Palliative care [48] Australia 41Palliative care [15] UK 126Palliative care [12] Japan 697Surgery [49] USA 582Surgery [20] UK 161Medical oncology [14] Canada 122Medical oncology [15] UK 60Medical oncology [20] UK 266Anaesthetics [50] Australia 422Internal medicine [17] New Zealand 50General Practice [51] Switzerland 1784Gastroenterology [20] UK 241Radiology [20] UK 214Radiation oncology [15] UK 207Colorectal surgery [6] UK 253Vascular surgery [6] UK 248
EE=emotional exhaustion; DP=depersonalization; PA=personal accomplishment; GHQAmerica; ND=no data available.
satisfaction and the three dimensions of occupational burnout areshown in Table 4.
Psychological morbidity
The mean score on the GHQ-12 was 1.34 (SD=2.11, range=0–7).Five respondents (17.2%) scored ≥4. In addition to the associationwith emotional exhaustion, higher levels of psychological morbidity
GHQ≥4 Percentage scoring
High EE High DP Low PA
17.2 35.7 10.7 3.726 34 14.3 32.4ND 24.1 15.2 9.627 22.5 7.5 2.525 23 13 2520 22 11 62ND 32 13 422 27 19 3225.4 53.3 22.1 48.432 25 15 3429 35 27 37ND 20 20 3712 34 28 38ND 19 22 1626 31 28 3829 33 21 4928 38 31 3830.2 31.1 17.4 26.635.7 32.2 24.9 31
=General Health Questionnaire-12, UK=United Kingdom; USA=United States of
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were also positively associated with global ratings of job stress(r=0.42, p=0.02), thoughts of early retirement (r=0.54, p=0.002)and greater percentage of time devoted to administrative duties(r=0.45, p=0.02). Table 5 contains data comparing rates ofpsychological morbidity and burnout using the same instrumentsacross a range of medical specialities.
Alcohol useAsked how often they drink alcohol, responses were: never, n=1
(3.4%); monthly or less, n=1 (3.4%); 2–4 times a month, n=6(20.7%); 2–3 times a week, n=9 (31%); and ≥4 times a week, n=12(41.4%). The number of standard drinks consumed on a typical daywas none, n=1 (3.4%); 1–2, n=18 (62.1%); 3–4, n=9 (31%), and 5–6, n=1 (3.4%). Occasions on which 6 or more drinks are consumedwere never, n=12 (41.4%); less than monthly, n=10 (34.5%);monthly, n=5 (17.2%); weekly, n=1 (3.4%); and daily, n=1 (3.4%).Three respondents (10.3%) had been recommended in the last yearthat they reduce their alcohol consumption. Mean scores ofpsychological morbidity (p=0.02), emotional exhaustion (p=0.03)and overall job stress (pb0.001) were significantly higher amongthese 3 respondents than among their counterparts.
Fellowship curriculum
Perceived adequacy of training curriculumSources of stress that 50% or more of respondents believed they
were not adequately prepared for by the fellowship program were:Having insufficient input into unit management (n=21, 72.4%),difficulties in relationships with administrative staff (n=17, 58.6%),uncertainty over future funding of the unit (n=15, 51.7%), applyingfor/maintaining grant support (n=16, 55.1%), conflicting demandson time (n=19, 65.5%), feeling poorly paid (n=15, 51.7 %), taking onmanagerial responsibilities (n=16, 55.1%), and difficulties in rela-tionships with colleagues (n=14, 51.9%).
Proposed changes to training curriculumRespondents' endorsements of possible changes to future fellow-
ship curricula are depicted in Table 6 alongside the findings from asurvey of UK medical oncologists [21]. Additional curriculum on end-of-life care and regular small group meetings for fellows to share/debrief were the most commonly proposed changes.
Table 6Proposed changes to future fellowship curriculum.
Proposed change Respondents whoendorsed thisproposed change n (%)
UK medical oncologistswho endorsed thischange (%) [21]
Additional curriculum onend-of-life care/delivering‘bad news'
22 (78.6) 95
Regular small group meetingsfor debriefing/sharing withother fellows
22 (78.6) 79
Additional curriculum onoffice management
20 (71.4) 73
Additional curriculum ongovernment/ insurancereimbursement policies
19 (67.9) 80
Additional curriculum orwork-life balance
16 (59.3) 73
Regular small groupmeetings to discusspatient death/suffering
16 (57.1) 79
Additional curriculum onapplying for andmaintaining grant support
14 (50) 64
Regular small group meetingswith a psychologist todiscuss stress
11 (39.3) 38
Additional suggestions included extra curriculum on exampreparation and business management and meetings for fellows tostudy and bond. It was suggested that training include several termswith other surgical disciplines to promote surgical skills, and that lesstime be spent in general gynaecology training but more in specialistgynaecologic oncologist training.
Discussion
The mental health and occupational wellbeing of those providingcare for individuals with cancer has far reaching implications for thequality of life of the medical practitioners, standards of patient care,and workforce maintenance. We report here on stress, satisfaction,psychiatric morbidity and burnout in Australian gynaecologiconcologists.
The majority of respondents were very satisfied with their careers.This is consistent with reports of job satisfaction among USgynaecologic oncologists of whom 84% would choose the same careeragain [27]. Compared with other medical specialities, personalaccomplishment scores among Australian gynaecologic oncologistscompare very favourably. While these are positive findings thatshould be reinforced to individuals considering a career in gynaeco-logic oncology, we also found that burnout was common. More than athird of respondents are emotionally exhausted, the central compo-nent of burnout thought to be caused by “excessive emotionaldemands that leave individuals feeling drained and depleted” [28].Compared with other medical practitioners, the rate of clinicallysignificant emotional exhaustion in our sample was amongst thehighest. Emotionally exhausted respondents were more likely toseriously consider leaving their jobs, had higher levels of psycholog-ical morbidity, and more harmful alcohol use.
Prevalence of alcohol abuse among medical practitioners isthought to be similar to the general population [29–31]. Directcomparison of the current findings with general population (Austra-lian) data is difficult because of varying units of measurement;however, our findings suggest excessive alcohol use.We reported that72.4% of respondents drink alcohol weekly, whereas this occurs inonly 41% of the general population [32]. Furthermore, 2009 nationalguidelines recommend that healthymen andwomen should consumeno more than 2 drinks per day to reduce their lifetime risk of harmfrom alcohol-related disease or injury [33]. On this basis, more thanone third of respondents consume alcohol in quantities thatsubstantially increase their risk of alcohol-related harm. The rate ofpsychological morbidity in this sample (17.2%) is lower than foundamongst other medical practitioners and this is likely due to theprotective effect of high levels of job satisfaction [20].
Our study design did not allow for conclusions to be drawn aboutcauses of burnout but the factors identified here such as home lifedisruption, high patient load, and institutional barriers are similar tothe findings of other studies [21,34,35]. It is of interest that frequentexposure to patient suffering and communication of bad news, theaspects of oncology practice thought to predispose oncologists tohigher levels of distress than other medical practitioners [36], werenot associated with burnout. Nonetheless, like their UK counterparts[21], the vast majority of respondents would like additionalcurriculum on these issues. The finding that 50% or more ofrespondents identified unit management issues (e.g., relationshipswith administrative staff and colleagues, uncertainty over unitfunding, insufficient input into unit, taking on managerial responsi-bilities) as sources of stress, suggests that more extensive training inleadership and business management skills might be protectiveagainst burnout.
Although recovery from burnout and psychological morbidity ispossible, prevention is ideal. Medicine attracts perfectionist andconscientious candidates with a mentality that allows for personal lifeto be put on hold during training [10,37]. This mindset of delayed
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gratification, propelled by belief in the myth that “things will getbetter”, continues from medical school to retirement [25,38].Although this disposition may make for a dedicated surgeon, it alsopredisposes to poor mental health [39]. Vulnerability to poor mentalhealth outcomes is exacerbated by the tendency of medical practi-tioners to self-diagnose and self-medicate [40]. It is in this respect thatmentorship is crucial [41,42]. In addition to nurturing professionalaspirations, mentors should promote physical, psychological, emo-tional and spiritual wellness. Traineeswill strive to emulate theirmostknowledgeable teachers, and in the absence of a modelled work-lifebalance during training, the problem of delaying gratification isperpetuated. Fellowship programs, in particular, should teach morethan how to treat disease, they should help trainees develop the skillsand habits necessary to manage the challenges of independentpractice and inoculate against burnout and psychological morbidity.
Formalized peer support for medical practitioners to managestress has been recommended [17]. A third of respondents wouldmeet with a psychologist in groups to discuss stress but relative toother means of managing stress, individual and group meetings wereranked very low. However, more than half of the respondents saidthey would meet with other oncologists for debriefing and sharingand this did have a protective effect: those who attended debriefingmeetings with peers had lower levels of emotional exhaustion anddepersonalization. Additionally, more than three quarters of thesample suggested amending training to include regular small groupmeetings for sharing with other fellows. One possibility may comprisepeer support attendance as contributing to Continuing MedicalEducation [17].
Professional societies and institutional leaders have an importantrole in promoting balance and well-being [43]. Some [44,45] havesuggested the implementation of organization-wide stress manage-ment programs to facilitate self-care, although more research onevidence-based interventions is needed. In light of our findings thatthe most experienced surgeons are the least satisfied and haveexpressed intentions to cut down on hours or retire early, werecommend further investigation of these issues to avoid a crisis ingynaecologic cancer care.
Ultimately, nurturing wellness is the responsibility of eachmedical practitioner. It has been suggested [21,34,38] that wellnessbegins with an honest self-appraisal to establish whether one has amentality of perpetual delayed gratification. Personal and profes-sional goals must be clearly identified so that choices can be madeabout achieving those objectives. To translate these concepts intoaction, a five-step program is proposed to identify professionalvalues, select the right practice/career type, focus on aspects of workthat are most meaningful, proactively manage stressors, achieve abalanced personal-professional life, and foster personal wellnessstrategies [46].
Our study has several limitations. The cross-sectional designrestricted conclusions to the evaluation of associations. The unavoid-ably small sample size limited the analyses that could be performed.There were multiple comparisons of the same data withoutadjustment of the p-value. There is a possibility of response bias. Itis impossible to analyse differences between responders and non-responders and difficult to know whether medical practitioners withburnout would be more or less likely to participate in such a survey. Itis possible that those with high burnout would be too apathetic toparticipate but equally could be said to havemore interest in the topicand bemore likely to participate. Responses were also not analysed bygender due to the lack of anonymity created by such analyses. Others[18] have reported that female surgeonsweremore likely thanmen tohave burnout and though womenmedical practitioners were satisfiedwith their careers, many would not choose to become doctors again[47]. Also, while the items used to assess stress managementtechniques are based on those of previous studies and have facevalidity; their criterion validity has not been investigated.
The strengths of this study include the high response rate and theanonymous questionnaire that is likely to have encouraged greaterhonesty. The use of well-validated questionnaires enabled easycomparison of findings. This is the first study of its kind amongAustralian gynaecologic oncologists and represents novel data.
Conflict of interest statementThe authors do not have a conflict of interest to declare.
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