Coping strategies to prevent or reduce stress and burnout among oncology physicians: a systematic review

ABSTRACT

The purpose of this systematic review (SR) was to identify interventions that are effective to prevent or reduce stress and burnout among oncologists. Search was conducted in eight electronic databases and grey literature databases, with no language or time restrictions. Included studies involved medical oncologists and contained interventions to prevent or deal with stress or burnout with outcomes assessment. In two selection phases process, 19 out of 3,020 studies were included. Risk of bias was low for nine studies, moderate for six studies and high for four ones. Certainty of evidence was considered low and very low for the analyzed outcomes. Interventions varied a lot and those which had a significant effect in stress and burnout reduction among oncologists were experience sharing between female doctors in virtual groups, integrative meetings outside the work environment, and team sessions supervised by counselors. Although interventions had variable effects on reducing or preventing burnout and stress, mores studies are needed due to outcomes low evidence.

RESUMO

O objetivo desta revisão sistemática (RS) foi identificar intervenções eficazes para prevenir ou reduzir o estresse e o burnout entre oncologistas. A busca foi realizada em oito bases de dados eletrônicas e bases de dados de literatura cinzenta, sem restrições de idioma ou tempo. Os estudos incluídos envolveram médicos oncologistas e continham intervenções para prevenir ou lidar com o estresse ou burnout com avaliação de resultados. Em duas fases de seleção, 19 dos 3.020 estudos foram incluídos. O risco de viés foi baixo para nove estudos, moderado para seis estudos e alto para quatro. A certeza da evidência foi considerada baixa e muito baixa para os desfechos analisados. As intervenções variaram muito e as que tiveram efeito significativo na redução do estresse e do burnout entre os oncologistas foram o compartilhamento de experiências entre médicas em grupos virtuais, reuniões integrativas fora do ambiente de trabalho e sessões de equipe supervisionadas por conselheiros. Embora as intervenções tenham efeitos variáveis na redução ou prevenção de burnout e estresse, mais estudos são necessários devido à baixa evidência dos resultados.

Keywords:

Oncologists - Burnout - Professional - Stress - Psychological - Systematic review - Evaluation of the efficacy-effectiveness of interventions

Descritores:

Oncologistas - Burnout - Profissional - Estresse Psicológico - Revisão sistemática - Avaliação da eficácia-efetividade das intervenções

Publication History

Received: 16 November 2021

Accepted: 13 February 2022

Article published online:
07 April 2022

• REFERENCES

• 1 Shanafelt T, Dyrbye L. Oncologist burnout: causes, consequences, and responses. J Clin Oncol 2012; Apr; 30 (11) 1235-1241
• 2 Banerjee S, Califano R, Corral J, Azambuja E, Mattos-Arruda L, Guarneri V. et al. Professional burnout in European young oncologists: results of the European Society for Medical Oncology (ESMO) Young Oncologists Committee Burnout Survey. Ann Oncol 2017; Jul; 28 (07) 1590-1596
• 3 Murali K, Banerjee S. Burnout in oncologists is a serious issue: what can we do about it?. Cancer Treat Rev 2018; 68 (10) 55-61
• 4 Maslach C, Jackson SE, Leiter MP, Schaufeli WB, Schwab RL. Maslach burnout inventory: consulting psychologists press. Palo Alto: Consulting Psychologists Press;; 1986
• 5 Tucunduva LTCM, Garcia AP, Prudente FVB, Centofanti G, Souza CM, Monteiro TA. et al. A síndrome da estafa profissional em médicos cancerologistas brasileiros. Rev Assoc Med Bras 2006; Apr; 52 (02) 108-112
• 6 Murali K, Makker V, Lynch J, Banerjee S. From burnout to resilience: an update for oncologists. Am Soc Clin Oncol Educ Book 2018; May; 38: 862-872
• 7 Shanafelt TD, Gradishar WJ, Kosty M, Satele D, Chew H, Horn L. et al. Burnout and career satisfaction among US oncologists. J Clin Oncol 2014; Mar; 32 (07) 678-686
• 8 Martins BP, Paiva CE, Paiva BSR. Evaluation of burnout, anxiety and depression in physicians of an oncology hospital. Ann Oncol 2016; (Suppl 6): 27
• 9 Cano DS, Moré CLOO. Psychological coping strategies of clinical medical oncologists. Psicol Teor Pesq 2016; 32 (03) 1-10
• 10 Asai M, Morita T, Akechi T, Sugawara Y, Fujimori M, Akizuki N. et al. Burnout and psychiatric morbility among physicians engaged in end-to-life care for cancer patients: a cross-sectional nationwide survey in Japan. Psychooncol 2007; May; 16 (05) 421-428
• 11 Medisauskaite A, Kamau C. Prevalence of oncologists in distress: systematic review and meta-analysis. Psychooncol 2017; Nov; 26 (11) 1732-1740
• 12 West CP, Dyrbye LN, Erwin PJ, Shanafelt TD. Interventions to prevent and reduce physician burnout: a systematic review and meta-analysis. Lancet 2016; Nov; 388 (10057): 2272-2281
• 13 Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M. et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015; Jan; 4 (01) 1-9
• 14 Booth AM, Clarke M, Dooley G, Ghersi D, Moher D, Petticrew D. et al. PROSPERO: an international prospective register of systematic reviews. York: University of York Centre for Reviews and Dissemination;
• 15 Moher D, Liberati A, Tetzlaff J, Altman DG. PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010; 8 (05) 336-341
• 16 Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S. et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ 2020; 368: l6890
• 17 Joanna Briggs Institute (JBI). Checklist for quasi-experimental studies (non-randomized experimental studies). The Joanna Briggs Institute critical appraisal tools for use in JBI systematic reviews. Adelaide: Joanna Briggs Institute;; 2016
• 18 Joanna Briggs Institute (JBI). Joanna Briggs Institute reviewers' manual 2014 - the systematic review of economic evaluation evidence. Adelaide: Joanna Briggs Institute;; 2014
• 19 Eldridge S, Campbell M, Campbell M, Drahota-Towns A, Giraudeau B, Higgins J. et al. Revised Cochrane risk of bias tool for randomized trials (RoB 2.0): additional considerations for cluster-randomized trials. Portsmouth: University of Portsmouth;; 2016
• 20 McGuinness LA. Risk-of-bias VISualization (robvis): a R package and web application for visualising risk-of-bias assessments. Res Synt Methods 2019; 12 (02) 55-61
• 21 Higgings JPT, Green S. Cochrane handbook for systematic reviews of interventions. Oxford: The Cochrane Collaboration;; 2011
• 22 Manheimer E. Summary of findings tables: presenting the main findings of Cochrane complementary and alternative medicine-related reviews in a transparent and simple tabular format. Glob Adv Health Med 2012; Mar; 1 (01) 90-91
• 23 Brown R, Butow P, Aldridge J, Uraskova I, Zoller P, Boyle F. et al. The impact of consultation skills training in shared decision making on doctor behavior, confidence and stress and burnout: a randomized controlled trial. Psychooncol 2014; Oct; 23: 148-149
• 24 Butow P, Cockburn J, Girgis A, Bowman D, Schofield P, D'Este C. et al. Increasing oncologists' skills in eliciting and responding to emotional cues: evaluation of a communication skills training program. Psychooncol 2008; Mar; 17 (03) 209-218
• 25 Bragard I, Libert Y, Etienne AM, Merckaert I, Delvaux N, Marchal S. et al. Insight on variables leading to burnout in cancer physicians. J Cancer Educ 2010; Mar; 25 (01) 109-115
• 26 Clemons M, Mazzarello S, Pond G, Amir E, Asmis T, Berry S. et al. A prospective intervention to improve happiness and reduce burnout in oncologists. Support Care Cancer 2019; Apr; 27 (04) 1563-1572
• 27 Dahn H, Thomson C, Bowes D, Ilie G, Rutledge R. “Resilience by design” - description of a pilot radiation oncology wellness program. Radiother Oncol 2019; 139: S47
• 28 Landaverde D, Perichon S, Flores R, Rojas R, Gurdian J, Molina JP. et al. Anti-stress strategies applied to the medical oncology team at Mexico Hospital, San Jose Costa Rica: a unique model in Central America, to reduce the risk of burnout syndrome in oncologists. Psychooncol 2018; 27 (Suppl 1): 53-98
• 29 Mache S, Vitzthum K, Hauschild I, Groneberg D. A. pilot study evaluation of psychosocial competency training for junior physicians working in oncology and hematology. Psychooncol 2017; Nov; 26 (11) 1894-1900
• 30 Bar-Sela G, Lulav-Grinwald D, Mitnik I. “Balint group” meetings for oncology residents as a tool to improve therapeutic communication skills and reduce burnout level. J Cancer Educ 2012; Aug; 27 (04) 786-789
• 31 Moody K, Kramer D, Santizo RO, Magro L, Wyshogrod D, Ambrosio J. et al. Helping the helpers: mindfulness training for burnout in pediatric oncology-a pilot program. J Pediatr Oncol Nurs 2013; Sep/Oct; 30 (05) 275-284
• 32 Barzelloni ML, Pellegrino R, Massimiliani V, Roselli M. Rosa/13 study on monitoring and prevention of work burnout the evaluation of the data after 1 year from the day of classroom training. Psychooncol 2014; 23: 175-176
• 33 Bui S, Pelosi A, Mazzaschi G, Tommasi C, Rapacchi E, Camisa R. et al. Burnout and oncology: an irreparable paradigm or a man-ageable condition? Prevention strategies to reduce burnout in oncology health care professionals. Acta Biomed 2021; 92 (03) e2021091
• 34 Italia S, Favara-Scacco C, Di Cataldo A, Russo G. Evaluation and art therapy treatment of the burnout syndrome in oncology units. Psychooncol 2008; Jul; 17 (07) 676-680
• 35 Le Blanc PM, Hox JJ, Schaufeli WB, Taris TW, Peeters MCW. Take care! The evaluation of a team-based burnout intervention program for oncology care providers. J Appl Psychol 2007; Jan; 92 (01) 213-227
• 36 Medisauskaite A, Kamau C. Reducing burnout and anxiety among doctors: randomized controlled trial. Psychiatr Res 2019; Apr; 274: 383-390
• 37 Tjasink M, Soosaipillai G. Art therapy to reduce burnout in oncology and palliative care doctors: a pilot study. Int J Art Ther. 2018;24(1)
• 38 Graff SL, Close J, Cole S, Matt-Amaral L, Beg R, Markham MJ. Impact of closed facebook group participation on female hematology/oncology physicians. J Oncol Pract 2018; Dec; 14 (12) e758-e69
• 39 Kesselheim J, Baker JN, Kersun L, Lee-Miller C, Moerdler S, Snaman JM. et al. Humanism and professionalism training for pediatric hematology-oncology fellows: results of a multicenter randomized trial. Pediatr Blood Cancer 2020; Nov; 67 (11) e28308
• 40 Pathak B, Eapen AM, Zell JA. FitFirms: a wellness option for oncology trainees. J Clin Oncol 2019; 37
• 41 Sekeres MA, Chernoff M, Lynch Junior TJ, Kasendorf EI, Lasser DH, Greenberg DB. The impact of a physician awareness group and the first year of training on hematology-oncology fellows. J Clin Oncol 2003; Oct; 21 (19) 3676-3682
• 42 Huet V, Holttum S. Art therapy-based groups for work-related stress with staff in health and social care: an exploratory study. Arts Psychother 2016; 50: 46-57
• 43 Moore PM, Mercado SR, Artigues MG, Lawrie TA. Communication skills training for healthcare professionals working with people who have cancer. Cochrane Database Syst Rev 2013; 2013 (03) CD003751
• 44 Balint M. The doctor, his patient and the illness. 1955; 268 (6866) 683-688
• 45 Clough BA, March S, Chan RJ, Casey LM, Phillips R, Ireland MJ. Psychosocial interventions for managing occupational stress and burnout among medical doctors: a systematic review. Syst Rev 2017; Jul; 6 (01) 144
• 46 Kabat-Zinn J. Mindfulness-based interventions in context: past, present, and future. Clin Psychol Sci Pract 2006; May; 10 (02) 144-156
• 47 Krasner MS, Epstein RM, Beckman H, Suchman AL, Chapman B, Mooney CJ. et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA 2009; Sep; 302 (12) 1284-1293
• 48 Petrie K, Crawford J, Baker ST, Dean K, Robinson J, Veness BG. et al. Interventions to reduce symptoms of common mental disorders and suicidal ideation in physicians: a systematic review and meta-analysis. Lancet Psychiatr 2019; Mar; 6 (03) 225-234
• 49 Rothenberger DA. Physician burnout and well-being: a systematic review and a framework for action. Dis Colon Rectum 2017; Jun; 60 (06) 567-576
• 50 Allegra CJ, Hall R, Yothers G. Prevalence of burnout in the u.s. Oncology community: results of a 2003 survey. J Oncol Pract 1: 140-147 2005;
• 51 Alorabi M, Ghali R, Boulos D. Cross-sectional study of burnout among a group of Egyptian oncologists at Ain Shams University. European Journal of Cancer 51: S219-S220 2015;
• 52 Ansmann L, Neumann MK, Jung J. et al. Resources, stressors and health of privatepractice hematologists and oncologists: Results of a German-wide survey within the WIN ON (Working Conditions in Oncology) project. Onkologie 36: 227 2013;
• 53 Armstrong J, Holland J. Surviving the stresses of clinical oncology by improving communication. ONCOLOGYWILLISTON PARK THEN HUNTINGTON THE MELVILLE NEW YORK 18: 363-372 2004;
• 54 Asai M, Morita T, Akechi T. et al. Burnout and psychiatric morbility among physicians engaged in end-to-life care for cancer patients: A cross-sectional nationwide survey in Japan. PsychoOncology 16: 421-428 2007;
• 55 Back AL, Steinhauser KE, Kamal AH. et al. Why Burnout Is So Hard to Fix. J Oncol Pract 13: 348-351 2017;
• 56 Balbay OA, Isikhan V, Balbay EG. et al. Burnout status of health care personnel working in oncology and their coping methods. HealthMed 5: 730-740 2011;
• 57 Balch C, Shanafelt TD, Sloan J. et al. Comparisons of demographics, burnout and career satisfaction of 407 surgical oncologists (so) with 7454 surgeons from other specialties: An american college of surgeons(ACS) survey. Annals of Surgical Oncology 17: S21-S22 2010;
• 58 Balch CM, Copeland E. Stress and burnout among surgical oncologists: a call for personal wellness and a supportive workplace environment. Ann Surg Oncol 14: 3029-3032 2007;
• 59 Balch CM, Freischlag JA, Shanafelt TD. Stress and Burnout Among Surgeons Understanding and Managing the Syndrome and Avoiding the Adverse Consequences. Archives of Surgery 144: 371-376 2009;
• 60 Balch CM, Shanafelt TD, Sloan J. et al. Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol 18: 16-25 2011;
• 61 Banerjee S, Califano R, Corral J. et al. Professional burnout in European young oncologists: results of the European Society for Medical Oncology (ESMO) Young Oncologists Committee Burnout Survey. Ann Oncol 28: 1590-1596 2017;
• 62 Barberio D, Abate V, Bolognini I. et al. If you are well you work well!. Annals of Oncology 26, 2015
• 63 Beas R, Díaz-Pardavé C. Categorization of Individuals With Burnout Syndrome: A Topic of Controversy. Journal of Pain and Symptom Management 52: e1 2016;
• 64 Berman R, Campbell M, Makin W. et al. Occupational stress in palliative medicine, medical oncology and clinical oncology specialist registrars. Clin Med (Lond) 7: 235-242 2007;
• 65 Bittner IV JG, Khan Z, Babu M. et al. Stress, burnout, and maladaptive coping. Bull Am Coll Surg 96: 17-22 2011;
• 66 Blanchard P, Truchot D, Albiges-Sauvin L. et al. Prevalence and causes of burnout syndrome among oncology residents in France: A comprehensive cross sectional study. European Journal of Cancer, Supplement 7: 178 2009;
• 67 Blanchard P, Truchot D, Albiges-Sauvin L. et al. Prevalence and causes of burnout amongst oncology residents: A comprehensive nationwide cross-sectional study. European Journal of Cancer 46: 2708-2715 2010;
• 68 Borate U. The Power of Professional Friendships and Sisterhood. ASCO Connection 8: 10-10 2017;
• 69 Bragard I, Dupuis G, Razavi D. et al. Quality of work life in doctors working with cancer patients. Occupational Medicine 62: 34-40 2012;
• 70 Bragard I, Etienne A-M, Libert Y. et al. Predictors and correlates of burnout in residents working with cancer patients. Journal of Cancer Education 25: 120-126 2010;
• 71 Bressi C, Manenti S, Porcellana M. et al. Haemato-oncology and burnout: An Italian survey. British Journal of Cancer 98: 1046-1052 2008;
• 72 Burki TK. Oncologists burnout in the spotlight. Lancet Oncol 19: e238 2018;
• 73 Camps C, Escobar Y, Esteban E. et al. Professional burnout among Spanish medical oncologists. Clinical & Translational Oncology 11: 86-90 2009;
• 74 Cano DS, Moré CLOO. Estratégias de enfrentamento psicológico de médicos oncologistas clínicos. [Psychological coping strategies of clinical medical oncologists.]. Psicologia: Teoria e Pesquisa 32: 1-10 2016;
• 75 Caruso A, Vigna C, Bigazzi V. et al. Burnout among physicians and nurses working in oncology. Med Lav 103: 96-105 2012;
• 76 Carvalho CMSd, Barata EMMA, Parreira PMSD. et al. Trabalho emocional e gestão de emoções em equipes de saúde oncológicas: um estudo qualitativo. Rev. enferm. UERJ 22: 9-15 2014;
• 77 Catt S, Fallowfield L, Jenkins V. et al. The informational roles and psychological health of members of 10 oncology multidisciplinary teams in the UK. Br J Cancer 93: 1092-1097 2005;
• 78 Chatwal MS, McDowell M, Vinci C. et al. A feasibility study to examine the role of a mindfulness-based wellness curriculum for early clinical trainees. Journal of Clinical Oncology 36, 2018
• 79 Ciammella P, Fiorentino A, De Bari B. et al. The “buongiorno” project - An italian survey on the incidence of burnout among young italian radiation oncologists. European Journal of Cancer 47: S209 2011;
• 80 Cotton K. Resilience While Caring for Seriously Ill Patients: Skills and Strategies to Prevent Burnout. ASCO Connection 10: 38-41 2018;
• 81 Creagan ET. Stress among medical oncologists: The phenomenon of burnout and a call to action. Mayo Clinic Proceedings 68: 614-615 1993;
• 82 Crowe C. Self-care and burnout in oncology professionals. Crowe, Christina: Faculty of Behavioral Sciences, Yorkville University; Yorkville Landing Suite 102, 100 Woodside Lane, Fredericton, NB, Canada, E3C 2R9, [e-mail] Hauppauge, NY, US, Nova Biomedical Books 2016
• 83 Cubero D, Fumis RRL, Cruz FM. et al. Burnout inmedical oncology fellows is high even before the program starts. Supportive Care in Cancer 21: S231 2013;
• 84 Cumbe VFJ, Pala AN, Palha AJP. et al. Burnout syndrome and coping strategies in Portuguese oncology health care providers. Rev. psiquiatr. clín. (São Paulo) 44: 122-126 2017;
• 85 Dahn H, McGibbon A, Bowes D. Burnout and Resiliency in Canadian Oncology Residents: A Nationwide Resident and Program Director Survey. Pract Radiat Oncol 9: e118-e125 2019;
• 86 Daruvala R, Ghosh M, Fratazzi F. et al. Emotional exhaustion in cancer clinicians: A mixed methods exploration. Indian Journal of Medical and Paediatric Oncology 40: 111-120 2019;
• 87 De Rezende SN, Santiag SM, Da Grac-a Garcia Andrade M. To think, to feel, to talk and to realize: A construction of a psychoanalytical work developed with health professionals dealing with cancer patients. Psycho-Oncology 20: 195-196 2011;
• 88 Dix D, Gulati S, Robinson P. et al. Demands and rewards associated with working in pediatric oncology: a qualitative study of Canadian health care providers. J Pediatr Hematol Oncol 34: 430-435 2012;
• 89 Dougherty E, Pierce B, Ma C. et al. Factors associated with work stress and professional satisfaction in oncology staff. American Journal of Hospice and Palliative Medicine 26: 105-111 2009;
• 90 Dubois C-A, Da Silva RB, Lavoie-Tremblay M. et al. Developing and maintaining the resilience of interdisciplinary cancer care teams: an interventional study. BMC Health Services Research 20: 1-10 2020;
• 91 Eelen S, Bauwens S, Baillon C. et al. The prevalence of burnout among oncology professionals: oncologists are at risk of developing burnout. Psychooncology 23: 1415-1422 2014;
• 92 Essaadi Z, Belbaraka R, Aloulou S. et al. Burnout in health caregivers: Experience of a Moroccan anti cancer center. European Journal of Cancer 49: S389-S390 2013;
• 93 Fang CK, Yang YC, Chen HW. et al. Burnout, demoralization, and spiritual well-being of physicians who had cared cancer patients. Psycho-Oncology 19: S113 2010;
• 94 Fiore F, Gargiulo L, Cardone C. et al. Evaluation of burnout syndrome and personalized intervention in the medical oncology unit of the Second University of Naples (SUN). Annals of Oncology 27, 2016
• 95 Fitzgerald CA, Le LH, Petrik DW. et al. Burnout prevalence in medical and radiation oncologists at British Columbia Cancer Agency (BCCA). Journal of Clinical Oncology 30, 2012
• 96 Flores M D, Vega C V, Del Río G C. et al. Ocuparse del bienestar de los profesionales de la salud: un desafío pendiente. Rev. chil. ter. ocup 14: 33-44 2014;
• 97 Ftanou M. Self-Care: “Provider, heal thyself”. Journal of Thoracic Oncology 12: S1716-S1717 2017;
• 98 Fujimori M, Uchitomi Y. Effect of communication skills training program for oncologists on their burnout and psychiatric disorder. Psycho-Oncology 24: 281 2015;
• 99 Fusco V, Grosso E, Como Costagliola M. et al. Burnout risk in cancer care staff: Is Laughter Yoga a possible tool for prevention?. Tumori 105: 170-171 2019;
• 100 Giansante M, Ballarini V. Perceived stress and coping strategies in medical and nursing staff in a department of clinical hematology: Pilot study. Giornale Italiano di Medicina del Lavoro ed Ergonomia 34: B23-B28 2012;
• 101 Girgis A, Cockburn J, Butow P. et al. Improving patient emotional functioning and psychological morbidity: evaluation of a consultation skills training program for oncologists. Patient Educ Couns 77: 456-462 2009;
• 102 Glasberg J, Horiuti L, Novais MAB. et al. Prevalence of the burnout syndrome among Brazilian medical oncologists. Rev. Assoc. Med. Bras. (1992) 53: 85-89 2007;
• 103 Granek L, Ariad S, Shapira S. et al. Barriers and facilitators in coping with patient death in clinical oncology. Supportive Care in Cancer 24: 4219-4227 2016;
• 104 Granek L, Barbera L, Nakash O. et al. Experiences of Canadian oncologists with difficult patient deaths and coping strategies used. Current Oncology 24: e277-e284 2017;
• 105 Granek L, Barrera M, Scheinemann K. et al. Pediatric oncologists' coping strategies for dealing with patient death. Journal of Psychosocial Oncology 34: 39-59 2016;
• 106 Granek L, Bartels U, Scheinemann K. et al. Grief reactions and impact of patient death on pediatric oncologists. Pediatr Blood Cancer 62: 134-142 2015;
• 107 Granek L, Ben-David M, Nakash O. et al. Oncologists' negative attitudes towards expressing emotion over patient death and burnout. Supportive Care in Cancer 25: 1607-1614 2017;
• 108 Granek L, Krzyzanowska MK, Nakash O. et al. Gender differences in the effect of grief reactions and burnout on emotional distress among clinical oncologists. Cancer 122: 3705-3714 2016;
• 109 Granek L, Krzyzanowska MK, Tozer R. et al. Oncologists' strategies and barriers to effective communication about the end of life. Journal of Oncology Practice 9: e129-e135 2013;
• 110 Grant L. Developing a clinical supervision service for oncologists. Psycho-Oncology 27: 28 2018;
• 111 Grootenhuis MA, Van Der Wel M, De Graaf-Nijkerk J. et al. Exploration of a selfprotective strategy in pediatric oncology staff. Medical and Pediatric Oncology 27: 40-47 1996;
• 112 Gross SE, Ernstmann N, Jung J. et al. Can a stressed oncologist be good in a consultation? A qualitative study on the oncologists' perception. Eur J Cancer Care (Engl) 23: 594-606 2014;
• 113 Grunfeld E, Whelan TJ, Zitzelsberger L. et al. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. Cmaj 163: 166-169 2000;
• 114 Guadagna F, Civilleri A, Lo Cascio V. et al. Well-being of physicians who work in oncology unit and in BMT unit: Analysis of protective factors from work stress. Bone Marrow Transplantation 47: S389 2012;
• 115 Guest RS, Baser R, Li Y. et al. Cancer surgeons' distress and well-being, I: the tension between a culture of productivity and the need for self-care. Ann Surg Oncol 18: 1229-1235 2011;
• 116 Guest RS, Baser R, Li Y. et al. Cancer surgeons' distress and well-being, II: modifiable factors and the potential for organizational interventions. Ann Surg Oncol 18: 1236-1242 2011;
• 117 Guveli H, Anuk D, Oflaz S. et al. Oncology staff: Burnout, job satisfaction and coping with stress. Psycho-Oncology 24: 926-931 2015;
• 118 Haley GR. The relationship between burnout and organizational commitment in academic oncologists. US, ProQuest Information & Learning 2004; 3730-3730
• 119 Hamilton J. Implementation of fellows support program. Psycho-Oncology 28: 23 2019;
• 120 Hegedus PD, Bearden JD, Grant B. Capturing and addressing emotional well-being: Utilization of ASCO's Quality Oncology Practice Initiative (QOPI) for performance improvement. Journal of Clinical Oncology 30, 2012
• 121 Henrik S, Mónika FM, András H. et al. Two-level tumor board operation-based social intelligence that serves the quality of cancer treatment and the prevention of burnout phenomenon. Orvosi Hetilap 162: 344-351 2021;
• 122 Hipp M, Pilz L, Al-Batran SE. et al. Workload and Quality of Life of Medical Doctors in the Field of Oncology in Germany - a Survey of the Working Group Quality of Life of the AIO for the Study Group of Internal Oncology. Oncology Research and Treatment 38: 154-159 2015;
• 123 Hlubocky FJ, Back AL, Shanafelt TD. et al. Occupational and Personal Consequences of the COVID-19 Pandemic on US Oncologist Burnout and Well-Being: A Study From the ASCO Clinician Well-Being Task Force. JCO Oncol Pract 17: e427-e438
• 124 Hlubocky FJ, Rose M, Epstein RM. Mastering Resilience in Oncology: Learn to Thrive in the Face of Burnout. Am Soc Clin Oncol Educ Book 37: 771-781 2017;
• 125 Hlubocky FJ, Shanafelt TD, Back AL. et al. Creating a Blueprint of Well-Being in Oncology: An Approach for Addressing Burnout From ASCO's Clinician Well-Being Taskforce. Am Soc Clin Oncol Educ Book 41: e339-e353
• 126 Holliday EB, Bonner JA, Formenti SC. et al. Emotional Intelligence and Burnout in Academic Radiation Oncology Chairs. Journal of Healthcare Management 62: 302-313 2017;
• 127 Hudson MF, O'Rourke MA, Blackhurst DW. et al. Clinical work intensity among medical oncologists. Journal of Clinical Oncology 36, 2018
• 128 Hunter R. Creating a culture shift: The implementation of a resilience skills program in oncology providers. PsychoOncology 28: 23 2019;
• 129 Huynh RA, Nguyen VS, Assanasen C. An evaluation of psychosocial needs among healthcare providers in vietnam. Pediatric Blood and Cancer 66: S186 2019;
• 130 Isc-En P, Bahadir G. Examination of conflict tendencies and ways of coping with stress of oncologists. PsychoOncology 20: 111-112 2011;
• 131 Jackson VA, Mack J, Matsuyama R. et al. A qualitative study of oncologists' approaches to end-of-life care. J Palliat Med 11: 893-906 2008;
• 132 Jasperse M, Dungey G. Investigating stress, burnout and job satisfaction within the New Zealand oncology care context. Asia-Pacific Journal of Clinical Oncology 8: 173-174 2012;
• 133 Jasperse M, Herst P, Dungey G. Evaluating stress, burnout and job satisfaction in New Zealand radiation oncology departments. Eur J Cancer Care (Engl) 23: 82-88 2014;
• 134 Joaquim A, Custódio S, Savva-Bordalo J. et al. Burnout and occupational stress in the medical residents of Oncology, Haematology and Radiotherapy: A prevalence and predictors study in Portugal. Psychology, Health and Medicine 23: 317-324 2018;
• 135 Jørgensen LH, Jacobsen CH. Gruppesupervision af læger på onkologisk afdeling. [Group supervision of oncologists.]. Psyke & Logos 30: 672-694 2009;
• 136 Joubert L, Hocking A, Hampson R. Social work in oncology-Managing vicarious trauma-The positive impact of professional supervision. Social Work in Health Care 52: 296-310 2013;
• 137 Jutagir D, Knies A, Ercolano E. et al. Screening for psychosocial distress program. Psycho-Oncology 26: 65 2017;
• 138 Karnyski J, Harris K. How Does the Doctor Feel?. Journal of Bronchology and Interventional Pulmonology 24: e37-e39 2017;
• 139 Kash KM, Holland JC, Breitbart W. et al. Stress and burnout in oncology. Oncology (Williston Park) 14: 1621-1633 discussion 1633-4, 1636-7 2000;
• 140 Kattlove H, Figlin RA, Belldegrun A. et al. Why oncologists burnout [1]. Journal of Clinical Oncology 10: 1503 1992;
• 141 Kavalieratos D, Siconolfi DE, Steinhauser KE. et al. “It Is Like Heart Failure. It Is Chronic … and It Will Kill You”: A Qualitative Analysis of Burnout Among Hospice and Palliative Care Clinicians. Journal of Pain and Symptom Management 53: 901-910.e1 2017;
• 142 Kaymak SU, Cankurtaran ES, Ozalp E. et al. Psychosocial consequences of working with dying patients. PsychoOncology 19: S120-S121 2010;
• 143 Kearney MK, Weininger RB, Vachon MLS. et al. Self-care of physicians caring for patients at the end of life “being connected…A key to my survival”. JAMA - Journal of the American Medical Association 301: 1155-1164 2009;
• 144 Kiguchi H, Singh S, Gulati N. et al. Building resilience during pediatric hematology/oncology fellowship: Implementing systematic debriefing sessions and resiliency curriculum to support trainees. Pediatric Blood and Cancer 65: S184-S185 2018;
• 145 Kinderman A, Gross D. Preparing for the marathon: Piloting a self-care and resilience workshop for oncology fellows. Journal of Pain and Symptom Management 47: 402 2014;
• 146 Kleiner S, Wallace JE. Oncologist burnout and compassion fatigue: investigating time pressure at work as a predictor and the mediating role of work-family conflict. BMC Health Serv Res 17: 639 2017;
• 147 Knight K, Schneider M, Wright C. et al. Occupational burnout among medical radiations professionals-a nation-wide multidisciplinary on-line survey of seven professions. Journal of Medical Imaging and Radiation Oncology 58: 144 2014;
• 148 Koh MYH, Chong PH, Neo PSH. et al. Burnout, psychological morbidity and use of coping mechanisms among palliative care practitioners: A multi-centre cross-sectional study. Palliative medicine 29: 633-642 2015;
• 149 Koo K, Zeng L, Zhang L. et al. Comparison and Literature Review of Occupational Stress in a Palliative Radiotherapy Clinic's Interprofessional Team, the Radiation Therapists, and the Nurses at an Academic Cancer Centre. J Med Imaging Radiat Sci 44: 14-22 2013;
• 150 Koocher GP. Adjustment and coping strategies among the caretakers of cancer patients. Social Work in Health Care 5: 145-150 1980;
• 151 Korones DN. Living in the moment. Journal of clinical oncology : official journal of the American Society of Clinical Oncology 28: 4778-4779 2010;
• 152 Kracen AC. Mindfulness, health, well-being, and patient care of oncologists. US, ProQuest Information & Learning 2011; 5833-5833
• 153 Kuerer HM, Eberlein TJ, Pollock RE. et al. Career satisfaction, practice patterns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 14: 3043-3053 2007;
• 154 Laurent J, Bragard I, Coucke P. et al. [Working conditions, stress and burnout of Belgian professionals in radiotherapy: Comparative analysis and emotional labor exploration]. Cancer Radiother 19: 161-167 2015;
• 155 Leones LMB, Berba CMP, Chua Jr. AV. et al. Caring for the carers: Safeguarding oncologists' mental health in the time of COVID-19. ecancermedicalscience 14, 2020
• 156 Liakopoulou M, Panaretaki I, Papadakis V. et al. Burnout, staff support, and coping in Pediatric Oncology. Supportive Care in Cancer 16: 143-150 2008;
• 157 Lievrouw A, Vanheule S, Deveugele M. et al. Coping With Moral Distress in Oncology Practice: Nurse and Physician Strategies. Oncology Nursing Forum 43: 505-512 2016;
• 158 López-Castillo J, Gurpegui M, Ayuso-Mateos JL. et al. Emotional distress and occupational burnout in health care professionals serving HIV-infected patients: A comparison with oncology and internal medicine services. Psychotherapy and Psychosomatics 68: 348-356 1999;
• 159 Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. The Lancet Oncology 2: 750-755 2001;
• 160 Lyckholm L: Avoiding stress and burnout in cancer care. Words of wisdom from fellow oncologists. Oncology (Williston Park) 21: 269 2007;
• 161 Mahendran R, Tan JYS, Lim HA. et al. Improving the quality of life and care of medical oncology patients: A quality improvement project. Annals of the Academy of Medicine Singapore 43: S46-S47 2014;
• 162 Mampuya AW, Matsuo Y, Nakamura A. et al. Evaluation of the prevalence of burnout and psychological morbidity among Japanese radiation oncologists practicing in Kyoto university hospital and affiliated institutions. International Journal of Radiation Oncology 96: E404 2016;
• 163 Mampuya WA, Matsuo Y, Nakamura A. et al. Evaluation of the prevalence of burnout and psychological morbidity among radiation oncologist members of the Kyoto Radiation Oncology Study Group (KROSG). J Radiat Res 58: 217224 2017;
• 164 Manochakian R. My first year as an oncologist. Journal of Palliative Medicine 17: 636-637 2014;
• 165 Martins BP, Paiva CE, Paiva BSR. Evaluation of burnout, anxiety and depression in physicians of an oncology hospital. Annals of Oncology 27, 2016
• 166 McFarland DC, Roth A. Resilience of internal medicine house staff and its association with distress and empathy in an oncology setting. Psycho-Oncology 26: 1519-1525 2017;
• 167 McLean M, Cleland JA, Worrell M. et al. “What am I going to say here?” The experiences of doctors and nurses communicating with patients in a cancer unit. Frontiers in Psychology 2, 2011
• 168 Mehlis K, Bierwirth E, Laryionava K. et al. High prevalence of moral distress reported by oncologists and oncology nurses in end-of-life decision making. Psycho-Oncology 27: 2733-2739 2018;
• 169 Mougalian SS, Lessen DS, Levine RL. et al. Palliative care training and associations with burnout in oncology fellows. J Support Oncol 11: 95-102 2013;
• 170 Mount BM. Dealing with our losses. J Clin Oncol 4: 1127-1134 1986;
• 171 Mukherjee S, Beresford B, Tennant A. Staff burnout in paediatric oncology: New tools to facilitate the development and evaluation of effective interventions. European Journal of Cancer Care 23: 450-461 2014;
• 172 Murali K, Banerjee S. Let's address burnout in oncologists and reimagine the way we work. Nature Reviews Clinical Oncology 16, 2019
• 173 Muriel AC, Hwang VS, Kornblith A. et al. Management of psychosocial distress by oncologists. Psychiatric Services 60: 1132-1134 2009;
• 174 Na KS. Interventions to reduce symptoms of common mental disorders and suicidal ideation in physicians. The Lancet Psychiatry 6: 369 2019;
• 175 Nabhan C. “How could you do this, doctor. . . ?”. American Journal of Hospice and Palliative Medicine 26: 239-240 2009;
• 176 Nissim R, Malfitano C, Coleman M. et al. A Qualitative Study of a Compassion, Presence, and Resilience Training for Oncology Interprofessional Teams. Journal of Holistic Nursing 37: 30-44 2019;
• 177 Nowakowski J, Borowiec G, Zwierz I. et al. “Stress in an oncologist's life: Present but not insurmountable: (Students should not be discouraged choosing oncology as their future specialisation)”: Erratum. Journal of Cancer Education 31: 183-183 2016;
• 178 O'Byrne KK, Peterson L, Saldana L. Survey of Pediatric Hospitals' Preparation Programs: Evidence of the Impact of Health Psychology Research. Health Psychology 16: 147-154 1997;
• 179 Paiva CE, Martins BP, Paiva BSR. Doctor, are you healthy? A cross-sectional investigation of oncologist burnout, depression, and anxiety and an investigation of their associated factors 11 Medical and Health Sciences 1117 Public Health and Health Services 17 Psychology and Cognitive Sciences 1701 Psychology. BMC Cancer 18, 2018
• 180 Paula Vega V, Rina González R, José Bustos M. et al. Relationship between grief support and burnout syndrome in professionals and technicians of pediatric health. Revista Chilena de Pediatria 88: 614-621 2017;
• 181 Penson RT, Dignan FL, Canellos GP. et al. Burnout: Caring for the caregivers. Oncologist 5: 425-434 2000;
• 182 Penson RT, Partridge RA, Rudd P. et al. Laughter: The best medicine?. Oncologist 10: 651-660 2005;
• 183 Poulsen M, Poulsen AA. Optimising motivation and reducing burnout for radiation oncology trainees: A framework using self-determination theory. Pigment Cell and Melanoma Research 31: 684-691 2018;
• 184 Poulsen MG, Poulsen AA, Khan A. et al. Work engagement in cancer workers in Queensland: The flip side of burnout. Journal of Medical Imaging and Radiation Oncology 55: 425-432 2011;
• 185 Poulsen MG, Poulsen AA, Khan A. et al. Factors associated with subjective wellbeing in cancer workers in Queensland. Journal of Medical Imaging and Radiation Oncology 56: 347-353 2012;
• 186 Pye K. Exploring moral distress in pediatric oncology; A sample of registered practitioners. Comprehensive Child and Adolescent Nursing 36: 248-261 2013;
• 187 Ramey SJ, Ahmed AA, Takita C. et al. Burnout Evaluation of Radiation Residents Nationwide: Results of a Survey of United States Residents. International Journal of Radiation Oncology Biology Physics 99: 530-538 2017;
• 188 Ramirez AJ, Graham J, Richards MA. et al. Burnout and Psychiatric-Disorder among Cancer Clinician. British Journal of Cancer 71: 1263-1269 1995;
• 189 Raphael MJ, Fundytus A, Hopman WM. et al. Medical oncology job satisfaction: Results of a global survey. Semin Oncol 46: 73-82 2019;
• 190 Rath K, Huffman L, Carpenter K. et al. Burnout is associated with decreased career satisfaction and psychosocial distress amongmembers of the Society of Gynecologic Oncology (SGO). Gynecologic Oncology 133: 44 2014;
• 191 Rath KS, Huffman LB, Phillips GS. et al. Burnout and associated factors among members of the Society of Gynecologic Oncology Presented at the 45th Annual Meeting on Women's Cancer, Society of Gynecology Oncology, Tampa, FL, March 22-25, 2014. American Journal of Obstetrics and Gynecology 213: 824.e1-824.e9 2015;
• 192 Ratti MM, Di Mattei V, Del Po F. et al. Psychological issues in oncology care: A multicentric study on burnout claudia yvonne finocchiaro. Psycho-Oncology 18: S231-S232 2009;
• 193 Rohan E, Bausch J. Climbing Everest: Oncology work as an expedition in caring. Journal of Psychosocial Oncology 27: 84-118 2009;
• 194 Romeo M, Belbusti V, Giampieri R. et al. Is burnout the real problem of the operators in oncology field? Exploratory analysis of data from a single institution in italy. Psycho-Oncology 25: 121 2016;
• 195 Romeo M, Giampieri R, Meletani T. et al. Psychological discomfort among operatives in oncology: Can burn-out be considered the main issue?. Annals of Oncology 27, 2016
• 196 Rosenstein D. “this feels like internship all over again-: A monthly support group for first year hematology/oncology fellows. Psycho-Oncology 28: 22-23 2019;
• 197 Roth M, Morrone K, Moody K. et al. Career burnout among pediatric oncologists. Pediatr Blood Cancer 57: 1168-1173 2011;
• 198 Royce TJ, Davenport KT, Dahle JM. A Burnout Reduction and Wellness Strategy: Personal Financial Health for the Medical Trainee and Early Career Radiation Oncologist. Pract Radiat Oncol, 2019
• 199 Russo A, De Luca R, Cicero G. et al. Well-being among Italian medical oncologists: an exploratory study. Oncology 86: 72-78 2014;
• 200 Sargsyan M, Gevorgyan D, Sargsyan A. Role of the personal peculiarities in the development of the emotional burnout syndrome among oncologists. Psycho-Oncology 26: 149 2017;
• 201 Sarra A, Feuz C. Examining the Prevalence of Compassion Fatigue and Burnout in Radiation Therapists Caring for Palliative Cancer Patients...RTi3 2019, University Of Toronto, Department of Radiation Oncology, May 31- June 1, 2019, Ontario, Canada. Journal of Medical Imaging & Radiation Sciences 50: S15-S15 2019;
• 202 Schirmers C. The plight of oncologists: Burnout and biotechnology. Ann Arbor: Boston University; 2016: 67
• 203 Schraub S, Marx E. Burn out syndrom in oncology. Bulletin Du Cancer 91: 673-676 2004;
• 204 Shanafelt T, Chung H, White H. et al. Shaping your career to maximize personal satisfaction in the practice of oncology. J Clin Oncol 24: 4020-4026 2006;
• 205 Shanafelt TD. Finding meaning, balance, and personal satisfaction in the practice of oncology. Journal of Supportive Oncology 3: 157-164 2005;
• 206 Shanafelt TD, Gradishar WJ, Kosty M. et al. Burnout and career satisfaction among US oncologists. J Clin Oncol 32: 678-686 2014;
• 207 Shanafelt TD, Kaups KL, Nelson H. et al. An interactive individualized intervention to promote behavioral change to increase personal well-being in US surgeons. Annals of surgery 259: 82 2014;
• 208 Shanafelt TD, Novotny P, Johnson ME. et al. The well-being and personal wellness promotion strategies of medical oncologists in the North Central Cancer Treatment Group. Oncology 68: 23-32 2005;
• 209 Shanafelt TD, Raymond M, Horn L. et al. Oncology fellows' career plans, expectations, and well-being: do fellows know what they are getting into?. J Clin Oncol 32: 2991-2997 2014;
• 210 Shanafelt TD, Raymond M, Kosty M. et al. Satisfaction with work-life balance and the career and retirement plans of US oncologists. Journal of Clinical Oncology 32: 1127-1135 2014;
• 211 Shayne M, Quill TE. Oncologists responding to grief. Archives of Internal Medicine 172: 966-967 2012;
• 212 Shereck E, Recht M, Steckler N. Intervention to prevent burnout in pediatric hematology/oncology fellows. Pediatric Blood and Cancer 61: S88 2014;
• 213 Sheth N, Osborn VW, Lee A. et al. Burnout in Radiation Oncology: A Pilot Residency Wellness Program. International Journal of Radiation Oncology Biology Physics 105: E156 2019;
• 214 Shimp W: Reluctant reflections. An oncologist's take on how physician and patient burnout might be prevented. Minnesota medicine 97: 32-34 2014;
• 215 Shinan-Altman S, Cohen M, Rasmussen V. et al. Burnout among psychosocial oncologists in Israel: The direct and indirect effects of job demands and job resources. Palliat Support Care 16: 677-684 2018;
• 216 Sundquist KJ, Pearce K, Blair T. Building resilience in challenging times. Asia-Pacific Journal of Clinical Oncology 5: A257-A258 2009;
• 217 Swetz KM, Harrington SE, Matsuyama RK. et al. Strategies for Avoiding Burnout in Hospice and Palliative Medicine: Peer Advice for Physicians on Achieving Longevity and Fulfillment. Journal of Palliative Medicine 12: 773-777 2009;
• 218 Tamura N, Park S, Sato Y. et al. Study protocol for evaluating the efficacy of Mindfulness for Health Professionals Building Resilience and Compassion program: a randomized, waiting-list controlled trial. Journal of Psychosocial Oncology Research and Practice 2: e22 2020;
• 219 Thompson M, Lightowlers S, Hunt S. Supporting trainee oncologists with the emotional demands of caring for cancer patients. European Journal of Surgical Oncology 44: S26 2018;
• 220 Torres B, Guarino L. Individual differences and burnout in venezuelan oncologists. Universitas Psychologica 12: 95-104 2013;
• 221 Tucunduva LTCdM, Garcia AP, Prudente FVB. et al. A síndrome da estafa profissional em médicos cancerologistas brasileiros. Rev. Assoc. Med. Bras. (1992) 52: 108-112 2006;
• 222 Turner TB, Kushner DM, Winkel AF. et al. The Society of Gynecologic Oncology wellness curriculum pilot: A groundbreaking initiative for fellowship training. Gynecol Oncol 156: 710-714
• 223 Vachon M, Fillion L, Goyette C. Improving palliative care through staff support: A collaborative research project. Psycho-Oncology 25: 110 2016;
• 224 Vasylyeva A. Psychopharmacotherapy of emotional burnout and depression among oncology staff. European Neuropsychopharmacology 21: S450-S451 2011;
• 225 Vetter MH, Vetter MK, Fowler J. Resilience, hope and flourishing are inversely associated with burnout among members of the Society for Gynecologic Oncology. Gynecol Oncol Rep 25: 52-55 2018;
• 226 Vici P, Krasniqi E, Pizzuti L. et al. Burnout of health care providers during the covid-19 pandemic: Focus on medical oncologists. International Journal of Medical Sciences 18: 2235-2238 2021;
• 227 Wan L. Caring for the carers. The Lancet Oncology 9: 212-213 2008;