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Results of a study indicate that 44.7% of practicing oncologists show signs of burnout.
Sarbajit Mukherjee, MBBS
Recalling the emotional exhaustion of his early months on the job, University of Oklahoma oncology fellow Sarbajit Mukherjee, MBBS, wrote an article exhorting colleagues to acknowledge the issue of burnout among oncology fellows.
"The first and most important step toward solving this problem, as with any other problem, is to acknowledge that it exists," Mukherjee wrote in the 2016 Asco Connection story.1
Since the 1970s, when psychologists began publishing research on developing language for occupational burnout, conversation about the phenomenon has grown. Mukherjee's article referenced a study published in 2014 indicating that about 40% of first-year oncology fellows experience burnout.2 The same year, results of another study indicated that 44.7% of practicing oncologists show signs of burnout.3 Citing “a clear need for interventions,” ASCO promised to continue the conversation, primarily by studying and hosting public discussions on the issue.4
But while psychologists have identified many of the causes and effects of burnout, practicalities often complicate the process of fighting it at independent oncology practices, said Robin Zon, MD, of Michiana Hematology Oncology in Elkhart and Mishawaka, Indiana, in a recent interview with Oncology Business ManagementTM (OBM).
Burnout is often caused by too much work, which can be linked to inadequate staffing, Zon said. Psychologists identify “a persistent imbalance of demands over resources” as a perennial cause of burnout, as a 2008 research paper put it.5
Demand for oncology services is growing. In 2016 an estimated 1.7 million new cases of cancer were diagnosed, up 2% from 2015, according to ASCO. Cancer was the leading cause of death in 22 states in 2016 and is projected to overtake cardiovascular disease as the leading cause of death by 2020, ASCO said.6
“There will be a deficit of oncologists and a surplus of patients. Burnout is part of that whole formula and needs to be paid attention to,” Zon said. Burnout is also often associated with nonproductive work, such as “administrative burden, authorizations, pre-authorizations, notes,” said Linda Bosserman, MD, a medical oncologist at City of Hope in Rancho Cucamonga, California, speaking to OBM in 2015.7 Zon agreed.
“There’s a potential for increased burnout because of increased regulations. Doctors are starting to do more and more secretarial work just to prove that we’re quality doctors. On top of that, we’re looking at an increased number of cancer patients and survivors, and now we’re dealing with a workforce shortage,” Zon said. “It’s a real concern, because if you’re looking at a shortage already, and doctors are going to have to work harder, what are you going to do?”
What practices can do depends upon the resources available to them, Zon said. Practices can support mitigating strategies such as self-care and an understanding atmosphere regardless of size, but those tactics address burnout’s effects, not its causes.
Larger practices can hire more support staff to take on administrative work, giving oncologists more freedom to focus on patient care, Zon said. If they can afford it, individual oncologists can also try hiring scribes, as she and others at her practice have done.
Overall, “the cultural changes needed to fight burnout are multifaceted. Does a practice have the resources to support the delegation of tasks? Your resources are becoming leaner and leaner, so how are you going to have the resources to hire more people if your reimbursement is going down?” Zon asked.Florida Cancer Specialists (FCS), a large network of community practices spread across Florida, has been able to take some of the pressure off its physicians by delegating responsibility for nondoctoring tasks, CEO Bradley Prechtl, MBA, said. For example, he makes a point to hire reimbursement specialists who know the ins and outs of negotiating on drug pricing. Prechtl said he deems this particularly important, considering that drugs are both the biggest expense and the biggest source of revenue for most practices. Prechtl acknowledged that such hires are more difficult at small practices.
This kind of delegation helps put and keep specialists where they’re needed, which improves the bottom line at FCS, Prechtl said. “A small practice would have to be negotiating on drug pricing, which is something that’s highly complex and changes literally daily,” Prechtl said. “Keeping up with all of those contracts is highly complex. You might be managing upward of 80 different contracts, each which can be different by drug.”
“You have to have somebody ... who knows the clinical aspects of the business, but you also have to have somebody who’s very savvy from a business standpoint, because you’re constantly having to ask whether you’re going to be reimbursed,” Prechtl said.
At FCS, “we take away a lot of that work” from oncologists,” Prechtl said. An administrative team handles the interaction with commercial payers and contract negotiation. Oncologists don’t have to deal with compliance issues, billing and collecting, or researching the newest drugs, either—administrators take care of all of that. At smaller practices that self-manage, paperwork related to federally mandated reporting piles up next to the paperwork that goes into running a business, Prechtl said. He said that handling turnover, workers’ compensation, and daily staffing needs can exhaust a practice without a human resources department to manage those issues.
“It’s overwhelming, the amount of work that a physician or a few physicians at a small practice have to take on administratively,” Prechtl said. At Zon’s practice, oncologists regularly work 12-hour days, followed by meetings and paperwork. Hiring scribes has helped ease the burden somewhat, but some documentation requires specific medical expertise to complete, she said.
Having a robust electronic medical records (EMR) system can help with that, Prechtl said. His practice doesn’t use scribes, although it does employ nurse practitioners and physician assistants who help with documentation. ONCO-EMR, which FCS helped develop, is “very efficient at documentation,” Prechtl said.
This is a big plus not only for a practice’s existing oncologist staff but also for its ability to attract new hires, Bosserman said. “Whoever develops more supportive electronic medical records and more supportive methodologies will be able to hire the best people,” Bosserman told OBM in 2015. “That’s what they go to work to do—perform high-level analytics, and then assess and educate patients and engage them in the best healthcare for their needs.”
Retaining employees is important from a business standpoint, said Prechtl, who holds accounting and finance degrees. He estimates that it costs FCS about $8000 to replace an employee—and that’s an administrator, not a physician.“I think oncology is a very difficult specialty,” Prechtl said. “You’re going to win battles, but you’re going to lose some as well, and when you don’t cure a patient, it takes a toll on the physician.”
Burnout research has stimulated research on job stress, particularly in the “helping” professions, psychologists wrote in a 2008 paper summarizing 35 years of burnout research.5 Stress can lead to burn- out, and many of the “helping” professions are both high-stress and high-stakes.
What’s more, many healthcare providers gravitate toward the profession with an intrinsically high level of dedication. When researchers looked at burnout in the 1960s, they found that “frustrated idealism was a defining quality of the burnout experience.”5 Long hours, excessive work, and frustration with limited treatment success can lead to oncologists burning out, and frustration with the effects of burnout can worsen the condition.
Frustrated idealism “was critical to the concept’s momentum: service providers were appalled at their diminished capacity to perform or to show compassion towards their recipients,” the psychologists wrote. “The experience of burnout was not merely an inconvenience or an occupational hazard, but a devastating attack on their professional identity.”
The main symptoms of burnout are depersonalization, emotional exhaustion, and decreased personal accomplishment. In oncology, these symptoms can have deleterious effects on a practice.
“One of my biggest concerns with burnout is the depersonalization. The patient’s not happy because the doctor’s not communicating as well, and it just kind of snowballs,” Zon said.
So how to combat this process? Mukherjee, the oncology fellow, suggested that training in palliative care and end-of-life discussion could do a great deal of good in “empowering [oncologists] with essential communication and self-care skills.” Adequate vacation and rest time could also help, he said, though Zon warned that on its own, this could amount to “putting a Band-Aid on it.”
Zon and Mukherjee both spoke of the benefits of having a supportive staff network. “If somebody is for whatever reason having a really tough time, they need to know it’s not shameful and it’s recognized as a concern,” Zon said. “We show all this empathy to our patients. We need to show this empathy to each other and ourselves.”
Part of practicing that self-compassion is allowing yourself to grieve when a patient dies, Laurie Lyckholm, MD, said in a Journal of Oncology Practice article in 2006.8 Lyckholm is a professor of hematology/ oncology in the department of internal Medicine at Carver College of Medicine in Iowa and a Giants of Cancer Care® award winner.
“You need closure. You should grieve in your own private way, and it helps to grieve with the family,” Lyckholm wrote. “Few physicians deal with death and grieving as often as oncologists.”
Jimmie C. Holland, MD, the Wayne E. Chapman Chair of Psychiatric Oncology at Memorial Sloan Kettering (MSK) Cancer Center in New York, New York, offered similar advice in the article. “In terms of your own survival, it is important to recognize that the death of some patients can affect you much more deeply than others,” she wrote. “You can often recognize a resemblance in appearance or age or temperament of the patient that reminded you of someone in your past, and you can see why the death affects you so much more deeply.”
Writing of ways to combat burnout on the ASCO blog in 2011, oncology physician assistant Heather Marie Hylton, PA-C, of MSK in New York, New York, opined that “the visibility of the impact of cancer on our patients, their families and friends” takes a toll on providers. ”If we do not take care of ourselves, renew ourselves, it will be exceedingly difficult to care for our patients.”9
Some of the tactics Hylton uses are talking about stressful situations with colleagues, sleeping and eating well, exercising, recording her thoughts, and keeping her life dynamic.
She also wrote that she likes to remember Lyckholm’s words: “Remember how much value there is in what you do, and how much you are valued. Every day, you directly and indirectly affect ... hundreds of people’s lives.”