Seminars in Oncology 46 (2019) 73–82 Contents lists available at ScienceDirect Seminars in Oncology journal homepage: www.elsevier.com/locate/seminoncol Medical oncology job satisfaction: Results of a global survey Michael J. Raphaela , b, Adam Fundytusa, Wilma M. Hopmanc , d, Verna Vanderpuyee, Bostjan Seruga f, Gilberto Lopesg, Nazik Hammadb, Manju Sengarh, Michael D. Brundagea , b , d , Richard Sullivan i , Christopher M. Bootha , b , d , ∗ a Division of Cancer Care and Epidemiology, Queen’s University Cancer Research Institute, Kingston, Canada b Department of Oncology, Queen’s University, Kingston, Canada c Kingston General Hospital Research Institute, Kingston, Canada d Department of Public Health Sciences, Queen’s University, Kingston, Canada e Korle Bu Teaching Hospital, Accra, Ghana f Division of Medical Oncology, Institute of Oncology Ljubljana, Ljubljana, Slovenia g University of Miami and Sylvester Comprehensive Cancer Center, Miami, United States h Department of Medical Oncology, Tata Memorial Centre, Mumbai, India i Institute of Cancer Policy, King’s College London, & King’s Health Partners Comprehensive Cancer Centre, London, United Kingdom a r t i c l e i n f o a b s t r a c t Article history: Background: While physician burnout is increasingly recognized, little is known about medical oncolo- Received 4 December 2018 gist job satisfaction, and the factors associated with low satisfaction. Here, we report the results of an Accepted 15 December 2018 international survey of medical oncologists. Methods: An online survey was distributed using a modified snowball methodology via national oncology Keywords: societies to chemotherapy-prescribing physicians in 65 countries. Oncologist job satisfaction was assessed Physician wellness by asking, “On a scale of 1-10, how would you rate your satisfaction as an oncologist? 1 = unsatisfying, Physician burnout 10 = satisfying.” Low, moderate and high job satisfaction was defined as scores of 1-6, 7-8, and 9-10, Oncology job-satisfaction respectively. Global oncology Results: 1,115 physicians from 42 countries completed the survey. Overall job satisfaction rates were 20% (222/1,115), 51% (573/1,115), and 29% (320/1,115) for low-, moderate-, and high-satisfaction, respectively. Respondents with low job satisfaction were younger ( P = 0.001) and had fewer years in clinical practice ( P = 0.013) compared to those with high satisfaction. Increasing hours worked by per week (p = 0.042), decreasing annual weeks of paid vacation ( P = 0.007), being on-call every night ( P = 0.016), higher clinic volumes ( P = 0.004) and lack of access to on-site radiotherapy ( P = 0.049), palliative care ( P = 0.005), and chemotherapy pharmacists ( P = 0.033) were associated with low-job satisfaction. Respondents with low- job satisfaction were less likely to discuss prognosis with their patients compared to those with moderate or high job satisfaction (median 45% of patients v 65% v 75%, P < 0.001). Conclusions: Globally, 1 in 5 medical oncologists report low job satisfaction. The main correlates of job satisfaction are related to system-level pressures resulting in less time for quality patient care and per- sonal resilience. Improving oncologist job satisfaction will require new approaches to models of care de- livery. © 2018 Published by Elsevier Inc. I i a [ i r c p v T h 0 ntroduction While the practice of medical oncology can be very reward- ng, oncologists face many challenges in the delivery of cancer are. Rising clinical volumes, the emotional toll of the disease,i r ∗ Corresponding author. Division of Cancer Care and Epidemiology, Queen’s Uni- ersity Cancer Research Institute, 10 Stuart Street, Kingston, ON, K7L 3N6, Canada. p el.: (613) 533-6895; fax: (613) 533-6794. E-mail address: c booth@queensu.ca (C.M. Booth). ttps://doi.org/10.1053/j.seminoncol.2018.12.006 093-7754/© 2018 Published by Elsevier Inc. ncreasing complexity of treatment, and financial constraints on ccess to therapies pose unique challenges to medical oncologists 1] . Amid these expectations and challenges, concern has been aised about job satisfaction and burnout among cancer care roviders [2] . Common contributing factors to these conditions nclude increased administrative workload, higher patient volumes, educed work-life balance, and loss of autonomy [1,3-5] . While many of the contributing factors are similar, it is im- ortant to recognize that job satisfaction and burnout are distinct oncepts [6-8] . Physicians may experience significant stress and/or 74 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 b f i a d c s c s m t c R a l S g t m C i p w d a ( f M s ( P m w p C a w t t c t w E g o p h t s B b 2 S H ( D p m i ( i s v s a i d J 2 l c f L o [ 1 w r t i 2 i h c w s l d S a s ( C c j f d w d q l ( e c T a a urnout but retain high levels of job satisfaction [9-11] . Burnout s commonly defined as a syndrome of emotional exhaustion, epersonalization, and feelings of low achievement [12] . Physician atisfaction is less well-defined, but is generally assessed as a elf-reported measure of subjective career satisfaction and desire o remain in the same specialty or choose it again if given the hance [13,14] . While multiple recent studies have demonstrated larming rates of burnout among medical oncologists, there is ess information available on job satisfaction, even less so in a lobal context [2,9,15] . Identifying potential contributing factors o job satisfaction is critically important to help inform optimal odels of care and human resource planning. To address this gap n knowledge, we explore job satisfaction, and factors associated ith satisfaction, among medical oncologists who participated in global workload and clinical practice survey. ethods articipants The methods of the survey design and distribution have been reviously described [16] . The eligible study population included ny practicing physician who administers chemotherapy; trainees ere excluded. Potential participants were identified by contacting he established national associations of medical oncologists in 54 ountries and two regions (Caribbean and Africa). When contact ith the national association was not possible, the senior investi- ator (C.M.B) contacted one personal contact per country to invite articipation and distribution of the survey using an informal na- ional network. This study was approved by the Research Ethics oard of Queen’s University. urvey design An online electronic survey was developed using Fluid Surveys Ottawa, ON). The survey was designed using multidisciplinary in- ut from study investigators practicing in diverse clinical environ- ents including those located in high-, middle- and low-middle ncome countries. The survey was then piloted and revised in an terative fashion based on feedback from 10 oncologists from di- erse global backgrounds. The final survey included 51 questions nd took 10–15 minutes to complete. The web-based survey was istributed using a modified snowball methodology in November 016. A reminder e-mail was sent via all national and/or regional ontacts in January 2017. Physician job satisfaction was assessed by asking, “On a scale f 1-10, how would you rate your satisfaction as an oncologist? = unsatisfying, 10 = satisfying.” A priori, it was determined that espondents answering 1-6 would be classified as having “low sat- sfaction,” 7-8 as having “moderate satisfaction,” and 9-10 as hav- ng “high satisfaction.” Several follow-up questions then aimed to larify contributing factors to job satisfaction. A full copy of the urvey tool can be found in Appendix A . tatistical analysis Countries were classified into low-middle income countries LMICs), upper-middle income countries (UMICs) and high-income ountries (HICs) based on the World Bank Criteria. The primary ob- ective of this study was to describe oncologist job satisfaction and actors associated with low and/or high job satisfaction. All data ere initially collected in Fluid Surveys (Ottawa, ON) and subse- uently exported to IBM Statistical Package for the Social Sciences SPSS) for Windows version 24.0 (SPSS, Armonk, NY, 2016). Data onsisted of categorical, ordinal, and continuous formats, occasion- lly collected as ranges. Pearson chi-sqaure tests were used to testor the difference in proportions, and the one-way analysis of vari- nce or the Kruskal-Wallis test was used to compare ordinal and ontinuous data by income stratification. A P value of 0.05 was onsidered as the criteria for statistical significance, and no adjust- ents were made for multiple comparisons. esults urvey distribution and response Among the 54 countries and 2 regional networks (Africa and aribbean), 42 countries and/or regional networks (75%) agreed to articipate. The study cohort included 1,115 respondents from 65 ifferent countries. Survey response rates were available for 40% 17 of 42) of all countries and/or regional networks and ranged rom 3% in Singapore and Portugal to 76% in Slovenia. Among tudy participants, 70% (782 of 1,115), 17% (186 of 1,115), and 13% 147 of 1,115) were from HICs, UMICs, and LMICs, respectively. The ean response rate across all countries for which response rate as available was 12% (461 of 3,967) ( Appendix B ). haracteristics of study participants Fifty-eight percent (647/1,115) of respondents were male and he median age was 44 years. The median number of years in prac- ice was 10, with a median of 6 years of postgraduate training. ighty-one percent (898/1,115) of respondents were medical oncol- gists, 10% (112/1,115) were clinical oncologists, 4% (49/1,115) were ematologists, and 5% (56/1,115) were other specialists that pre- cribed chemotherapy. Participants from LMICs were more likely to e clinical oncologists (ie, delivering chemotherapy and radiation; 0%; 29 of 147) than were those from UMICs (9%; 16 of 186) and ICs (9%; 67 of 782; P < 0.001). emographics, practice setting, and job satisfaction Overall job satisfaction rates were 20% (222/1,115), 51% 573/1,115), and 29% (320/1,115) for low-, moderate-, and high- atisfaction, respectively ( Table 1 ). Respondents with low-job atisfaction were younger ( P = 0.001) and had fewer years in clin- cal practice ( P = 0.013) compared to those with high satisfaction. ob satisfaction did not vary substantially by sex. Across country- evel economic groups, the only outlier were medical oncologists rom UMICs which were more likely than medical oncologists in MICs and HICs to have high-job satisfaction (38% [71/186] v 28% 41/147] and 27% [208/782], respectively, P = 0.006]. Physicians orking in the private sector had higher job satisfaction than hose working exclusively in the public sector (35% (133/381) v 6% [187/733], P = 0.001). Medical oncologists working at smaller ospitals ( P = 0.011) and within smaller clinical groups ( P = 0.051) ere more likely to have high-job satisfaction then those at arger centres. Medical oncologists without access to on-site ra- iotherapy ( P = 0.049), palliative care ( P = 0.005), and chemother- py pharmacists ( P = 0.033) were more likely to have low-job atisfaction. linical workload and job satisfaction Increasing hours worked per week was associated with a gra- ient of decline in job satisfaction ( P = 0.042) ( Table 2 ). Likewise, ecreasing annual weeks of paid vacation was associated with ess job satisfaction ( P = 0.007). Physicians who were on-call ev- ry night also had significantly lower job satisfaction ( P = 0.016). he annual number of new patient consultations was not associ- ted with lower job satisfaction ( P = 0.257). However, there was an M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 75 Table 1 Demographics and clinical practice setting of respondents to a global medical oncology workload survey for those with low, moderate, and high job satisfaction (N = 1,115).∗ Job satisfaction P value Low Moderate High N = 222 N = 573 N = 320 N (% by row) Demographics Sex Male 120 (19) 330 (51) 197 (30) 0.237 Female 101 (22) 239 (52) 123 (27) Economic status Low-middle income country 29 (20) 77 (52) 41 (28) 0.006 Upper-middle income country 42 (23) 73 (39) 71 (38) High income country 151 (19) 423 (54) 208 (27) Age (median) 43 44 46 0.001 Years in practice (median) 9 11 10 0.013 Specialty Medical oncologist 172 (19) 464 (52) 262 (29) 0.057 Clinical oncologist 25 (22) 50 (45) 37 (33) Pediatric oncologist 2 (18) 3 (27) 6 (55) Hematologist 11 (22) 34 (69) 4 (8) Surgeon 6 (33) 6 (33) 6 (33) Internal medicine 5 (26) 11 (58) 3 (16) Other 1 (13) 5 (63) 2 (25) Years postgraduate training (median) 6 6 6 0.591 Clinical practice setting System Public 158 (22) 388 (53) 187 (26) 0.011 Private+ 64 (17) 184 (48) 133 (35) Setting# Hospital in-patient 178 (21) 4 4 4 (52) 237 (28) 0.234 Hospital outpatient 177 (19) 503 (53) 267 (28) 0.012 Other outpatient 12 (9) 78 (59) 43 (32) 0.004 Hospital type General hospital 145 (20) 374 (52) 205 (28) 0.054 Cancer hospital 77 (20) 195 (51) 107 (28) Not in hospital setting 0 (0) 4 (33) 8 (67) Oncology in-patient beds in center 0-9 20 (20) 4 8(4 8) 33(33) 0.011 10-50 95 (18) 262 (50) 171 (32) 51+ 107 (20) 259 (49) 108 (20) Number of chemotherapy prescribers 1-4 45 (25) 81 (45) 56 (31) 0.051 5-10 49 (16) 160 (52) 99 (32) 11+ 128 (20) 332 (53) 165 (26) Radiotherapy on site ̂ Yes 184 (20) 473 (51) 263 (29) 0.049 No 38 (21) 96 (52) 49 (27) Palliative care on site ̂ Yes 175 (19) 478 (52) 270 (29) 0.005 No 47 (25) 91 (51) 42 (23) Chemotherapy pharmacist on site ̂ Yes 176 (19) 478 (52) 267 (29) 0.033 No 45 (25) 91 (50) 45 (25) Training program in center Yes 156 (19) 439 (53) 228 (28) 0.088 No 66 (23) 134 (46) 92 (32) Supervise trainees Yes 180 (20) 439 (49) 270 (30) 0.220 No 42 (24) 80 (47) 50 (29) EMR Yes 177 (24) 465 (63) 260 (35) 0.854 No 44 (21) 104 (50) 58 (28) Clinic assistants Nurse 168 (21) 415 (41) 235 (29) 0.649 Nurse practitioner 95 (17) 291 (52) 179 (32) 0.011 Medical Students 52 (16) 167 (52) 101 (32) 0.113 Residents 114 (17) 366 (53) 208 (30) 0.002 Other physicians 53 (17) 152 (50) 98 (32) 0.195 Percentages do not always equal 100 due to rounding. ∗ Job satisfaction was reported on a 10-point Likert scale with 10 representing high satisfaction. Respondents were classified as low (1-6), moderate (7-8), and high (9-10) job satisfaction. ^ Data were missing for 12 radiotherapy on site; 12 palliative care; 13 chemotherapy pharmacist responses. # Respondents could select more than one response. + Respondents worked exclusively in the private sector or in both private and public sectors. 76 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 Table 2 Delivery of clinical care by respondents to a global medical oncology workload survey for those with low, moderate, and high job satisfaction (N = 1,115).∗ Job satisfcation P value Low Moderate High N = 222 N = 573 N = 320 Delivery of Clinical Care Work Week No. hours worked/week (median) 51-60 41-50 41-50 0.042 No. days worked/week (mean) 5.4 5.3 5.2 Leave No. weeks annual vacation (median) 4 4 4 0.007 ̂ No. weeks annual vacation (mean) 3.8 4.1 4.4 No. weeks annual conference leave (median) 1 2 2 0.022 On-call duties# No. days on-call/month (median) 3.5 3 3 0.562 Respondents on-call every night # (%) 33 22 28 0.016 Allocation of duties % Time on clinical duties (mean) 64 64 62 0.246 % Time on research (mean) 12 14 14 0.080 % Time on teaching (mean) 8 9 9 0.332 % Time on administration (mean) 13 13 14 0.494 Clinical Volumes No. annual new consults (median) 151-200 151-200 151-200 0.257 ≤100 N (%) 68 (23) 142 (48) 80 (28) 10 0-30 0 102 (19) 284 (52) 165 (30) > 300 49 (19) 140 (53) 73 (28) No. patients seen per clinic day (median) 21-30 21-30 11-20 0.004 ≤20 N (%) 94 (17) 274 (50) 176 (32) 20-40 101 (22) 238 (52) 118 (26) > 40 25 (23) 59 (54) 25 (23) ∗ Job satisfaction was reported on a 10-point Likert scale with 10 representing high satisfaction. Rrespondents were classified as low (1-6), moderate (7-8), and high (9-10) job satisfaction. ^ Number of weeks with paid vacation had an identical median but the means differed resulting in a significant difference using both the one-way ANOVA and the Kruskal-Wallis test. # On-call duties were not reported by all respondents, actual responses for low, moderate, high were 57/174, 90/411, 56/198, respectively. Table 3 Top 5 reported barriers to patient care as reported by respondents to a global medical oncology workload survey for those with low, moderate, and high job satisfaction (N = 1,115).∗ Job satisfaction Low Moderate High (N = 222) (N = 573) (N = 320) High clinical volumes (70%, 156/222) High clinical volumes (60%, 344/573) High clinical volumes (48%, 155/320) Insufficient time for reading (40%, 89/222) Insufficient time for reading (41%, 234/573) Limited access to newer treatments (37%, 119/320) Shortage of oncologists (32%, 72/222) Limited access to newer treatments (34%, 196/573) Insufficient time for reading (32%, 103/320) Limited access to newer treatments (25%, 56/222) Shortage of oncologists (29%, 166/573) Shortage of oncologists (25%, 81/320) Shortage of nurses (21%, 46/222) Shortage of nurses (26%, 146/573) Shortage of nurses (22%, 71/320) ∗ Job satisfaction was reported on a 10-point Likert scale with 10 representing high satisfaction. Respondents were classified as low (1-6), moderate (7-8), and high (9-10) job satisfaction. a D > t w i w 1 t v p o t p B m t d a j w h j l c e O i s t o i o rssociation with daily clinic volumes: medical oncologists who saw 40 patients per day were less likely to have high-job satisfac- ion (23% [25/109] v 32% [176/544], P = 0.052) compared to those ho saw < 20 patients per day. Physicians with low-job satisfaction ere less likely to discuss prognosis with their patients compared o those with moderate- or high-job satisfaction (median 45% of atients v 65% v 75%, respectively, P < 0.001). arriers to care and job satisfaction The top barriers to patient care reported by study respondents re shown in Table 3 . Physicians expressing low-job satisfaction ere substantially more likely than those with moderate- or high- ob satisfaction to report high clinical volumes as a major barrier to are (70% [156/222] v 60% [344/573] v 48% [155/320], P = < 0.001). ther common barriers reported by those physicians with low job atisfaction include: insufficient time for reading (40%), shortage of ncologists (32%), limited access to treatments (25%), and shortage f nurses (21%). iscussion To our knowledge, this is the first international study evaluat- ng oncologist job satisfaction. Representing 42 countries and over ,100 oncologists from a diverse background of socioeconomic en- ironments and practice settings, this survey provides an overview f oncology job satisfaction from a global context. Several impor- ant findings have emerged. First, 20% of oncology providers ex- ress low job satisfaction. Second, job satisfaction is related to easures of clinical workload. Oncologists expressing low satisfac- ion worked more hours per week, saw more clinic patients per ay, and had less annual paid vacation. Third, oncologists with low ob satisfaction are more likely to work in the public system and ave less access to supporting services such as radiotherapy, pal- iative care, and chemotherapy pharmacists. This study provides vidence to support what is intuitive: oncologists value working n a multidisciplinary environment with the resources and time o properly care for their patients and for themselves. The intu- tiveness of this finding makes its confirmation no less important; ather, it should be a call to action. M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 77 h c n c d b l l t d p m i o F o c o F O t b t d i r s o b s a m M s m q t a a t r i c t l i a f r A o a o s s t 7 s p o t t m t w b p c d r c i I s d j s m [ a s C s r p s A s r l The findings of this study add to a growing body of evidence oncerning physician wellness. Physician wellness is a multifaceted oncept characterized not only by the absence of distress, but also y the achievement of success in one’s personal and professional ife [17] . Burnout and job satisfaction are thus two related but istinct components of physician wellness that share many com- on determinants. To date, the majority of the publications in the ncology literature have focused on wellness from the perspective f oncologist burnout. In 2012, Shanafelt et al reported on a survey f US oncologists identified from the American Society for Clinical ncology membership file [9] . Among 1,500 respondents, 45% were urned out on the emotional exhaustion and/or depersonalization omains of the Maslach Burnout Inventory. Hours per week di- ectly devoted to patient care was identified as the greatest profes- ional predictor of burnout. Other important factors contributing to urnout included increasing hours per week spent on work tasks t home, focus on one certain type of cancer, and increasing age. ore recently, Banerjee et al reported on a survey of 737 young edical oncologists from 41 European countries recruited through he European Society for Medical Oncology website. Alarmingly, mong this group of medical oncologists under the age of 40, 71% eported experiencing symptoms of burnout [15] . Factors asso- iated with burnout included lack of access to support services, iving alone, work-life balance, and inadequate vacation time. In contrast, much less is known about oncologist job satis- action and its correlates. In our global study, 20% of oncologists eported low job satisfaction. This is comparable to the 2012 study f US oncologists by Shanafelt et al where 20% of respondents nswered “no” to the question of whether they would become an ncologist again [9] . Balch et al reported on a 2008 survey of US urgical oncologists and identified a 25% prevalence of low-career atisfaction [18] . More concerning, however, is the longitudinal rend in oncologist job satisfaction. In a 2011 Medscape report, 9% of oncologists indicated they would choose oncology as a pecialty again; this dropped drastically to 51% in an update erformed in 2015 [19] . Few previous studies have examined factors associated with ncologist job satisfaction. In a study using survey and focus group echniques, Grunfeld et al reported that, counter to popular belief, he daily interaction with suffering and dying patients is not a ajor source of job stress for cancer care providers [20] ; in fact, hose interviewed identified that helping patients and families as the major source of their job satisfaction. This is supported y 2 findings in our study. First, although higher annual new atient volume is not associated with lower job satisfaction; in ontrast, working more hours and seeing more patients per clinic ay are both associated with lower job satisfaction. Second, our esults show that those oncologists with high job satisfaction were onsiderably more likely than those with low satisfaction to have mportant conversations with their patients regarding prognosis. t is interesting to note that physicians from LMICs, despite having ignificantly higher clinical volumes, days per week worked, on call uties, and less paid vacation, were not more likely to have low ob satisfaction. This highlights that strategies to improve physician atisfaction, much like those needed to address physician burnout, ust be tailored according to geographical and cultural needs 15] . Finally, common contributors to oncologist job satisfaction nd physician burnout, such as less onsite access to supporting ervices, working more hours per week, having less paid vacation, uggest that system-level changes to delivery of care and human esource planning have the potential to significantly improve hysician wellness. These efforts are needed given the projected hortages in cancer care providers in the coming years [21] . There are several methodologic limitations important to con- ider in the interpretation of our study. First, as with any survey, espondents may not be representative of all providers in theirealth system. Second, 16 of 42 countries did not have a formal ational association, and therefore, relied on informal survey istribution by one oncologist contact. Third, two of the world’s argest countries, the United States and Russia, declined to par- icipate in this study. Given that much of the previous data on hysician satisfaction derives from the United States, this lim- ts our ability to compare and contrast with past publications. ourth, the assignment of job satisfaction scores to categories orresponding to low-, medium-, and high-satisfaction is arbitrary. inally, like any survey, the results are subject to the validity of he response; questions concerning job satisfaction may be prone o social desirability bias, that is, the tendency to answer question n a manner that will be viewed favorably. In conclusion, this international study demonstrates that 1 in 5 ncologists express low job satisfaction. The main correlates of job atisfaction appear to be related to system-level pressures which ay result in less time for quality patient care and personal re- ilience. Therefore, improving oncologist job satisfaction will re- uire innovative new approaches to models of care delivery and ttention to health human resources. Physician wellness is impor- ant to the sustainability of the oncology workforce in the face of ncreasing system pressure. In order for physicians to care well, hey must be well themselves. Further research into methods to mprove physician wellness, both from the perspective of burnout nd job satisfaction, are needed. uthorship Responsibility, and Contribution to Manuscript Michael J. Raphael—Original idea for the research; data analy- ses; first draft of the manuscript Adam Fundytus—Original idea for the research; collection of data; review of manuscript for critically important intellec- tual content Wilma Hopman—Original idea for the research; collection of data; data analyses; review of manuscript for critically im- portant intellectual content Verna Vanderpuye—Original idea for the research; collection of data; review of manuscript for critically important intellec- tual content Bostjan Seruga—Original idea for the research; collection of data; review of manuscript for critically important intellec- tual content Gilberto Lopes—Original idea for the research; review of manuscript for critically important intellectual content Nazik Hammad—Original idea for the research; review of manuscript for critically important intellectual content Manju Sengar—Original idea for the research; collection of data; review of manuscript for critically important intellectual content Michael Brundage—Original idea for the research; review of manuscript for critically important intellectual content Richard Sullivan—Original idea for the research; review of manuscript for critically important intellectual content Christopher Booth—Original idea for the research; collection of data; data analyses; review of manuscript for critically im- portant intellectual content onflicts of interest The authors have no disclosures. cknowledgments Dr Booth is supported as the Canada Research Chair in Popu- ation Cancer Care. Professor Sullivan acknowledges the support of 78 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 t p C S f 0 A T a i p d c l c g i o s y U p y p w c o N a l c a he NCI Centre for Global Health. Dr Seruga acknowledges the sup- ort of the Slovenian Research Agency. Dr Raphael is funded by the anadian Association of Medical Oncologists fellowship program. upplementary materials Supplementary material associated with this article can be ound, in the online version, at doi: 10.1053/j.seminoncol.2018.12. 06 . ppendix A. Global Oncology Workload Survey Cancer is now the second leading cause of death worldwide. here is an urgent need to build health system capacity globally to ddress the growing burden of disease. This is particularly relevant n low and middle-income countries, who experience a dispro- ortionate burden of cancer. There is no contemporary data that escribes work environment and clinical volume of practicing on- ologists worldwide.To address this gap in the literature, we have reated this brief survey to learn from thousands of oncologists lobally in high income and low-middle income countries. This nformation will be useful to national societies in advocating for ncology specific resources within their own health setting. This tudy has been approved by the Research Ethics Board at Queen’s niversity in Canada. This survey will take 5-10 minutes to com- lete. This survey is anonymous. You are under no obligation to articipate. Completion of the survey will be regarded as implied onsent to participate.Thank you for supporting this effort in global ncology. Do you consent to participate in this research study? • Yes • No Do you prescribe chemotherapy? • Yes • No Which best describes you? • Medical trainee • Fully qualified physician who has completed training Do you provide? • Chemotherapy • Both chemotherapy and radiation therapy Which of the following best describes you? • Medical Oncologist • Clinical Oncologist (prescribes chemotherapy and radiotherapy) • Hematologist • Surgeon • Internal medicine physician • Gynecologist • Other ______________________ You have selected clinical oncologist. What proportion of your linical time is spent on (enter as numerical value in percent) • Radiation therapy • Chemotherapy Which country do you currently practice in? • Afghanistan • Albania • Algeria • American Samoa • Andorra • Angola • Anguilla • Antigua and Barbuda • Argentina • Armenia • … 215 additional choices hidden … • Uruguay • Uzbekistan • Vanuatu • Venezuela • Vietnam • Virgin Islands • Wallis and Funtana Islands • Yemen • Zambia • Zimbabwe Did you complete your core oncology training in the country isted above? • Yes • No After medical school, how many years of clinical training did ou complete? How many years have you been practicing since you completed our training?Please enter as numerical value in years with no ords Do you work in the • Public health care system • Private health care system • Both Is your primary practice location in an urban or rural center? ote: rural is defined as a population of less than fifty thousand nd not within a two hour reasonable commuting distance of a arger center. • Urban • Rural Which cancers do you treat? (Select as many as apply) • All cancers • Brain • Breast • Endocrine/Neuroendocrine • Gastrointestinal • Genitourinary • Gynecological • Head and Neck • Lung • Lymphoma/Leukemia • Sarcoma • Skin/Cutaneous • Other ______________________ Which of the following best describes your oncology practice? • Adults only • Pediatric patients only • I treat both adult and pediatric patients Which of the following describes your practice? (select all that pply) • Hospital inpatient care • Hospital based outpatient clinics • Non-hospital outpatient clinics M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 79 p c e d m o t t r i c d If hospital was selected is it a • General hospital • Dedicated cancer hospital • I do not work in a hospital setting at all What proportion of your clinical time is spent on • Inpatient care • Outpatient care How many physicians prescribe chemotherapy at your primary linic/hospital? • 1 (I am the only physician that prescribes chemotherapy at my center) • 2-4 • 5-7 • 8-10 • 11-14 • > 15 In an average month how often do you participate in a multi- isciplinary case conference (tumor board, multidisciplinary team eeting)? • 0 (This is not available at my center) • 1 • 2 • 3 • 4 + Is there radiotherapy on site? • Yes • No Is there palliative care team or specialist on site? • Yes • No Are there dedicated chemotherapy pharmacists at your institu- ion? • Yes • No How many oncology IN-PATIENT beds are there in your institu- ion? Include all beds for hemato-oncology, medical oncology and adiation oncology. • 0 • 1-9 • 10-20 • 21-50 • 51-100 • > 100 Is there an oncology residency or fellowship training program n your center? • Yes • No Is there an on oncology residency training program in your ountry? • Yes • No Do you supervise trainees (Medical Students, Registrars, Resi- ents or Fellows) in clinic? • Yes • No Which of the following assist you in your outpatient clinical ractice? (select all that apply) • Nurses • Oncology nurse specialist/practitioner • Medical students • Resident physicians/ Registrar physicians • Other physicians who work under your supervision Are you responsible for overnight or weekend call-duties? • Yes • No How many days per month are you on call on average? Please nter as numerical value in days • ______________________ • I am always on call unless I am away on leave Typically, how many days per week do you work? • < 1 • 1 • 2 • 3 • 4 • 5 • 6 • 7 Typically, how many days per week do you see patients in the utpatient clinic? • < 1 • 1 • 2 • 3 • 4 • 5 • 6 • 7 How many hours do you typically work per week? • 0-10 • 11-20 • 21-30 • 31-40 • 41-50 • 51-60 • 61-70 • 71-80 • > 80 How many weeks of paid leave (vacation) do you get per year? • 0 • 1 • 2 • 3 • 4 • 5 • 6 • > 6 How many weeks of paid conference leave do you get per year? • 0 • 1 • 2 80 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 a t e a s i a y • 3 • 4 • 5 • 6 • > 6 What percentage of your time is spent on • Clinical Practice • Research • Teaching (formal lectures/seminars) • Administrative duties • Other How many new cancer patient consults do you see per year? • < 50 • 51-100 • 101-150 • 151-200 • 201-250 • 251-300 • 301-350 • 351-400 • 401-450 • 451-500 • 501-600 • 601-700 • 701-800 • 801-900 • 901-10 0 0 • 1001-1250 • 1251-1500 • 1501-1750 • 1751-20 0 0 • > 20 0 0 What is the average wait time for a new consult to be seen fter referral? • New consults are seen same day without a referral • 1-3 days • 4-7 days • 1-2 weeks • 3-4 weeks • 5-6 weeks • 7-8 weeks • > 8 weeks What percentage of your patients will be prescribed anti-cancer ystemic therapy (i.e cytotoxic chemotherapy, hormonal therapy, mmunotherapy, targeted therapy)? • 0-20% • 21-40% • 41-60% • 61-80% • 81-100% In a typical full day out-patient clinic how many patients will ou see? • < 10 • 10-20 • 21-30 • 31-40 • 41-50 • 51-60 • 61-70 • 71-80 • 81-90 • 91-100 • 100 + What is the average time that you as the consultant spend with new patient during the initial consultation? • < 5 minutes • 5-10 minutes • 10-20 minutes • 21-30 minutes • 31-40 minutes • 41-50 minutes • 51-60 minutes • > 1 hr What is the average time spent per clinic visit with an outpa- ient who is receiving chemotherapy? • < 5 minutes • 5-10 minutes • 10-20 minutes • 21-30 minutes • 31-40 minutes • 41-50 minutes • 51-60 minutes • > 1 hr In what percentage of your new patient consults do you discuss stimated survival or prognosis? • 0-10% • 11-20% • 21-30% • 31-40% • 41-50% • 51-60% • 61-70% • 71-80% • 81-90% • 91-100% Does your primary work site have an electronic medical record? • Yes • No How do you order chemotherapy? • Handwritten • Electronic • Both • With regards to recording clinic notes do you (check all that apply) • Dictate notes • Hand-write clinic notes • Type clinic notes On a scale of 1-10 how would you rate your job satisfaction as n oncologist?1 = unsatisfying, 10 = satisfying • 1 • 2 • 3 • 4 • 5 • 6 • 7 • 8 • 9 • 10 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 81 y A High patient volumes adversely affect my job satisfaction • Strongly Disagree • Disagree • Neutral • Agree • Strongly Agree What are the three biggest barriers to effective patient care in our practice (select up to three maximum) • High clinical patient volumes • Insufficient time to read current literature • Unavailability or limited access to diagnostic imaging • Unavailability or limited access to accurate pathology • Unavailability or limited access to standard chemotherapy • Unavailability or limited access to newer anti-cancer treatment options (i.e immune therapy, targeted therapies) Country World Bank Classification Distribution Method C Bahrain HIC Declined participation 0 Belgium HIC Declined participation 0 Czech Republic HIC Declined participation 0 Israel HIC Declined participation 0 Jordan UMIC Declined participation 0 Korea HIC Declined participation 0 Lebanon UMIC Declined participation 0 Montenegro UMIC Declined participation 0 Netherlands UMIC Declined participation 0 Nicaragua LMIC Declined participation 0 Norway HIC Declined participation 0 Taiwan HIC Declined participation 0 Uruguay HIC Declined participation 0 USA HIC Declined participation 0 Australia HIC National Organization 3 Bosnia UMIC National Organization 3 Brazil UMIC National Organization 5 Canada HIC National Organization 5 Chile HIC National Organization 2 Colombia UMIC National Organization 2 Estonia HIC National Organization 1 Finland HIC National Organization 2 Greece HIC National Organization 2 Hungary HIC National Organization 4 Italy HIC National Organization 2 Japan HIC National Organization 1 Mexico HIC National Organization 2• Unavailability or limited access to radiotherapy • Patients unable to pay for treatment, diagnostic imaging, pathology • Patients cannot reach clinic for regular follow-up • Shortage of oncologists • Shortage of chemotherapy pharmacists • Shortage of nurses • Lack of electronic medical record • Other, please specify… ______________________ Sex • Male • Female Age ppendix B. Country-level participation and response rates omplete Responses Denominator Country specific response rate ̂ Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A Declined N/A 9 N/A N/A N/A N/A 7 N/A N/A 8 322 18% 3 108 21% 0 N/A N/A 0 20 50% 1 217 10% 5 N/A N/A 1 N/A N/A 5 N/A N/A 60 N/A N/A 4 N/A N/A 82 M.J. Raphael, A. Fundytus and W.M. Hopman et al. / Seminars in Oncology 46 (2019) 73–82 R [ [ eferences [1] Shanafelt T , Dyrbye L . Oncologist burnout: causes, consequences, and re- sponses. J Clin Oncol 2012;30:1235–41 . [2] Grunfeld E , Whelan TJ , Zitzelsberger L , et al. Cancer care workers in Ontario: prevalence of burnout, job stress and job satisfaction. Canadian Med Assoc J 20 0 0;163:166–9 . [3] Murali K , Banerjee S . Burnout in oncologists is a serious issue: what can we do about it? Cancer Treat Rev 2018;68:55–61 . [4] Shanafelt TD , Dyrbye LN , West CP . Addressing physician burnout: the way for- ward. JAMA 2017;317:901–2 . [5] West CP , Dyrbye LN , Erwin PJ , et al. Interventions to prevent and re- duce physician burnout: a systematic review and meta-analysis. Lancet 2016;388:2272–81 . [6] Taylor C , Graham J , Potts HW , et al. Changes in mental health of UK hospital consultants since the mid-1990s. Lancet 2005;366:742–4 . [7] Ramirez AJ , Graham J , Richards M , et al. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724–8 . [8] Ramirez A , Graham J , Richards M , et al. Burnout and psychiatric disorder among cancer clinicians. Br J Cancer 1995;71:1263 . [9] Shanafelt TD , Gradishar WJ , Kosty M , et al. Burnout and career satisfaction among US oncologists. J Clin Oncol 2014;32:678 . [10] Neumann JL , Mau L-W , Virani S , et al. Burnout, moral distress, work–life bal- ance, and career satisfaction among hematopoietic cell transplantation profes- sionals. Biol Blood Marrow Transplant 2018;24:849–60 . [11] Elit L , Trim K , Mand-Bains I , et al. Job satisfaction, stress, and burnout among Canadian gynecologic oncologists. Gynecol Oncol 2004;94:134–9 . [12] Maslach C , Jackson SE , Leiter MP . Maslach Burnout Inventory: Third edition. In: Zalaquett CP, Wood RJ, editors. Evaluating stress: A book of resources. Lanham, MD: Scarecrow Education; 1997. p. 191–218 . [13] Kuerer HM , Eberlein TJ , Pollock RE , et al. Career satisfaction, practice pat- terns and burnout among surgical oncologists: report on the quality of life of members of the Society of Surgical Oncology. Ann Surg Oncol 2007;14: 3043–3053 . [14] Frank E , McMurray JE , Linzer M , et al. Career satisfaction of US women physi- cians: results from the Women Physicians’ Health Study. Arch Intern Med 1999;159:1417–26 . [15] 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 2017;28: 1590–1596 . [16] Fundytus A , Sullivan R , Vanderpuye V , et al. Delivery of global cancer care: an international study of medical oncology workload. J Global Oncol 2017;4:1–11 . [17] Shanafelt TD , Sloan JA , Habermann TM . The well-being of physicians. Am J Med 2003;114:513–19 . [18] Balch C , Shanafelt T , Sloan J , et al. Burnout and career satisfaction among surgical oncologists compared with other surgical specialties. Ann Surg Oncol 2011;18:16–25 . [19] Medscape: Medscape Oncologist Compensation Report 2015, in Peckham C (ed). New York, New York, 2015 20] Grunfeld E , Zitzelsberger L , Coristine M , et al. Job stress and job satisfaction of cancer care workers. Psychooncology 2005;14:61–9 . 21] Yang W , Williams JH , Hogan PF , et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract 2014;10:39–45 .