Finding Time for Stress Relief Increasingly Difficult for Oncologists

Keith Lerro, MD

Keith Lerro, MD, is the sole oncologist at his Wilson, North Carolina practice and often puts in seven day weeks. That is despite the fact that his practice, Regional Oncology Medical Center, employs no fewer than six administrators to manage business accounts, interact with payers, and arrange care and payment for underinsured patients. In 2003, a practice of Regional’s size could have gotten by with one or two administrators, Lerro estimates. But things have changed.

Many doctors in oncology are pushing themselves to similar extremes. Longer workdays have become a fact of life. Physicians interviewed for this article said they are spending less and less time with patients and more time on the phone with payers, more time in late night business meetings, and more time filling out electronic health records (EHR). Their personal time also has evaporated as the complexity of running an independent practice has grown. Doctors said they no longer have enough time for relaxing activities that ease the stress of putting in so many work hours.

Working With Payers Is One of the Biggest Challenges

Source: Shanafelt, Gradishar et al, 2014.

Lerro said that he may owe his longevity in this now-grueling profession to the business exposure he received at his former practice, Southeastern Medical Oncology, also of Wilson. When he was there, he voluntarily attended business meetings because he was interested in that side of practicing oncology. Little did he realize that the knowledge he was acquiring would be critical for sustaining his current practice. Without that knowhow, he would have been underequipped for managing today’s reporting quality measures and more restrictive payment policies of insurers. “The evolution of the mandates and the shrinking margins have forced many private practices out of business,” he said. “Many of them were reasonably well run, but they just couldn’t survive.”Now, working with payers consumes more of the workday than ever before, oncologists said. In addition, much more concentration, skill, and knowledge are needed to work successfully with payer policies and government regulations. Even after putting in additional time and effort, oncologists find it difficult to get approvals for the treatments they think are most appropriate. “The role of the physician has shifted into being a mediator between the insurance company and the patient,” Lerro said. “The doctor cannot treat the patient based on his own evidence-based review of the literature. He needs to know all of the treatment options possible and choose the one that the insurance company will pay for and the patient’s copay can handle.”Part of the additional effort that has to be invested comes in the form of actually confronting payers over denials that seem unjustified based on evidence and standards of care, according to Myron Bednar, MD, a medical oncologist at Hunterdon Hematology and Oncology in Flemington, New Jersey, who said he is spending much more time on paperwork, phone calls, and case reviews with payer representatives. “Even when we follow [National Comprehensive Cancer Network] guidelines, we get pushback or denial from insurance companies, and we have to present our cases through peer-to-peer meetings or by written letter to get approval,” he said.

Bednar said one heartbreaking example of this involved a fruitless, eightweek struggle to get a payer to cover a promising, off-label treatment for a stage IV breast cancer patient. The patient had failed multiple treatment options and was unable to obtain insurance coverage for a targeted agent, which had been approved for kidney cancer and was predicted to work based on the gene sequencing of the woman’s tumor. Eventually, after the payer wouldn’t budge on its coverage decision, Bednar was able to get the treatment through a program from the pharmaceutical company. The patient is responding well to the drug several months later, but Bednar stated the case is an example of how meetings, letters, and phone calls are not always successful and take time away from patient care.

Outdated Payer Policies Lead to Debates

Genomic testing and targeted therapies may have improved the likelihood that treatment decisions will succeed, but carte blanche freedom to prescribe is a thing of the past, Bednar said. “When I first started practicing 16 years ago, we could use a drug, even if it was approved for a different disease state, because it was [FDA] approved and available,” said Bednar. “We’re doing a lot more multiplex gene testing that predicts response to therapies and, based on the genomics of the tumor, it may predict response to a drug approved for another disease. Sometimes, I’m not able to treat patients with what I think might be the best treatment.”Sometimes, payer policies are not up-to-date with advances in modern medicine, and this requires that physicians spend time arguing with payers approved therapy pathways are too restrictive said Robin Zon, MD, a medical oncologist at Michiana Hematology Oncology of Indiana. Clinical pathways policies also reduce physician autonomy and stand in opposition to the effort to individualize therapy based on patient and tumor characteristics, she said. “Medical oncologists want to deliver state-of-the-art care with highlevel evidence. The problem is that there is a lot of interference because of the payers’ requirements for preauthorization and their denials of coverage.”

Electronic records result in better standardization of care and provide many other benefits, but physicians find that these systems for aggregating data and sharing it across platforms are gluttons for time. Although many physicians would prefer to spend more face time with their patients, these computerized tasks are hogging increasingly larger portions of the day. Many physicians are skeptical that the net result is an improvement. More than 40% of respondents in the 2015 ASCO Trends Survey said that implementation of EHR makes it difficult or very difficult to improve efficiency, and only one-third reported being satisfied or very satisfied with their EHR.¹

Switching to Electronic Records Was Like Learning a Language Zon said the initial process of converting from paper to electronic records was like “learning a new language,” and although she stated that the system has become easier to manage over the years, the additional requirements to satisfy quality metrics for Centers for Medicare & Medicaid Services (CMS) payment have substantially increased her hours spent at work. Zon indicated that many of her colleagues spend several hours on weekends catching up on these requirements, and some have even hired scribes to ease the workload.

Similarly, Patrick Elwood, MD, medical oncologist and president of the Mark H. Zangmeister Center in Columbus, Ohio, estimated that the greater need for electronic recordkeeping means that over half of the time spent with each patient involves recording information on the computer. “It has effectively taken away 50% of our time with patients.”

Previously, there were financial incentives that made it worth the effort for physicians to participate in quality improvement programs. These incentives helped to pay for the overhead of maintaining computerized systems, Lerro said. Now, many of those incentives have disappeared, yet it has become necessary to participate in quality improvement programs in order to stave off financial disaster, he said. “Many of these [EHR] programs involve things that we’ve always done but now have to capture. That takes time, and the intellectual skills needed to comply with these federal mandates continue to increase.”

Zon and Bednar said their practices have in-house technology specialists whose job it is to confirm that CMS and private payer reporting requirements have been met. Zon said her practice has hired a business analyst to ensure that operations are cost-effective and in compliance with government regulations. Even with this help, she and her colleagues spend many evenings discussing how to manage the practice in the face of the shifting requirements. “Recently, we were in a business meeting until 9 pm, just to figure out how to keep our doors open with these requirements,” she said.

The increasing demands on physicians’ time are taking some of the enjoyment out of the profession. Symptoms of burnout are increasingly prevalent, and oncologists are retiring at earlier ages than before; and young physicians, who are aware of the higher workload and decreasing job satisfaction in oncology, have become harder to recruit.

A recent survey of randomly sampled ASCO members revealed that although the majority (>80%) of oncologists were satisfied with their choice of oncology as a career, 45% reported at least one symptom of burnout.² In addition, only 33% were satisfied with their work-life balance.³ Symptoms of burnout and levels of satisfaction with work-life balance were the strongest predictors of whether physicians intended to reduce clinical hours or retire early. Burnout and job dissatisfaction are two factors, along with an aging population and increased rates of cancer survival, that are expected to cause a shortage of medical oncologists by 2020.⁴

“Many physicians who are reaching the age of 60 years are beginning to wonder whether the extra work is worth it, said Richard Brown, executive director of the Mark H. Zangmeister Center. “They went into medicine to take care of patients, but they’re finding less of that because of the obligations from the government and insurance carriers.” He said it has become harder for him to recruit younger physicians and retain senior-level ones.

Zon said that the shift from time with patients to time spent on EHR reporting that does not directly benefit her or her patients further contributes to dissatisfaction with work. “I am happiest when I’m in the room with the patient and the family. I am least happy when I’m sitting in front of a computer at night clicking boxes, trying to make sure I’m ready for the next day and that my pathway compliances have been met,” she said.

Oncology Is Still a Very Rewarding Profession

Furthermore, physicians are more likely to experience burnout if they don’t have opportunities to work off the stress, such as by engaging in exercise or meditation, Zon said.Bednar said that oncology continues to be extremely rewarding when he is working with patients, but he said the job can be highly demanding, given the complexity of cancer and the difficulty of helping patients manage their personal and professional lives as they undergo treatment. Bednar stated that interaction with colleagues from other specialties at weekly tumor board meetings helps him to manage these challenges. Practice pressures are also reduced with the aid of a social worker, who not only works with patients at Bednar’s practice but also attends the tumor board meetings and addresses medical and social issues that the oncologists may have when caring for patients. “With some of the situations we’re faced with, it is helpful to bounce ideas off each other,” said Bednar.

Zon said medical societies should continue to collaborate to solve the problems of increasing workload and burnout that afflict professionals in all medical specialties. She said ASCO’s The State of Cancer Care in America reports, which began in 2014, and special sessions at the organization’s 2015 annual meeting were helpful in boosting awareness of the problems of overwork. She said that such efforts may lead to interventions that promote a fulfilling, productive environment for physicians and their patients.

References

1. ASCO. The state of cancer care in America, 2016: a report by the American Society of Clinical Oncology. J Oncol Pract. 2016 Apr;12(4):339-383. doi: 10.1200/JOP.2015.010462.
2. Shanafelt TD, Gradishar WJ, Kosty M, et al. Burnout and career satisfaction among US oncologists. J Clin Oncol. 2014 Mar 1;32(7):678-686. doi: 10.1200/JCO.2013.51.8480.
3. Shanafelt TD, Raymond M, Kosty M, et al. Satisfaction with work-life balance and the career and retirement plans of US oncologists. J Clin Oncol. 2014 Apr 10;32(11):1127-1135. doi: 10.1200/ JCO.2013.53.4560.
4. Erikson C, Salsberg E, Forte G, et al. Future supply and demand for oncologists: challenges to assuring access to oncology services. J Oncol Pract 3:79-86, 2007. doi: 10.1200/JOP.0723601.