By Aaron Tallent
In oncology, burnout has been a growing issue as physicians and other healthcare professionals (HCPs) try to balance long hours, increased patient volume, overwhelming paperwork and administrative burdens, and decreased autonomy at work. The pandemic, which forces HCPs to prioritize care, wear personal protective equipment (PPE) or be creative in making it, and limit face-to-face interactions with patients, has only exacerbated physician burnout.
“Some people are able to adapt and accommodate [burnout] with a cool thermostat,” said Ray D. Page, DO, PhD, FACOI, FASCO, President of The Center for Cancer and Blood Disorders in North Texas, “but then you have an equal number of people that through all these stressors their thermostat is set on hot and it’s been really hard for them to adapt.”
The Consequences of Burnout
With more medical professionals’ thermostats moving from cool to hot, the effects of burnout can be detrimental, especially during a pandemic. A Physicians Foundation survey conducted in August 2020, found that 18% of respondents (n=2,334) said they have increased their use of medications, alcohol, or illicit drugs since the start of the pandemic, 22% know another physician who has committed suicide, and 26% know a doctor who has thought about it.
The effects of burnout can be felt by the both the individual physician and the practice. Physicians may neglect their health, which could harm them long-term, while others may choose a career change and/or early retirement.
At the practice level, this leads to staff turnover and physician shortages, which can result in lost revenue and burnout amongst the remaining HCPs. A cost-consequence analysis in the Annals of Internal Medicine estimates that $4.6 billion is lost to burnout each year in the United States through costs related to physician turnover and reduced clinical hours.
An even more concerning consequence of burnout are medical errors or poor quality of care. Last year, researchers at Stanford Medicine published an analysis of 123 articles on burnout and quality of care. They determined that if physicians are experiencing burnout, the level of care they provide is likely also to suffer.
“We don’t like to say that we take it out on our patients, but as a human being, that probably happens,” said Piyush Srivastava, MD, an oncologist at Kaiser Permanente Walnut Creek Medical Center in California. “Those attitudes can harm patient satisfaction and team communication, all of these things which are essential to quality of health care.”
ASCO Addresses Burnout
The impact of burnout amongst oncologists has prompted the American Society of Clinical Oncology (ASCO) and other members of the oncology community to take steps to address it. ASCO convened a focus group to better understand workplace stressors during COVID, how they impact patient care, and strategies for dealing with them. Participants reported burnout stressors that included experiencing death and self-isolation in a new way, seeing racism firsthand, financial problems, and managing childcare while working from home.
Others discussed unique challenges they faced within their workplace, such as not having enough PPE. “[Our] hospital initially determined that oncology was low risk, not recognizing that projectile vomiting could be a significant risk factor,” said one participant.
At ASCO’s 2019 Annual Meeting, the society’s Ethics Committee held a roundtable to develop recommendations for addressing burnout. The main recommendation that has since been implemented was the creation of an Oncology Clinician Well‐Being Task Force with a mission of improving the quality of cancer care through reducing burnout and enhancing the well‐being of oncology clinicians.
From that task force an organizational road map was created and for the next five years, ASCO and its leadership is supporting three specific goals related to burnout, including clinician well-being, diversified resources, and increased promotion of research on burnout.
“It’s not a one size fits all thing, but I think we’ve got a great group that can come up with good suggestions to create solutions,” said Dr. Page, a member of the Oncology Clinician Well-Being Task Force.
A key first step has already taken place in the fact that more oncology professionals are comfortable discussing their struggles with burnout and getting advice on how to overcome them.
“I think it’s amazing that [we] can even be talking about burnout very openly,” said Dr. Srivastava, co-chair of the Oncology Clinician Well-Being Task Force. Dr. Srivastava’s goal is a community where no oncology clinician is embarrassed about experiencing burnout or seeking help.
While many oncology professionals are satisfied with their career choices, the demands of the job make them susceptible to burnout. In 2014, ASCO published findings from a survey of nearly 1,500 oncologists evaluating career satisfaction and burnout. While more than 80% were satisfied with their career choices, 44.7% reported some level of burnout.
The survey also found that respondents worked an average of nearly 60 hours per week and saw a mean of 52 outpatients — oncologists who gave the greatest amount of time to their patients were at the highest risk for burnout.
Another challenge for oncologists is managing the day-to-day inefficiencies within a practice or the bureaucracy of working with insurance companies to make sure patients receive treatment in a timely manner. Physicians often find themselves in situations where they are having to work the phones and advocate for their patients.
“I recently I had to make seven different phone calls just so a patient could get a biopsy in a timely fashion,” said Dr. Srivastava.
Administrative burdens are also demanding more of physicians and cutting into their time with patients. Prior authorization, where physicians have to seek approval from insurance providers before prescribing a procedure or medication, often puts HCPs in a position where treatment outcomes and timeliness of care hinges on how quickly an insurance company approves a type of treatment that is part of the standard of care. If a patient is not responding to standard treatment, but may benefit from off-label or nonevidence-based care, obtaining prior authorization for it can be futile, adding stress to the HCP and the patient.
Finally, the enactment of two massive healthcare bills in the last decade in the Affordable Care Act and the Medicare Access and CHIP Reauthorization Act, has collectively produced thousands of pages of rules, with the latter creating new reimbursement policies that oncologists had to take time to implement and understand.
In addition, the Centers for Medicare and Medicaid Services continue to adjust its reporting requirements for Medicare reimbursement. Since 60% of people who have cancer are 65 and older, this presents oncology with a greater administrative challenge than many other medical specialties.
While electronic health records (EHRs) were intended to reduce administrative duties, the lack of interoperability between different systems has hindered them from achieving that goal. “We’re doing the work for the EHRs. They’re not doing the work for us,” said Dr. Page.
Burnout During COVID-19
Going into 2020, many oncologists were experiencing and trying to overcome burnout. The COVID-19 pandemic only made things worse. Physicians suddenly found themselves having to suspend clinical trials, meet with patients virtually, and wear more PPE, as well as make do when faced with PPE shortages. Prioritizing care by delaying critical surgeries or substituting treatments because of the surge of COVID-19 patients was likely unnerving for every oncologist forced to make those tough decisions.
“[Oncologists] had to prioritize because infusion centers operated on zero to limited capacity and IV drugs are not easily administered,” said Dr. Srivastava. “For the first time, the oncologist had to actually become preoccupied with delaying diagnosis, delaying treatment, and having to prioritize who receives treatment and who doesn’t.”
According to Dr. Srivastava, the perfect storm for burnout is when the oncologist is seeing several patients a day and seeing them at their greatest time of suffering. “I think it’s that emotional burden that compounds the workload, which probably leads to a perfect storm for burnout,” she concluded.
As part of this effort to address burnout, ASCO recently published an editorial on ways to address burnout during and beyond the COVID-19 pandemic. The authors recommend having leaders in oncology practices collaborate with their physicians to improve the environment and culture during and after COVID-19. Evidence-based methods for doing so include formal assessments of the work climate, COVID-19 oncology team education, peer support, and trauma-informed supportive collaboration.
SIDEBAR: Defining Physician Burnout
The first scientifically developed measurement system for assessing burnout was the Maslach Burnout Inventory (MBI), which was co-developed in 1981 by Christina Maslach, Ph.D., a social psychologist and Professor Emerita of Psychology at the University of California, Berkeley. The MBI assesses 22 symptom items pertaining to occupational burnout across three dimensions: 1) energy depletion or exhaustion, 2) increased negative or cynical feelings, and 3) reduced professional efficacy. To be suffering from full burnout, one has to receive negative scores in all three dimensions.
In May 2019, the World Health Organization (WHO) included in its 11th Revision of the International Classification of Diseases (ICD-11) a definition of burnout stating that it “is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed.” The WHO also said that burnout was characterized by the three dimensions in the MBI.
While overcoming burnout can be a personal challenge, Dr. Maslach says overcoming burnout is often an organizational challenge. If a workplace subjects its employees to unfavorable conditions, including demand overload, social toxicity, and value conflicts, then it is likely prone to burnout.
“A common response to burnout is to focus on helping individuals cope better with ongoing stressors. But research points to a different response – help the workplace modify its sources of stress. In other words, fix the job, not just the person,” said Dr. Maslach. “We need to create new models of healthy work environments, which are more sustainable and effective, so that everyone can work smarter instead of harder.”