While compensation plans for hematologists and oncologists based on clinical productivity alone are associated with high clinician burnout, increased support from advanced practitioners (APs) may be associated with reduced burnout among physicians who treat patients with hematologic and other malignancies, according to a study in Blood Advances.
Lead author Alfred Ian Lee, MD, PhD, of Yale School of Medicine in Connecticut, commented that many hematologists and oncologists are unaware of the burnout they or their colleagues are experiencing, and discussions on burnout are largely lacking in modern medicine.
“As a result, when providers experience burnout, they often think they are alone and that there’s something wrong with them, and they don’t know how to seek help or that help is even available,” Dr. Lee said. “I think on a personal level, the greatest challenge to burnout is getting physicians to recognize it in themselves and in others, to talk about it with each other, and to seek help when they experience it.”
According to Dr. Lee, the study survey, titled Survey of Practicing Hematologists & Oncologists, was part of a multiyear study of the hematology workforce that the American Society of Hematology launched in 2017. Dr. Lee is a chair of the initiative.
In the survey, clinicians were queried on 27 multiple-choice and open-ended questions that assessed practice activities, practice satisfaction, compensation, and practice settings.
Dr. Lee and researchers pilot tested the survey with 14 attending physicians in academic and community practice, and the final survey was distributed between May and July 2019 to 2,500 hematologists and oncologists in the U.S.
A single-item instrument from the Physician Work Life Study was used to assess respondents’ level of burnout on a 5-category ordinal scale. The definition of “any burnout” was a score of 3 or higher, along with one or more symptoms of burnout such as emotional or physical exhaustion. A score of 4 or higher characterized a “high burnout” outcome.
In addition to burnout assessment, the researchers queried respondents on career satisfaction, AP support, and compensation models, among other metrics.
The overall response rate to the survey was 25% (n=631). A total of 411 hematologists and oncologists had complete responses that were included in the final regression models.
Approximately 22% of respondents reported receiving payment through a relative value unit (RVU)-only compensation plan, and around 24% of respondents were paid through a combination of an RVU-based compensation plan and salary. Fifty survey respondents (12%) said they had other compensation arrangements, including bonuses, stipends, grants, or profit sharing and shareholder agreements.
Almost 37% of respondents with complete survey data reported burnout, and 12% of respondents had high burnout. Approximately 8% of those who responded to the survey had persisting burnout symptoms, while 4% endorsed the need or desire to seek professional help for their burnout symptoms.
For the total cohort, 33% of respondents had burnout, while around one out of 10 physicians reported high levels of burnout.
Weighted multivariate logistic regression models showed a positive association between high burnout and RVU-only compensation (adjusted odds ratio [aOR] = 4.37; 95% CI 2.00-9.58; p≤0.01) and female sex (aOR=2.56; 95% CI 1.24-5.28; p<0.05). An inverse association was found between high burnout and working often with APs (aOR=0.40; 95% CI 0.20-0.80; p≤0.01) and physician age below 40 (aOR=0.23; 95% CI 0.07-0.80; p<0.05).
The investigators noted that AP support did not significantly prevent the risk of high burnout among academic providers compared with community providers, despite the former group having greater access to APs. The authors wrote that this finding “may reflect intrinsic differences in the responsibilities of academic and community physicians, as academic providers in our survey spent much more of their time involved in mentoring and research, where AP support would likely have a lesser role.”
A limitation of the study was the reliance on the validated, single-item Physician Work Life Study question to assess burnout rather than the use of the complete Maslach Burnout Inventory. Additionally, some of the participants who reported burnout may have been either more or less inclined to respond to the survey because of burnout.
Dr. Lee noted that he and his colleagues hope the survey data may “encourage the development of physician compensation systems not based on clinical productivity entirely and expand the role of APs in clinical practice” to help combat burnout in the physician community.
Any conflicts of interest declared by the authors can be found in the original article.
Reference
Lee AI, Masselink LE, De Castro LM, et al. Burnout in U.S. hematologists and oncologists: impact of compensation models and advanced practice provider support [published online ahead of print, 2022 Apr 27]. Blood Adv. doi: 10.1182/bloodadvances.2021006140.
Perspectives
The authors used a national survey to examine the effect of physician compensation and the availability of clinical support staff on burnout among hematologists and oncologists. The analysis of the responses revealed compensation plans based entirely on generating RVUs were significantly associated with high burnout among academic and community physicians. Among academic physicians, female gender was also associated with high burnout. Among community physicians, the availability of APs had an inverse association on burnout.
Incentive pay models for physicians have been previously associated with increasing the risk of burnout compared to other salary models.1 This study by Lotte Dyrbye, MD, of the University of Colorado School of Medicine, and colleagues reveals this association can be attributed to hematologists and medical oncologists. Transparent and continuous discussions between physicians and administrators are key to addressing expectations and payment models in order to achieve a balance of appropriate compensation and satisfaction.
Female gender was found to be an independent risk factor for high burnout, in keeping with findings from several prior studies. This represents an urgent call to delve deeply into possible contributors to dissatisfaction and obstacles for female physicians. Given that the Association of American Medical Colleges annual report on medical school enrollment in 2019 revealed that the majority of medical students (50.5%) are women,2 there is a pressing need to address this problem with precision.
The study also revealed an inverse association of working with APs and high burnout among community physicians. The integration of APs in varying constructs and patient care models represents a worthwhile strategy to address physician shortages across the U.S. However, careful consideration regarding the ultimate roles and responsibilities of these providers must be undertaken. Published assessments reveal APs report feeling overwhelmed if not provided with adequate training within the field of hematology and oncology, which could ultimately contribute to job turnover.3,4 As more institutions develop programs for specialized training in hematology for APs, organizations constructing patient care models must keep in mind that this training is not the equivalent of that of the hematologist or medical oncologist counterpart. It would be unfortunate to inadvertently cause burnout among our AP colleagues.
Hematology and medical oncology continue to reside on the cutting edge of innovation. Individuals committed to the accurate delivery of the most appropriate, up-to-date care must have resources and strategies to battle burnout. The authors of this piece reveal areas in need of closer examination and subsequent action to ensure patients and providers receive the attention and consideration needed for the highest quality care.
Chancellor Donald, MD
Tulane University School of Medicine
New Orleans, Louisiana
References
- Dyrbye LN, Shanafelt TD, Sinsky CA, et al. Burnout among health care professionals: a call to explore and address this underrecognized threat to safe, high-quality care. Washington, DC: National Academy of Medicine; July 5, 2017.
- The majority of U.S. medical students are women, new data show. Published December 9, 2019. Accessed May 23, 2022. https://www.aamc.org/news-insights/press-releases/majority-us-medical-students-are-women-new-data-show.
- Hwa YL, Marshall AL, Shelly JL, Colborn LK, Nowakowski G, Lacy M. Assessment of the need for a hematology-specific fellowship curriculum for advanced practice providers using a needs-based survey. J Oncol Pract. 2019;15(7):e593-e599.
- Thomassen A. Fellowship programs: reflections of an advanced practice nurse fellow. Clin J Oncol Nursing. 2018;22(4):383-385.