Oncology training programs must adapt to equip graduates with administrative experiences necessary for real-world practice, warts and all.
Steve Lee, MD
After a series of high-profile house staff suicides, ACGME residency and fellowship programs have struggled to balance service responsibilities and education in attempts to increase wellness and reduce burnout. Oncology training programs have not been spared, with a 2014 JCO study reporting 34% of fellows reporting burnout, peaking at 43% in year 1.
Personal narratives published by fellows identify the emotional toll of caring for oncology patients as driving burnout, with recommendations for enhancing self-care and teaching resilience suggested as coping mechanisms. In response, some program directors have reduced patient loads as well as non-clinical responsibilities to improve fellow satisfaction.
Unfortunately, burnout remains a reality in practicing oncologists, with 45% of oncologists in 2012-2013 describing burnout conditions. Structural stressors are paramount in independent practice. The 2018 ASCO State of Cancer Care in America (SOCCA) results reported in JOP found that 58% of survey responders identified payer pressure as the primary point of pain, among which 75% specified prior authorizations (PAs) as especially noxious.
There is no relief in sight for PA, as SOCCA editorials by Newcomer and Balaban identify both business and legislative barriers to streamlining PA processes. Consequently, PA burden grows as new FDA approvals of pricey Part B and Part D drugs demand further clinical justifications—and time—from prescribing oncologists. This is particularly poignant as each additional hour of administrative tasks per week increases burnout risk by 5%.
Interestingly, career expectations by fellows do not quite correspond to reality as reported by practicing oncologists. Fellows in 2014 significantly underestimated hours worked per week, number of patients seen per week, as well as hours spent on non-clinical administrative tasks. Published fellow narratives notably do not identify hours on hold for peer-to-peer appeals as reasons for their burnout. Not surprisingly, burnout rates spike between the final year of fellowship (28%) and practice (34%). These discrepancies suggest a fundamental disconnect between the oncology training environment and practice.
As oncology fellowship programs exist to train successful oncologists, these findings demand changes to curricula to better reflect future patient loads and administrative demands. This is important because all but the most laboratory-based oncology graduates are compelled to earn their keep through patient billing in a predominantly RVU-based environment. After all, 76% of oncology practices remain small operations of 1-5 physicians despite an industry-wide trend towards consolidation.
The hematology/oncology training program at New York University School of Medicine, of which I am a recent graduate, offers a compelling training model. Fellows’ outpatient time is split between shadowing disease-specific faculty at the flagship cancer center and managing their own patient panels at the municipal public hospital. In this traditional system, fellows in the public clinic take primary longitudinal ownership of their patients, with rotating faculty serving as weekly consultants and safety monitors. As primary oncologists, fellows must navigate PAs and appeals for pharmacy and radiology orders as well as various other administrative tasks such as requests for disability.
It is not a surprise that our fellows in their longitudinal clinics identify payer pressures including PA, an area of particular program dissatisfaction. Heavy outpatient patient loads are also identified as reasons for stress and loss of educational opportunity. Program leadership has responded by reducing clinic volume and delegating less interesting clinical and non-clinical responsibilities to others in favor of more didactic time and faculty contact. Ironically, fellows are not explicitly introduced to practice innovations at NYU such as the CMS Oncology Care Model or discussion about adopting clinical pathways.
But in improving work-life balance and shifting training to more purely the science of oncology, are we doing our fellows a disservice? After all, the ACGME core competency of Systems Based Practice requires trainees to “Work effectively in various health care delivery settings and systems relevant to their clinical specialty [and] coordinate patient care within the health care system relevant to their clinical specialty.” These changes seem to specifically avoid the area causing stress in actual practice.
Until physician advocates can correct the burnout-inducing environment into which fellows graduate, practice is what it is. Oncology training programs must engage fellows in the ugly details of the practice of oncology, which include administrative tasks and higher patient loads, to avoid career burnout due to a perceived bait-and-switch upon starting their careers. Much may ride on the success of resilience and self-care programs in both the fellow and practice settings.