ORIGINAL RESEARCH Identifying and preventing burnout in young oncologists, an overwhelming challenge in the COVID-19 era: a study of the Spanish Society of Medical Oncology (SEOM) P. Jiménez-Labaig1, V. Pacheco-Barcia2, A. Cebrià3, F. Gálvez4, B. Obispo5, D. Páez6, A. Quílez7, T. Quintanar8, A. Ramchandani9, J. Remon10, J. Rogado5, D. A. Sánchez11, M. Sánchez-Cánovas12, E. Sanz-García13, A. Sesma14, N. Tarazona15,16, A. Cotés17, E. González18, J. Bosch-Barrera19, A. Fernández20, E. Felip21, R. Vera22, Á. Rodríguez-Lescure8 & E. Élez21* 1 Department of Medical Oncology, Cruces University Hospital, Barakaldo, Bizkaia; 2Department of Medical Oncology, Gómez Ulla Military Hospital, Madrid; 3 Department of Mental Health, Parc Taulí University Hospital, Sabadell, Catalunya; 4Department of Medical Oncology, Jaén University Hospital, Jaén, Andalucía; 5 Department of Medical Oncology, Infanta Leonor University Hospital, Madrid; 6Department of Medical Oncology, Santa Creu i Sant Pau University Hospital, Barcelona, Catalunya; 7Department of Medical Oncology, Can Misses Hospital, Área de salud de Ibiza y Formentera (ASEF), Ibiza, Illes Balears; 8Department of Medical Oncology, Elche University General Hospital, Elche, Comunitat Valenciana; 9Department of Medical Oncology, University Hospital Complex, Insular-Materno Infantil de Gran Canaria, Las Palmas de Gran Canaria, Islas Canarias; 10Department of Medical Oncology, HM Delfos Hospital, Barcelona, Catalunya; 11Department of Medical Oncology, Virgen de La Arrixaca University Hospital, Murcia, Región de Murcia; 12Department of Hematology and Medical Oncology, Morales Meseguer University General Hospital, Murcia, Región de Murcia; 13Department of Medical Oncology, HM Sanchinarro HospitaldCentro Integral Oncológico Clara Campal (CIOCC), Madrid; 14 Department of Medical Oncology, Lozano Blesa University Clinical Hospital, Zaragoza, Aragón; 15Department of Medical Oncology, INCLIVA Biomedical Research Institute, Comunitat Valenciana; 16Instituto de Salud Carlos III, CIBERONC, Madrid; 17Department of Medical Oncology, Elda General Hospital, Elda, Comunitat Valenciana; 18Department of Medical Oncology, Virgen de las Nieves University Hospital, Granada, Andalucía; 19Department of Medical Oncology, Dr. Josep Trueta University Hospital, Institut Català d’Oncologia (ICO), Girona, Catalunya; 20Department of Medical Oncology, University Hospital Complex of Ourense (CHUO), Ourense, Galicia; 21Department of Medical Oncology, Vall d’Hebron University Hospital & Institute of Oncology (VHIO), Vall d’Hebron Hospital Campus, Barcelona, Catalunya; 22 Department of Medical Oncology, University Hospital Complex of Navarra, Pamplona, Navarra, Spain Available online 26 July 2021 Background: Young oncologists are at particular risk of professional burnout, and this could have a significant impact on their health and care of their patients. The coronavirus disease 2019 (COVID-19) pandemic has forced rapid changes in professionals’ jobs and training, with the consequent physical and psychological effects. We aimed to characterize burnout levels and determinants in young oncologists, and the effects of the pandemic on their training and health. Methods: Two online surveys were conducted among oncology residents and young oncology specialists in Spain. The first addressed professional burnout and its determinants before the COVID-19 pandemic, while the second analyzed the impact of the pandemic on health care organization, training, and physical and psychological health in the same population. Results: In total, 243 respondents completed the first survey, and 263 the second; 25.1% reported significant levels of professional burnout. Burnout was more common among medical oncology residents (28.2%), mainly in their second year of training. It was significantly associated with a poor workelife balance, inadequate vacation time, and the burnout score. Nearly three-quarters of respondents (72%) were reassigned to COVID-19 care and 84.3% of residents missed part of their training rotations. Overall, 17.2% of this population reported that they had contracted COVID-19, 37.3% had scores indicating anxiety, and 30.4% moderate to severe depression. Almost a quarter of young oncologists (23.3%) had doubts about their medical vocation. Conclusions: Burnout affects a considerable number of young oncologists. The COVID-19 pandemic has had a profound impact on causes of burnout, making it even more necessary to periodically monitor it to define appropriate detection and prevention strategies. Key words: professional burnout, young oncologists, residents, cancer care, COVID-19 *Correspondence to: Dr Elena Élez, Department of Medical Oncology, Vall d’Hebron University Hospital & Institute of Oncology (VHIO), Vall d’Hebron Hospital Campus, UAB, P. Vall d’Hebron 119-129, 08035, Barcelona, Cata- lunya, Spain. Tel: þ34 93 274 6085 INTRODUCTION E-mail: meelez@vhio.net (E. Élez). In recent years, the impact of the emotional well-being of 2059-7029/© 2021 The Author(s). Published by Elsevier Ltd on behalf of health professionals on the quality of patient care has European Society for Medical Oncology. This is an open access article under the become evident. Cancer care professionals in particular are CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Volume 6 - Issue 4 - 2021 https://doi.org/10.1016/j.esmoop.2021.100215 1 ESMO Open P. Jiménez-Labaig et al. well known to be at special risk of developing burnout measures to address well-being and improve resilience are syndrome, due mainly to direct contact with seriously ill essential. patients and their families and a continuously changing Since previous studies have shown that doctors in medical landscape. training and specialists in their first years of practice are The 11th revision of the International Classification of especially susceptible to burnout,13,14 we focused on the Diseases (ICD-11) defines burnout as a syndrome concep- impact of COVID-19 on the young oncologist population in tualized as resulting from chronic workplace stress that has Spain in terms of occupational, educational, and psycho- not been successfully managed. It is characterized by three logical effects, and propose a set of interventions that might dimensions: feelings of energy depletion or exhaustion; help minimize the impact of future COVID-19 waves or increased mental distance from one’s job, or feelings of similar health emergencies. negativism or cynicism related to one’s job; and reduced professional efficacy.1,2 METHODS Professional burnout is an important issue for health care systems, with potentially significant consequences on the We conducted a study to assess the prevalence of burnout quality of patient care. Studies indicate that physician among young oncologists in Spain, before and after the burnout affects quality of care, patient safety, and patient onset of the SARS-CoV-2 pandemic. Work and lifestyle fac- satisfaction.3 It also carries numerous personal costs4 with tors were also investigated in this population to evaluate a subsequent effect on organizational costs, including their potential correlation with burnout levels and to define absenteeism, increased turnover, and a decline in job per- specific interventions to reduce and prevent burnout. formance. Understanding the variety of factors that are The study was supported by the Spanish Society of responsible for professional burnout will help highlight key Medical Oncology (SEOM) þ MIR Section [represented by leverage points for prevention.5 12 oncologists, including specialists, residency mentors, and Young oncologists (oncology residents and oncology resident medical interns (or MIR, Médico Interno Resi- specialists in their first 5 years of practice) are a special risk dente)], a section devoted to analyzing and addressing the population, due to a heavy workload, academic pressure, specific concerns of young medical oncologists in Spain. and other specific factors related to cancer care.6 Low perceived health status and a desire to leave medicine or change specialty are significantly associated with burnout, Pre-COVID-19 burnout analysis according to a study conducted among hematology and A survey based on the validated Maslach Burnout medical and radiation oncology residents.7 An European InventoryeHuman Services Survey for Medical Personnel Society for Medical Oncology (ESMO) study of professional (MBI-HSS MP)2 was conducted to analyze pre-pandemic burnout in young European oncologists showed that it is burnout levels amongst young Spanish oncologists (resi- common in this population, although rates vary across re- dents and oncologists in the first 5 years of their profes- gions. It reported that achieving a good workelife balance, sional career). This online survey remained open for 7 access to support services, and adequate vacation time may months and 15 days, between 16 May and 31 December reduce burnout levels.8 2019. It was sent individually to a total of 913 young on- A more recent study showed that to reduce professional cologists. The survey consists of 22 items on work and burnout and restore job satisfaction, organizations should emotional reactions toward it. The respondent must answer achieve the following three primary goals: meet human each item by expressing how often they have experienced social and psychological needs, eliminate or mitigate that feeling. Answers range from 0 to 6, as follows: 0: never; structural and functional drivers of burnout, and strengthen 1: a few times a year or less; 2: once a month or less; 3: a individual resilience.9 Evidence suggests that investing in few times a month; 4: once a week; 5: a few times a week; reducing burnout and promoting engagement is fully justi- and 6: every day. Burnout syndrome was also classified fied and return on investment measurable.10 following the model defined by Leiter and Maslach in 2016, During the analytical phase of the study, we witnessed which classifies the syndrome into five profiles15 based on the worldwide emergence of the new severe acute respi- the results obtained in each of the three dimensions ratory syndrome coronavirus 2 (SARS-CoV-2) and the asso- of burnout: exhaustion, cynicism, and efficacy (see ciated coronavirus disease 2019 (COVID-19). This Supplementary Table S1, available at https://doi.org/10. precipitated a global health problem that was declared a 1016/j.esmoop.2021.100215). Participants were classified pandemic on 11 March 2020. By the closing of this article into five profile groups according to the reported answers: on 7 June 2021, 173 005 553 cases had been diagnosed (i) Burnout: problematic results on both emotional worldwide, with a total of 3 727 605 confirmed deaths, of exhaustion and depersonalization; (ii) Disengaged: high which 80 099 occurred in Spain.11 As a result, our health depersonalization score. The disengaged individual has systems had to be reorganized to attend the large number energy and confidence but finds it difficult to dedicate of COVID-19 patients. themselves to their work; (iii) Overextended: high A recent ESMO study has shown, for the first time, emotional exhaustion score. The individual is fulfilled and how COVID-19 is impacting the well-being and job perfor- involved, but emotionally drained; (iv) Ineffective: low mance of oncology professionals,12 indicating that urgent personal accomplishment score, characterized by 2 https://doi.org/10.1016/j.esmoop.2021.100215 Volume 6 - Issue 4 - 2021 P. Jiménez-Labaig et al. ESMO Open diminished feelings of competence and successful achieve- number of cases detected in Spain, when most of the ment in one’s work; and (v) Engaged: scores well on all country was in the advanced stages of lockdown de- three scales. escalation. The invitation and link to access the survey Twenty-three additional questions were added to explore were sent individually by e-mail to a total of 952 physi- work and lifestyle factors in terms of demographics, work- cians, including 482 residents and 470 medical oncologists place, and lifestyle (see Supplementary Material, available in their first 5 years post-residency, comprising a at https://doi.org/10.1016/j.esmoop.2021.100215). geographical and profile sample representative of the Statistical analyses, including linear regression, were whole country. carried out to test the relationships between overall burnout score and work and lifestyle factors. This statistical analysis was carried out using IBM SPSS Statistics v27 RESULTS software (Armonk, NY). A linear regression model was fitted to assess the association between overall burnout score and Burnout survey: participant demographics and lifestyle work and lifestyle factors, using the overall burnout score A total of 243 completed surveys were received, with a (total of three individual subscales) as a continuous vari- response rate of 26.6%. The sample was representative in able. Two types of association analyses, univariate and terms of age, sex, geographic region, and professional multivariate, were conducted. Variables that were signifi- profile (residents and specialists). Most participants were cantly associated with the presence of burnout in the uni- between 26 and 30 years of age. Distribution of participants variate analysis were included in the multivariate analysis. according to the year of residency was homogeneous, with All P values <0.05 were considered statistically significant. a slight predominance of fourth-year residents (31.3%). Respondents’ demographics and work and lifestyle data are COVID-19 impact analysis summarized in Table 1. An online questionnaire was designed to study the effect of Most respondents (84.4%) worked in a university hospi- the pandemic on young oncologists (see Supplementary tal. Almost two-thirds (64.2%) of them reported that their Material, available at https://doi.org/10.1016/j.esmoop. hospitals did not offer their physicians access to psycho- 2021.100215). The survey consisted of 23 questions on logical support, while 61.7% believed that they did not have employment status, COVID-19 data, health care and training a good workelife balance. activities, and three psychological questionnaires [Profes- The most effective measure to alleviate the risk of sional Quality of Life Scale-30 (ProQOL-30),16 Generalized burnout identified by respondents was to reduce the Anxiety Disorder-7 (GAD-7),17and Patient Health number of patients seen, increase the time per patient, and Questionnaire-9 (PHQ-9)18]. relieve the burden of care. Offering anti-stress sessions, The Eval&GO platform (https://www.evalandgo.com/es/) psychological help, or in-hospital support was also widely was used to design and administer the online survey. This proposed by the respondents. online survey is compliant with General Data Protection Regulation rules and the confidentiality and anonymity of the participants are guaranteed. Burnout status One-quarter of the young medical oncologist population Psychological scales was identified as having a burnout profile. The predomi- To analyze the psychological status among this same pop- nant profile was ineffective, representing 32.1% of the ulation during the pandemic, three specific validated population analyzed. The proportion of burnout profiles questionnaires were used (see COVID-19 impact survey in was higher among medical oncology residents (28.2%) the Supplementary Material, available at https://doi.org/ than among young specialists (19.8%), and higher in men 10.1016/j.esmoop.2021.100215). (29.0%) than in women (22.5%). Moreover, the highest percentage of burnout profiles was observed in second- ProQOL-30 questionnaire. This scale is used to measure the year residents (35.7%). These figures gradually decreased, positive and negative effects of helping others who expe- in parallel with an increase in the engaged profile rience suffering and trauma. ProQOL has subscales for (Figure 1). compassion satisfaction, burnout, and compassion fatigue. A multivariate correlation analysis was carried out using GAD-7 questionnaire. This is a seven-item instrument to the burnout score and demographic and lifestyle variables. measure or assess the severity of anxiety. Younger age (P ¼ 0.005), perceived lack of leisure time (P ¼ 0.043) or vacation time (P < 0.0001), and a poor PHQ-9 questionnaire. This scale helps to screen for perception of workelife balance (P < 0.0001) were vari- depression and grade severity of symptoms in general ables positively associated with burnout; these four items medical and mental health settings. were independent prognostic factors. The variables living The online survey designed to analyze the impact of alone and having children were removed for the multi- COVID-19 remained open for 26 days, between 12 June variate analysis as they were not statistically significant and 8 July 2020. This period coincided with a fall in the (see Table 2). Volume 6 - Issue 4 - 2021 https://doi.org/10.1016/j.esmoop.2021.100215 3 ESMO Open P. Jiménez-Labaig et al. and 172 (65.4%) from residents, most of whom were in Table 1. Burnout survey participant demographics their third or fourth year; 87 of the respondents (33.1%) Variable n (%) had also completed the previous burnout survey. The Gender median age of respondents was 30 years. Nearly 21.7% Male 93 (38.3) reported having risk factors for severe SARS-CoV-2 (see Female 147 (60.5) Prefer not to answer 3 (1.2) Table 3). Position Resident 131 (53.9) Specialist (first 5 years of career) 96 (39.5) COVID-19 impact survey Prefer not to answer 16 (6.6) Residents by year Physical impact. In total, 46 respondents (17.2%) reported First-year resident 12 (9.2) having been infected with SARS-CoV-2. Most of them had Second-year resident 28 (21.4) mild or asymptomatic forms of the illness and only 8.7% Third-year resident 29 (22.1) Fourth-year resident 41 (31.3) developed a moderate form of viral pneumonia, with or Fifth-year resident 21 (16.0) without hospital admission (see Figure 2A). Age range (years) 21-25 8 (3.3) Occupational and training impact. Most respondents (84%) 26-30 122 (50.2) reported changes in their daily work tasks; 71% of survey 31-35 95 (39.1) 36-40 11 (4.5) respondents participated in COVID-19 patient care in the 41-45 4 (1.6) first wave of the pandemic. >45 1 (0.4) Over 84% of residents reported some disruption of their Prefer not to answer 2 (0.8) Hospital type planned training program, with 64% reporting changes in University hospital 205 (84.4) their internal training rotations and 20.3% in their external Cancer center 10 (4.1) training residencies in hospitals in Spain or abroad. The General hospital 21 (8.6) participation of medical oncologists in the care of COVID-19 Private clinic 5 (2.1) Other 2 (0.8) patients has been high. Specifically, residents’ professional Lifestyle and work factors activity was primarily centered on hospital wards and 1. Currently in a relationship emergency departments, while remote monitoring was led Yes 183 (75.3) No 53 (21.8) by oncology specialists. Prefer not to answer 7 (2.9) 2. Has children Psychological impact. See Figure 2B for detailed informa- Yes 34 (14.0) tion regarding psychological impact. No 208 (85.6) Sixty-four participants (23.3%) reported having doubts Prefer not to answer 1 (0.4) 3. Perceived good workelife balance about their medical vocation. Almost 94% were concerned Yes 86 (35.4) at some point with becoming infected or infecting others. No 150 (61.7) Prefer not to answer 6 (2.9) Results of the ProQOL-30 questionnaire on professional 4. Lives alone quality of life. In the three subscales, the mean scores were Yes 65 (26.7) No 177 (72.8) in the range of moderate impairment of professional quality Prefer not to answer 1 (0.4) of life. 5. Perceived sufficient vacation time Yes 92 (37.9) Results of the GAD-7 questionnaire for generalized No 145 (59.7) anxiety disorder screening. A total of 37.3% of respondents Prefer not to answer 6 (2.5) 6. Hospital offers psychological support services had a mean score >10, indicating an increased risk of Yes 23 (9.9) suffering a anxiety. No 156 (64.2) Prefer not to answer 63 (25.9) Results of the PHQ-9 questionnaire for major depressive 7. Work commute (minutes) 0-15 81 (33.3) disorder screening. A total of 30.4% of respondents 15-30 98 (40.3) obtained scores within the range of moderate to severe 30-45 37 (15.2) symptoms of depression. 45-60 23 (9.9) Overall, the results showed that, during the COVID-19 60-90 2 (0.8) 90-120 1 (0.4) pandemic, one-third of the professionals tested had >120 0 (0.0) scores indicating anxiety and moderate depression levels. Young oncologists’ proposals for improvement. The main improvements noted by the survey respondents were related to providing sufficient care, recognition, and remu- COVID-19 impact survey: participant demographics and neration to young oncologists for their work during the lifestyle pandemic, and improved work distribution and organiza- A total of 263 responses were received (27.6% participation tion. The respondents also strongly demanded that resi- rate), of which 91 (34.6%) were from oncology specialists dents’ training during the pandemic be guaranteed. 4 https://doi.org/10.1016/j.esmoop.2021.100215 Volume 6 - Issue 4 - 2021 P. Jiménez-Labaig et al. ESMO Open A Disengaged 4.5% B Disengaged C Disengaged 4.6% 5.2% Overextended Overextended 11 Ineffective Burnout 14.6% Ineffective Overextended 19.1% 6 28.2% 32.1% 5 41.7% 17.3% 42 78 25 37 14 40 51 18 61 30 Engaged Engaged 33 Ineffective Engaged 21.0% Burnout 22.9% 18.8% 19 25.2% 25.1% Burnout 19.8% D 12 28 29 41 21 100% Disengaged Overextended 2 Disengaged 2 Disengaged 2 16.7% 4 14.3% 4.9% 9.5% 90% 7 Overextended Overextended 24.1% 9 Overextended 4 Overextended 80% 1 8.3% 19.0% Engaged 22.0% 6 21.4% 70% Engaged Engaged 2 5 16.7% 17.2% 60% 11 Engaged Engaged 26.8% 6 28.6% 8 Ineffective 50% 28.6% Ineffective 8 Ineffective 40% 4 27.6% 33.3% Ineffective 9 Ineffective 22.0% 4 30% 19.0% 20% Burnout 10 Burnout Burnout Burnout Burnout 10% 3 35.7% 9 31.0% 10 24.4% 5 25.0% 23.8% 0% MIR 1 MIR 2 MIR 3 MIR 4 MIR 5 Burnout Ineffective Engaged Overextended Disengaged Figure 1. Burnout rates among young Spanish oncologists. (A) Overall burnout profile types. (B) Burnout profiles among medical oncology residents. (C) Burnout profiles among young specialists. (D) Burnout profiles among residents by year of residency. Five burnout profiles are based on the three dimensions (exhaustion, cynicism, and inefficacy) of the Maslach Burnout Inventory (MBI): burnout (score high on all three dimensions), engagement (score low on three dimensions), overextended (high on exhaustion only), disengaged (high on cynicism only), and ineffective (high on inefficacy only). MIR, Médico Interno Residente. Table 2. Multivariate correlation analysis Table 3. COVID-19 impact survey participants’ demographics Variable Coefficient (95%CI) Variable n (%) P value Gender Burnout score Men 105 (39.9) Women 158 (60.1) Age 3.55 (6.02 to 1.09) P ¼ 0.005 Employment situation during the pandemic Hours of recreational activities 0.20 (0.40 to 0.01) P ¼ 0.043 First and second year 47 (17.9) Perceived lack of workelife balance 7.85 (3.89 to 11.82) P < 0.0001 Third and fourth year 83 (31.6) Perceived lack of vacation time 7.94 (4.08 to 11.81) P < 0.0001 Fifth year 42 (16.0) CI, confidence interval. Medical oncologist for 1-5 years 91 (34.6) Age, years (median) 30 Participants with risk factors for severe COVID-19 DISCUSSION No 206 (78.3) Yes 57 (21.7) For medical oncologists and many other specialties, training COVID-19, coronavirus disease 2019. is one of the most intense and challenging periods in their working life. Medical oncology is a wide-ranging and highly demanding specialty. Rapid changes as new scientific evi- dence emerges require that clinicians remain abreast of the mental and physical health of young oncologists is still latest developments, in addition to a strong daily commit- unknown, but these individuals, who are immersed in an ment and adaptability, especially when starting out on their intensive few years of training, are especially vulnerable. career. Young medical oncologists and residents have The aim of this study was to investigate the prevalence experienced an added burden caused by the COVID-19 and characteristics of burnout syndrome in young oncolo- pandemic, which has profoundly disrupted their daily life, gists, and the effect that the pandemic has had on their training, and health. The real impact of the pandemic on the health and training. Volume 6 - Issue 4 - 2021 https://doi.org/10.1016/j.esmoop.2021.100215 5 ESMO Open P. Jiménez-Labaig et al. A Infected by SARS-CoV-2 17.5% Type of infection: Asymptomatic 26.1% Type of infection: Mild 65.2% Type of infection: Moderate 8.7% No confirmation of disappearance of the virus before return to work 37.0% Changes in work tasks during the pandemic 84.0% Participation in care of COVID-19 patients 71.1% Reuse of protective material 81.7% Use of nonapproved protective material 55.1% No training in the use of protective material 49.4% Perception of extra workload during the pandemic 63.5% Changes in their external training residencies in hospitals in Spain or abroad 20.3% Changes in their internal training rotations 64.0% Doubts about medical vocation 23.3% Concern about the risk of becoming ill or infecting other 93.9% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% B Psychological impact n (%) Doubts about medical vocation (yes) 64 (23.3) Concern about the risk of becoming ill or infecting other (yes) 237 (93.9) ProQOL-30 questionnaire (subscales) n (grade) Compassion Satisfaction Scale 39.8 (moderate) Burnout Scale 27.7 (moderate) Secondary Traumatic Stress Scale 23.9 (moderate) Mean overall score 30.8 GAD-7 questionnaire n (%) Participants with an average total score ≥10 points 98 (37.3) Mean overall score 8.3 PHQ-9 questionnaire (mean) n (%) (1-4) Subclinical depression 97 (36.9) (5-9) Mild depression 86 (32.7) (10-27) Moderate to severe depression 80 (30.4 ) Figure 2. COVID-19 impact survey: main findings. (A) Physical, occupational, and training impact. (B) Psychological impact. COVID-19, coronavirus disease 2019; GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9; ProQOL-30, Professional Quality of Life Scale-30; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2. Previous studies have indicated the need to investigate vacations, a younger age, and a difficulty in achieving a the causes of burnout among young medical professionals balance between work and family life. Our data are as a growing trend.19,20 In the case of young oncologists in consistent with the results obtained from previous studies Spain, along these lines, our study showed that the overall that suggested that burnout is common amongst young prevalence of burnout profile among young oncologists and European oncologists, reaching a prevalence between 44% residents was 25.1%, reaching a peak in the second year of and 79.1%7,8 but with important variations between coun- training (35.7%). During the first year of residence, the tries across Europe. They suggested that achieving a good trainees are assigned to different training rotations in the workelife balance, access to support services, and main specialties of general medicine. In the second year, adequate vacation time may reduce burnout levels, and they usually enter the clinical oncology department. recommended raising awareness, support, and interven- Although there may be several causes for the second-year tional research. burnout peak, one possible explanation is that this transi- Organizational research has shown that institutional tion may be difficult for residents. resources are essential for optimizing the clinical practice Our study is one of the first to date to specifically environment and promoting the well-being of clinicians.6 describe the evolution of burnout profiles over time during On an individual level, emphasis has been placed on the the early years of the medical oncologist’s professional importance of identifying burnout symptoms, acquiring career. Furthermore, multiple variables were identified as resilience skills, and building positive relationships among significantly correlated with the appearance of burnout: a colleagues. Interventions, such as psychological support, perceived lack of time spent on leisure activities and lecture series, or contact with colleagues,21 are key to 6 https://doi.org/10.1016/j.esmoop.2021.100215 Volume 6 - Issue 4 - 2021 P. Jiménez-Labaig et al. ESMO Open both identifying and reducing burnout. Our findings professionals associated with neglecting chronic non- highlighted differences in burnout profiles and the need COVID-19 diseases detected after the pandemic. for adapted interventions to prevent and reduce burnout In short, this study reveals even more worrisome data on among young oncologists, reinforcing the need for in- the physical and mental health of young Spanish oncologists terventions to improve workelife balance and stress than similar studies carried out in other countries. We management. These efforts should focus on the early believe that these differences are largely due to the dra- years of training as when professional the burnout profile matic situation that Spain found itself in during the first is more prevalent. wave of the pandemic, which saw a mortality rate of 62.1/ The COVID-19 pandemic has added countless challenges 100 000 inhabitants.26 As the ESMO Resilience Task Force to this already sensitive situation. The training program of points out, one of the main predictors of well-being and job 84.3% of the residents surveyed had been disrupted, and performance in oncologists was the COVID-19 mortality rate electives in other hospitals in Spain and abroad were sus- in the reference country.12 Spain was one of the first pended. Due to demands on the organization of care and countries in the world in which the disease spread on a the provision of services, it is very unlikely that these ro- large scale, when medical knowledge was still scant, and tations will be rescheduled or even conducted at all. the infrastructures to respond to it (PPE, dedicated units, Almost three-quarters of respondents (71.1%) were specialized personnel, etc.) were virtually nonexistent. reassigned to COVID-19 care under clearly inadequate A potential limitation of our study is the selection bias of working conditions and almost a fifth were infected by an online survey, as individuals who have experienced more COVID-19, rates that are clearly higher than overall rates extreme and more negative situations are most likely to among European health professionals (8.5%)22 and those respond. The time frame in which the survey was conducted reported by other specialties.23 A recent study of a group of could also have influenced our findings. The current young oncologists in France reported that only one-third pandemic has evolved constantly, changing the health care was reassigned to COVID-19 care. Almost 70% of French landscape rapidly and without precedent, and the re- oncologists had adequate, adapted personal protective sponses obtained would probably have been different if the equipment (PPE), compared to <30% of our sample.24 data had been collected at the peak of the first wave (end of In addition to the impact on physical health, the mental March 2020). Another main limitation of the study is that it health of professionals was also analyzed. The results is not possible to compare the psychological status of this revealed that 37.3% had scores indicating anxiety, and population before and after the pandemic, as we used 30.4% moderate to severe depression. As a study limitation, different scales. We considered using the MBI-HSS MP to we should point out that these findings are only based on measure burnout levels to compare our data with previous psychological questionnaires, and a clinical interview may international studies. However, we eventually decided to be necessary to confirm a diagnosis; furthermore, we have use psychological scales during the pandemic to evaluate no data to compare with the situation before the COVID-19 issues not only related to the occupational context, as we pandemic. Overall, respondents reported a moderate already knew the baseline burnout levels in our population, deterioration in the quality of their working life. Alarmingly, which was indicative of a population at special risk for 23.4% had doubts about their medical vocation. The cu- impact by additional psychological stress. Despite this lim- mulative effect of constant overexertion and the lack of itation, we believe that our paper establishes an appro- adequate training may further aggravate the effects that the priate connection between the two studies, since it involves pandemic is having on these professionals.25 These levels the same study population: medical oncology residents and are similar to those observed in European studies, where newly trained young specialists, in two different scenarios 25% of participants indicated being at risk of distress (poor (pre- and post-pandemic) with up to 33.1% of respondents well-being), 38% reported feeling burnout, and 66% re- participating in both studies (2019 and 2020). ported not being able to perform their job compared with Based on the results obtained in these two surveys and the pre-COVID-19 period.12 the suggestions provided by the respondents of the second, Despite these figures, 64.2% of respondents said that we also propose a series of measures aimed at reducing they did not have access to psychological support in their burnout in our specialty. In terms of prevention, we workplace. It is striking in the face of such alarming data consider it essential not to exceed the established working that so few measures are in place to reduce burnout among hours so as to guarantee leisure and vacation time. In terms young professionals in this critical situation. Most survey of detection and management, we propose more exhaus- respondents noted the importance of caring for oncology tive mentoring in critical periods of residency, such as the residents, as well as recognizing and remunerating their second year, to detect and address burnout, as well as efforts during the pandemic. progressive integration into the medical oncology depart- Given the likelihood of future waves and foreseeable ment. It is also necessary to implement psychological infection outbreaks, the psychological effects of the counseling programs for doctors who need them. Regarding pandemic in this group should be monitored and prevented the current COVID-19 pandemic situation, it is essential that in the mid and long term. It is also important to highlight young oncologists do not miss training in their specialty or the future impact on the mental health of these in the safe management of infected patients. Recognition Volume 6 - Issue 4 - 2021 https://doi.org/10.1016/j.esmoop.2021.100215 7 ESMO Open P. Jiménez-Labaig et al. and remuneration of young doctors who have been in the 7. Blanchard P, Truchot D, Albiges-Sauvin L, et al. Prevalence and front line during the pandemic should also be reconsidered. causes of burnout amongst oncology residents: a comprehensive nationwide cross-sectional study. Eur J Cancer. 2010;46(15):2708- This nationwide survey highlights worrisome and previ- 2715. ously unknown data on pre-pandemic burnout profiles of 8. Banerjee S, Califano R, Corral J, et al. Professional burnout in European residents and young specialists in medical oncology, and a young oncologists: results of the European Society for Medical preliminary approach to the COVID-19 impact. According to Oncology (ESMO) Young Oncologists Committee Burnout Survey. Ann the pre-pandemic situation and the predicted long-term Oncol. 2017;28(7):1590-1596. 9. Swensen SJ, Shanafelt T. An organizational framework to reduce COVID-19 pandemic effects, burnout detection and pre- professional burnout and bring back joy in practice. Jt Comm J Qual vention strategies are highly necessary. Interventions aimed Patient Saf. 2017;43(6):308-313. at improving the workelife balance, stress management, 10. Shanafelt T, Goh J, Sinsky C. The business case for investing in physician and training of young Spanish oncologists could be effective well-being. JAMA Int Med. 2017;177(12):1826. in improving their mental and physical health and ensure 11. WHO Health Emergency Dashboard. WHO (COVID-19) Homepage. Available at https://covid19.who.int/. Accessed June 7, 2021. better health care for cancer patients in the long term. 12. Banerjee S, Lim KHJ, Murali K, et al. The impact of COVID-19 on oncology professionals: results of the ESMO Resilience Task Force ACKNOWLEDGEMENTS survey collaboration. ESMO Open. 2021;6(2):1-10. We thank SEOM for their technical and human support. The 13. Murali K, Makker V, Lynch J, Banerjee S. From burnout to resilience: an update for oncologists. Am Soc Clin Oncol Educ Book. 2018;38:862-872. analysis of the psychological impact was made possible 14. Semiglazova T, Safina S, Tsimafeyeu I, et al. Results of emotional thanks to the help of Dr. Annabel Cebrià with the psycho- burnout study among oncologists in Russia. J Clin Oncol. 2020;38: logical questionnaires. This report has been possible thanks 11011. to the collaboration of the MIR community that partici- 15. Maslach C, Jackson SE, Leiter MP. Mind Garden, Inc Manual 4th edi- pated in the survey and the Spanish Society of Medical tion. 2018. Available at www.mindgarden.coms. Accessed March 3, 2021. Oncology (SEOM), and the SEOM þ MIR section in partic- 16. ProQOL webpage. Available at https://proqol.org/ProQol_Test.html. ular. The project received technical support from Ascendo Accessed March 3, 2021. Sanidad & Farma. 17. Data sheet of GAD-7 at Cibersam. Available at https://bi.cibersam.es/ busqueda-de-instrumentos/ficha?Id¼238. Accessed March 3, 2021. 18. Data sheet of PHQ-9 at Oncology Nursing Society (ONS). Available at FUNDING https://www.ons.org/sites/default/files/PatientHealthQuestionnaire9_ This project received funding from the Spanish Society of Spanish.pdf. Accessed March 3, 2021. Medical Oncology (SEOM). 19. Hariharan TS. A review of the factors to burnout at the early-career stage of medicine. Med Teach. 2019;41(12):1380-1391. 20. Tang L, Pang Y, He Y, Chen Z, Leng J. Burnout among early-career DISCLOSURE oncology professionals and the risk factors. Psychooncology. 2018;27(10):2436-2441. The authors have declared no conflict of interest. 21. Rogers SC, Benson DM, Kraut EH, et al. Storytelling as a means of improving community and decreasing burnout in a large academic cancer center. J Clin Oncol. 2020;38:11018. REFERENCES 22. Gebbia V, Bordonaro R, Blasi L, et al. Liability of clinical oncologists and 1. Burn-out an “occupational phenomenon”: International Classification the COVID-19 emergency: between hopes and concerns. J Cancer of Diseases. WHO. Available at https://www.who.int/news/item/28- Policy. 2020;25:100234. 05-2019-burn-out-an-occupational-phenomenon-international-classifi- 23. Resident survey of the Digestive System specialty promoted by the cation-of-diseases. Accessed March 3, 2021. Spanish Society of Digestive Pathology. 2020. Available at https:// 2. Maslach C, Jackson SE, Leiter MP, Schaufeli WB, Schwab RL. Maslach sepd.es/storage/cid/Investigacion/SEPD_EncuestaResidentes_ Burnout Inventory. Vol. 21. Palo Alto, CA: Consulting Psychologists ResultadosPreliminares.pdf. Accessed March 3, 2021. Press; 1986:3463-3464. 24. Hilmi M, Boilève A, Ducousso A, et al. Professional and psychological 3. Shanafelt TD, Noseworthy JH. Executive leadership and physician well- impacts of the COVID-19 pandemic on oncology residents: a national being. Mayo Clin Proc. 2017;92(1):129-146. survey. JCO Global Oncol. 2020;6:1674-1683. 4. Physician Burnout Solutions. Available at https://www.mindgarden. 25. Mason D, Friese CR. Protecting health care workers against com/content/34-physician-burnout-solutions. Accessed March 3, 2021. COVID-19dand being prepared for future pandemics. JAMA Forum. 5. DeChant P, Shannon DW. Preventing Physician Burnout: Curing the Available at https://www.ecdc.europa.eu/en/publications-data/ Chaos and Returning Joy to the Practice of Medicine. CreateSpace infection-prevention-and-control-and-preparedness-covid-19-healthcare- Independent Publishing Platform; 2016. settings. Accessed March 3, 2021. 6. Hlubocky FJ, Back AL, Shanafelt TD. Addressing burnout in oncology: why 26. Villani L, McKee M, Cascini F, Ricciardi W, Boccia S. Comparison of cancer care clinicians are at risk, what individuals can do, and how or- deaths rates for COVID-19 across Europe during the first wave of the ganizations can respond. Am Soc Clin Oncol Educ Book. 2016;36:271-279. COVID-19 pandemic. Front Public Health. 2020;8:620416. 8 https://doi.org/10.1016/j.esmoop.2021.100215 Volume 6 - Issue 4 - 2021