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Don’t give up the day job
Anyone who has been reading the peer-reviewed oncology literature or publications like HemOnc Today will be familiar with the increasing problem of burnout among oncologists.
The largest study of this subject in the United States showed that almost 45% of oncologists have symptoms of burnout, suggesting that many of you who are reading this have firsthand knowledge of this phenomenon.
It is now clear that the syndrome of burnout presents a major threat to our ability to deliver effective and compassionate oncology care. Although oncologists, for the most part, have high levels of satisfaction with their specialty, the risk for burnout is high and appears to be highest among younger oncologists who are seeing the highest numbers of patients.
Brewing storm clouds
Based on these observations, it’s not surprising that I have not experienced burnout (or at least have not recognized it in myself). I am clearly not in the demographic of those who are most at risk based on age and patient volumes.
The trajectory of my professional life over the last few years has been increasingly toward lowering my clinical commitment and increasing the amount of time I spend on administrative tasks. This may have afforded me some protection from burnout, but it comes at a price. In my case, I have taken on these new responsibilities by reducing my time in clinic. I now spend less time than ever in face-to-face contact with my patients.
The administrative role has been a rewarding and enjoyable challenge for me. I have gained new insights and experiences, learned how it is sometimes possible to make a difference at an organizational rather than individual patient level, and come to understand the impact that diverse perspectives and expertise can have in solving problems.
I am definitely not an expert on the causes or solutions to the problem of oncologist burnout, but I see storm clouds brewing for our ability to deliver cancer care in the future if we do not take steps to address this.
As the incidence of cancer increases in our population, along with the number of cancer survivors, we face major workforce issues.
Knowing that poor teamwork and ineffective leadership appear to be key factors in causing oncologist burnout, we need to be sure that we do not transmit these deficiencies to other team members.
One generally recognized potential solution to workforce shortfalls is to engage more advanced practice clinicians on our care teams. Collaborative practice has been at the heart of the development of advanced practice clinician-led cancer services. It is, therefore, disturbing that a national study of physician assistants practicing oncology in the United States revealed that almost 35% have experienced burnout. Interestingly, time spent on indirect patient care, a poor relationship with the collaborative physician and oncology subspecialty were associated with higher burnout. The relationship with direct patient care was less clear.
The power of choice
There are often days when I think that maybe the time has come to give up my clinical practice, free up the time I spend on patient care issues — both during and outside clinic hours — and focus full time on administration. So far, I have resisted doing that.
I have been very fortunate in that respect, because I work with a great clinical team of physicians, nurses and advance practice clinicians who work with me to ensure that our patients’ needs are met whether I am in the clinic, in a meeting or in another country.
The title of this article is not original, but certainly resonates with me. When I first discussed giving up patient care with a former colleague of mine, his response was, “Don’t give up the day job.” It was among the best professional advice I have ever received. I can list many reasons for believing this:
- continued involvement in clinical research and observing on an individual patient level the impact of new emerging therapies;
- the positive emotional experiences associated with direct patient care and the feeling that one can make a difference in the lives of some patients and their families;
- the intangible rewards and positive reinforcement that come from the privileged position we have as cancer physicians; and
- the feeling that I am fulfilling the role I have been trained to do over many years.
These reasons reflect my need to stay in touch with why I chose oncology as my career path in the first place. Of course, many pressures encroach upon my clinical responsibilities and make it difficult to maintain a meaningful practice.
Those pressures have the potential to be stressful but, overall, I have been lucky enough to be able to manage this — largely because I chose to take my career in the direction of more administration. Many of those practicing oncology in 2018, whether as physicians or other health care professionals, don’t make that choice, but rather are forced into spending more and more of their time in functions other than direct care of their patients.
Indirect care burdens
The relationship between our direct face-to-face time with patients and the likelihood of developing burnout is blurry.
The observation that busier oncologists are at higher risk for burnout is probably partly a reflection of the indirect components of patient care, although some studies suggest otherwise. At our institution, time spent documenting in the electronic medical record is a major dissatisfier for physicians.
The Association of Community Cancer Centers’ 2017 Trending Now in Cancer Care survey cites several problems associated with EMR use — specifically, 80% of respondents to that survey stated that the workload of physicians and staff has increased as a result of EMR use, and over 65% reported that their time spent in direct patient care has decreased either slightly or significantly.
The EMR represents just one of the many indirect patient care factors that may be influencing burnout rates. Anecdotally, preauthorization issues and peer-to-peer discussions with payers have increased dramatically in our center, adding another to the many indirect care burdens we face. The additional administrative burden of the Medicare Access and CHIP Reauthorization Act, known as MACRA, and other regulatory requirements only add to this.
As we strive to better understand the factors that contribute to oncology provider burnout and place continued emphasis on wellness and work-life balance, it’s important to remember that the interaction and relationships with our patients are at the center of what makes us want to be oncologists. Time in the exam room with patients and their caregivers is still the main reason we do this job.
Although not minimizing the effect of repeated, difficult conversations and decisions — and the toll this can take on us as oncologists — it is important to remember that so many of the factors that contribute to burnout occur outside the exam room. The low-hanging fruit in the quest for physician wellness rests with improved administrative and IT support for our care teams to allow more face time with patients and less time overall at work.
We and our patients have a lot to lose if we give up on the “day job” of direct patient care.
References:
Association of Community Cancer Centers. Trending now in cancer care. Available at: www.accc-cancer.org/surveys/CancerProgramTrends-2017.asp. Accessed on Jan. 23, 2018.
Shanafelt TD, et al. J Clin Oncol. 2014;doi:10.1200/JCO.2013.53.4560.
Tetzlaff ED, et al. J Oncol Pract. 2018;doi:10.1200/JOP.2017.025544.
For more information:
John Sweetenham, MD, FRCP, FACP, is HemOnc Today’s Chief Medical Editor for Hematology. He also is senior director of clinical affairs and executive medical director of Huntsman Cancer Institute at The University of Utah. He can be reached at john.sweetenham@hci.utah.edu.
Disclosure: Sweetenham reports no relevant financial disclosures.