Oncology practices struggle ‘to run at all levels’ amid workforce shortage
Fears of an oncology workforce shortage have been mounting for more than a decade as both the percentage of oncologists nearing retirement age and number of Americans with a history of cancer increase annually.
ASCO experts saw a shortage coming in 2007, when they projected demand for oncologists would increase 48% between 2005 and 2020, but that the supply of services they provided during the same period would rise by only 14%.
However, the experts did not foresee the COVID-19 pandemic that has exacerbated the crisis, leading to more burnout, stress and staffing challenges in oncology and throughout the health care industry.
“More than 300,000 health care providers dropped out of the workforce in 2021, including physicians, nurse practitioners, physician assistants and other clinicians who left the workforce that year,” Shikha Jain, MD, FACP, associate professor of medicine with tenure in the division of hematology and oncology at University of Illinois Cancer Center in Chicago, consulting editor for Healio Women in Oncology and host of Healio's Oncology Overdrive podcast, told Healio | HemOnc Today. “For oncology in particular, a lack of oncologists means delays in diagnosis and treatment for patients with cancer. A several-months delay in being seen by an oncologist could lead to disease progression, making patients no longer candidates for curative therapy, which is quite concerning.”
Shortages of clinicians across the board have caused the health care system to be “stretched to its limits,” Jain said.
“Patient visits are being delayed by inappropriate amounts of time due to staffing shortages — they are struggling to be seen by their physicians or a nurse for acute care visits,” she said. “We are in trouble, and we need to do something soon to right the ship.”
Healio | HemOnc Today spoke with oncologists about the workforce shortage, continued issues of physician burnout, low recruitment and increasing administrative burdens, and efforts to address these challenges.
‘Flat-out burned out’
Rates of physician burnout, which had been rising long before COVID-19, increased dramatically during the first 2 years of the pandemic, according to a study by Shanafelt and colleagues published in December in Mayo Clinic Proceedings.
In May, U.S. Surgeon General Vivek H. Murthy, MD, MBA, issued an advisory addressing the high rate of burnout among all health care workers.
“Confronting the long-standing drivers of burnout among our health care workers must be a top national priority,” Murthy said in an HHS press release. “COVID-19 has been a uniquely traumatic experience for the health workforce and for their families, pushing them past their breaking point. Now, we owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk.”
In a nationwide survey of 1,000 U.S. health care professionals more than half (57%) of respondents reported concerns about burnout from repetitive tasks and required documentation, 28% reported quitting a job in health care due to burnout and 48% reported concerns about the health care system’s ability to retain and hire staff if automation is not prioritized.
Oncologists are “flat-out burned out,” Jain said.
“There is a lot of unnecessary paperwork and administrative overhead,” she said. “We have prior authorizations, peer to peers, and all of these issues are taking away from our ability and time to do what we are meant to do — practice medicine.”
Results of an ASCO Practice Census Survey, published in 2018 in JCO Oncology Practice, highlight the challenges of day-to-day operational functions, including prior authorizations and use of electronic health records, for oncology practices.
Researchers identified annual decreases in the number of hematology/oncology practices between 2013 and 2017, but increases in practice size. Among 394 practices that completed the survey, 78% cited prior authorizations among payer pressures. Electronic health records also remained a burden on oncology practices, of which only 15% reported full interoperability.
“Our findings likely represent conservative estimates of such burdens because they are driven by responses from midsized to large-sized organizations, which have lower relative administrative burden, greater market influence, and potentially better ability to adapt in a changing health care environment,” the researchers wrote.
Health care teams face more and more administrative burdens every year, according to Stephen S. Grubbs, MD, FASCO, vice president of care delivery at ASCO.
“Multiple factors are at play, including time spent to have the payer community agree on covering a treatment for a patient and reporting on that,” Grubbs told Healio | HemOnc Today. “Also, we all have to use electronic health records, which have been built in a way that is adding significant burden to everyone on the health care team.”
Staff are asked to work harder and for longer hours, affecting work-life balance, Grubbs added.
“On top of all of this, the reimbursement system is becoming increasingly more difficult for oncology practices,” Grubbs said. “Health care costs are going up and everybody is doing everything they can to try to control costs. A lot of that is coming back to the practice level in terms of rising practice expense and lagging reimbursement to support oncologists and staff. This adds pressure on everyone. If the business of oncology practice does not work properly, then it becomes difficult to provide care at the level we want and everyone suffers.”
Recruitment challenges
Amid these added pressures, the number of oncologists and supporting staff exiting the profession has increased while recruitment has remained low.
“Oncology practices are experiencing significant challenges recruiting staff across the spectrum of the cancer care delivery team,” Grubbs said. “Although we do not have exact numbers on the current state of the oncology workforce, there is no question that the issue is everywhere and across every type of practice, whether it’s a large academic institution, a large hospital system or an independent practice. We are struggling to have enough personnel to make our practices run at all levels.”
The oncology workforce shortage poses a significant challenge for all practices, but particularly for nonacademic institutions, according to experts with whom Healio | HemOnc Today spoke.
“In community practice, whether it’s hospital-based or private-practice, it is very difficult to recruit oncologists right now — there simply are not enough,” Barbara L. McAneny, MD, FASCO, MACP, medical oncologist and former AMA president, told Healio | HemOnc Today. “It is the perfect storm of inadequate numbers of people graduating from medical school and specializing in oncology. We are also keeping people alive for years and years longer than we did before. This is great but very labor intensive and increases the need for oncologists, but fewer and fewer are coming out of training.”
The administrative “time sinks” are taking oncologists away from treating the patient, McAneny said, adding to the need for more administrative staff across oncology practices.
“Oncologists should spend their time effectively with patients,” McAneny said. “They should be making diagnoses, explaining diagnoses, staging disease, developing treatment regimens, and coordinating all the information with patients and their families. Oncologists are such valuable commodities right now, and we want them to focus on our patients with cancer.”
Experts unanimously agreed that recruitment efforts are desperately needed.
“We are all recruiting — every oncology practice in the National Cancer Care Alliance is recruiting because we are all so busy that we need more people,” McAneny said. “We’re trying to create a process so that we can work smarter because we never want our oncologists doing all of the quality measures that we are all asked to do. Why would we want to waste an oncologist’s time having them calculate and enter data on BMI, when we as oncologists are not terribly worried about obesity but instead are trying to get our patients to eat?”
Effect on clinical research
The oncology workforce shortage also has contributed to challenges in clinical research.
In August, the Society for Immunotherapy of Cancer (SITC) conducted a virtual summit to identify the scope of what the society identified as a clinical research crisis and offer practical solutions to fix the system.
According to SITC, 95% of cancer centers reported personnel issues resulting from the “great resignation” and a poll of 44 NCI-designated cancer centers showed clinical trial accrual rates down 20% from January 2020 levels.
Ongoing staffing issues have affected not only clinical trials at academic medical centers but also all stakeholders in the development of cancer therapies, including contract research organizations and trial sponsors, summit co-chair Leisha A. Emens, MD, PhD, SITC vice president, professor of medicine in hematology and oncology at University of Pittsburgh School of Medicine, and co-leader of UPMC Hillman Cancer Center’s cancer immunology and immunotherapy program, told Healio | HemOnc Today at the time of the summit.
“Part of what has made clinical trials more challenging is the terrific progress we’ve made with drugs in terms of harnessing key biological pathways that can be targeted for better therapies,” Emens said. “[This] has made clinical trials more complex, which translates into more complex regulatory processes, more complex protocols and an increasing volume of work.”
The COVID-19 pandemic accelerated the ongoing staffing deficit to what is now “a critical breaking point,” Emens said. The SITC’s Crisis in Clinical Research Virtual Summit aimed to develop solutions and help keep the cancer research pipeline moving, she added.
“We need to address how to streamline things so that we can maximize the ability of the available workforce to get the work we need done to make better drugs for patients,” she told Healio.
Potential solutions the panels proposed included standardization of data, data collection and processes across sites; centralized institutional and scientific review; efforts to bring trials closer to a greater number and more diverse group of patients; and workforce development with new benefits, including performance-based pay linked to trial accrual.
“We are now at the best time in history to improve clinical outcomes for patients everywhere,” she added. “If we can't solve this crisis, then it is going to limit our ability to deliver these advances to patients with cancer.”
Efforts to ‘bring joy back’
To help address the challenges facing the oncology workforce, ASCO has developed a patient centered oncology medical home certification, success of which could alleviate some of the issues with prior authorizations, according to Grubbs.
“There will be improved communication among electronic health records and utilization of them,” he said. “The oncology team will be able to practice at the highest level and not be bogged down with administrative duties that take time away from providing patient care. The hope is that the certification will allow for oncology practices to transform into the new model and mitigate some of the ongoing workforce issues because we want to remove some of the pressures from the care delivery team and bring joy back into the practice of medicine.”
The U.S. Surgeon General health advisory recommended ways for “the whole of society” to address factors contributing to burnout, as well as improve infrastructure and well-being for health care workers. The recommendations emphasized the need to reduce administrative burdens to help health care workers have productive time with patients, communities and colleagues, and the need for further research on health care worker burnout and well-being across all health care settings.
‘Dismantle and then rebuild’
Experts with whom Healio | HemOnc Today spoke said an “all-hands-on-deck” approach is needed to fix the issues at hand.
“We have individual institutions, help lines and stress-reduction efforts in place to address the burden on the oncology workforce,” Grubbs said. “However, the biggest contributors are not sufficiently addressed, including prior authorizations and other administrative burdens, electronic health records, escalating physician pay cuts and continuing turbulence in the marketplace.”
Jain said a “deep dive” is needed into the challenges facing oncology care delivery.
“My hope is that we dismantle and then rebuild the entire medical system in a better way, so that we are able to retain more oncologists in the field,” she said. “The way to do that is to make oncology more appealing for clinicians to stay in oncology and also recruit more people to join the field of oncology. But it’s difficult to do that until we fix the underlying issues that are resulting in many people leaving.”
Grubbs agreed with resolving the issues that detract from an appealing career.
“Policymakers and payers need to work with ASCO and others in the oncology community to implement policies that result in a supportive care delivery environment that mitigates burnout and encourages clinicians to remain engaged in patient care,” Grubbs said. “Long-term, we need to focus on education, increasing diversity in the workforce, and creating novel care delivery and payment models that allow practices to survive and thrive, and for patients to receive the care they need.”
McAneny said oncology training needs to be reformed.
“Oncologists learn oncology at academic medical centers but come out of the academic medical center and join a community practice, so we have to retrain them not to send every patient who is sick to the hospital,” McAneny said. “Academic medical centers should partner with strong community practices to provide training in clinical oncology in the outpatient setting because with cancer becoming a chronic disease, the hospital is an overpriced and inappropriate way to treat patients with cancer. We have to restructure that and save the hospital for acute care things like COVID-19, and get cancer out of the hospital. We saw that need during the pandemic.”
This will require CMS to rethink the way it pays for graduate medical education, McAneny continued.
“We need more graduate medical education spots for oncologists and internal medicine residents because we draw from internal medicine, just as every other subspecialty does, and the pipeline is just not robust enough,” she said. “We need to truly look at how we are training our oncologists to ensure that we improve the oncology workforce.”
References:
- 2021 Snapshot: State of the Oncology Workforce in America. JCO Oncol Pract. 2021;doi:10.1200/OP.21.00166.
- ASCO State of Cancer Care in America. Key trends in tracking supply of and demand for oncologists. Available at: old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-and-guidelines/documents/2020-workforce-information-system.pdf. Published May 2018. Accessed Nov. 17, 2022.
- Erikson C, et al. J Oncol Pract. 2007;doi:10.1200/JOP.0723601.
- HHS. Health worker burnout. Available at: www.hhs.gov/surgeongeneral/priorities/health-worker-burnout/index.html. Accessed Nov. 17, 2022.
- Kirkwood MK, et al. J Oncol Pract. 2018;doi:10.1200/JOP.18.00149.
- Majority of health care workers worry about burnout from increasing burden of administrative work (press release). Available at: resources.notablehealth.com/press-release-state-of-automation-p1. Published April 26, 2022. Accessed Nov. 17, 2022.
- New surgeon general advisory sounds alarm on health worker burnout and resignation (press release). Available at: www.hhs.gov/about/news/2022/05/23/new-surgeon-general-advisory-sounds-alarm-on-health-worker-burnout-and-resignation.html. Published May 23, 2022. Accessed Nov. 17, 2022.
For more information:
Stephen S. Grubbs, MD, FASCO, can be reached via ASCO at elaiza.torralba@asco.org.
Shikha Jain, MD, FACP, can be reached at sjain03@gmail.com.
Barbara L. McAneny, MD, FASCO, MACP, can be reached at mcaneny@nmohc.com.
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