Commentary

The contagiousness of burnout

Editor’s note: This is the first of HemOnc Today’s columns for advanced practice providers (APPs). These regular columns will tackle common issues APPs face, discuss day-to-day practice and regulatory concerns, and share research advances. To contribute to this column, contact Alexandra Todak at stodak@healio.com.

Is professional burnout contagiously moving through the ranks of oncology professionals?

A HemOnc Today cover story in February 2017 announced the “tipping point” of burnout among oncologists. More recent publications have backed this trend among hematopoietic cell transplantation professionals. Nursing studies have shown burnout or compassion fatigue as a problem generally, and a study of oncology physician assistants (PAs) found burnout rates above 30%.

Mark Hyde, PhD, PA-C
Mark Hyde

I have wondered if this phenomenon moves from the top down, bottom up or bidirectionally.

The study looking at oncology PAs, published in 2017 in Journal of Oncology Practice, mentions some of the sources of oncology PA burnout. These include, among others, the amount of time spent on indirect patient care and the relationship with the collaborating physician.

In my role as director of advanced practice in a National Comprehensive Cancer Network institution, I am continually evaluating these contributors and how they lead to burnout. The proverbial ounce of prevention may go a long way if we understand these factors better and can develop effective interventions.

Efficient models of collaboration

For the sake of this review, I want to look at two familiar fictional cases. These cases illustrate a well-known debate about the best way for APPs and physicians to efficiently work together. I want to explore the effects these models might have on satisfaction and burnout for both parties.

First is the case of the oncology APP and collaborating physician team who work in tandem 100% of the time — the APP either sees the patient first and presents to the physician, who then sees the patient, or they see the patient together. This can be referred to as the “resident model,” but I will refer to it as the tandem model.

Conversely, the second case is the APP and physician who work relatively separate from each other — or the autonomous model. The APP sees his or her patients, and the physician sees his or her patients. Only rarely do they discuss or collaborate.

I concede that it is rare for either model to be practiced homogeneously but, for the sake of argument, I have oversimplified.

It seems clear that the tandem model is best for APPs who are new or have little specialty-specific experience. This model offers superb supervision and training opportunity. In time, however, it seems that APPs begin to feel undervalued or underutilized. It is very easy for the APP to accept the routine of constant and direct supervision unknowingly. It is also very easy for the physician to become accustomed to having the ability to delegate less enjoyable tasks to the APP.

This seemingly natural progression within the relationship is not likely the best for long-term satisfaction for either party. My experience suggests that reducing supervision (co-dependency) as experience increases, improves satisfaction and reduces the burnout rate. This is an opinion that may be unpopular with some physicians.

In the autonomous model — it may be hard for some APPs to concede — there can be a lack of experience or knowledge that might undermine our effort to provide the highest quality of care. A respected mentor once expressed his concern with APPs working autonomously when he said, “It is not the things you know you don’t know, but the things you don’t know that you don’t know that worry me,” alluding to unseen knowledge gaps.

Image. APP-physician spectrum.

Source: Courtesy of Mark Hyde, PhD, PA-C.

In my experience, the knowledge gaps of which APPs aren’t aware can be minimized by more supervision. So, some degree of supervision or collaboration is inherently necessary. This can increase confidence and create an atmosphere of support when done correctly, leading to less burnout. This opinion may be unpopular with some APPs.

The ‘correct’ model

Finally, it is important to address that the increasing demands of indirect patient care can lead to burnout in any member of the medical team. Awareness of this workload so that it can be shared equally seems to be a valid solution. Again, referring to my experience, most physicians and APPs are anxious to decant as much of this workload as possible. Open and honest conversations with the team about an equal and economic division of this workload is important. Maybe more staff is necessary, although this is a viewpoint unpopular with practice managers. Making the indirect care process more efficient or outsourcing where possible may also be necessary. In the end, we may have to accept that the changing face of medicine will require continuing increases in the demands of the indirect-care workload.

When we chose to practice oncology, or shortly thereafter, we all became aware of the emotional stress that accompanies our relationships with our patients, and we all have to find ways to cope with this stress. We should be able to admit when we are reaching our maximum capacity, which varies based on a number of other influences. These other influences include the quality of the relationship that exists between team members, particularly between physician, APP and nurse. Recognizing and encouraging each team member to practice at the top of their license or training is economic and helps create a satisfying career. Take the challenge and independently have each team member place an X on the APP physician spectrum where they feel the team resides (see Image). You may be surprised what your colleagues think.

I would propose that a progressive approach balancing the tandem model and the autonomous model based on mutual and earned trust and respect from all parties is the correct model. As experience increases, the team moves toward the autonomous end of the spectrum but, just as it should never be purely autonomous, it should likewise never be purely tandem. Satisfaction lies in the mutual flexibility that the spectrum provides. Burnout among all team members stems, in part, from inflexibility.

References:

Neumann JL, et al. Biol Blood Marrow Transplant. 2017;doi:10.1016/j.bbmt.2017.11.015.

Tetzlaff ED, et al. J Oncol Pract. 2017;doi:10.1200/JOP.2017.025544.

For more information:

Mark Hyde, PhD, PA-C, is the director of advanced practice at the Huntsman Cancer Institute at The University of Utah. He can be reached at mark.hyde@hci.utah.edu. Hyde acknowledges that Julie O’Brien, APRN, and Staci Oldroyd helped edit and review this article.

Disclosure: Hyde reports no relevant financial disclosures.

Editor’s note: This is the first of HemOnc Today’s columns for advanced practice providers (APPs). These regular columns will tackle common issues APPs face, discuss day-to-day practice and regulatory concerns, and share research advances. To contribute to this column, contact Alexandra Todak at stodak@healio.com.

Is professional burnout contagiously moving through the ranks of oncology professionals?

A HemOnc Today cover story in February 2017 announced the “tipping point” of burnout among oncologists. More recent publications have backed this trend among hematopoietic cell transplantation professionals. Nursing studies have shown burnout or compassion fatigue as a problem generally, and a study of oncology physician assistants (PAs) found burnout rates above 30%.

Mark Hyde, PhD, PA-C
Mark Hyde

I have wondered if this phenomenon moves from the top down, bottom up or bidirectionally.

The study looking at oncology PAs, published in 2017 in Journal of Oncology Practice, mentions some of the sources of oncology PA burnout. These include, among others, the amount of time spent on indirect patient care and the relationship with the collaborating physician.

In my role as director of advanced practice in a National Comprehensive Cancer Network institution, I am continually evaluating these contributors and how they lead to burnout. The proverbial ounce of prevention may go a long way if we understand these factors better and can develop effective interventions.

Efficient models of collaboration

For the sake of this review, I want to look at two familiar fictional cases. These cases illustrate a well-known debate about the best way for APPs and physicians to efficiently work together. I want to explore the effects these models might have on satisfaction and burnout for both parties.

First is the case of the oncology APP and collaborating physician team who work in tandem 100% of the time — the APP either sees the patient first and presents to the physician, who then sees the patient, or they see the patient together. This can be referred to as the “resident model,” but I will refer to it as the tandem model.

Conversely, the second case is the APP and physician who work relatively separate from each other — or the autonomous model. The APP sees his or her patients, and the physician sees his or her patients. Only rarely do they discuss or collaborate.

I concede that it is rare for either model to be practiced homogeneously but, for the sake of argument, I have oversimplified.

It seems clear that the tandem model is best for APPs who are new or have little specialty-specific experience. This model offers superb supervision and training opportunity. In time, however, it seems that APPs begin to feel undervalued or underutilized. It is very easy for the APP to accept the routine of constant and direct supervision unknowingly. It is also very easy for the physician to become accustomed to having the ability to delegate less enjoyable tasks to the APP.

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This seemingly natural progression within the relationship is not likely the best for long-term satisfaction for either party. My experience suggests that reducing supervision (co-dependency) as experience increases, improves satisfaction and reduces the burnout rate. This is an opinion that may be unpopular with some physicians.

In the autonomous model — it may be hard for some APPs to concede — there can be a lack of experience or knowledge that might undermine our effort to provide the highest quality of care. A respected mentor once expressed his concern with APPs working autonomously when he said, “It is not the things you know you don’t know, but the things you don’t know that you don’t know that worry me,” alluding to unseen knowledge gaps.

Image. APP-physician spectrum.

Source: Courtesy of Mark Hyde, PhD, PA-C.

In my experience, the knowledge gaps of which APPs aren’t aware can be minimized by more supervision. So, some degree of supervision or collaboration is inherently necessary. This can increase confidence and create an atmosphere of support when done correctly, leading to less burnout. This opinion may be unpopular with some APPs.

The ‘correct’ model

Finally, it is important to address that the increasing demands of indirect patient care can lead to burnout in any member of the medical team. Awareness of this workload so that it can be shared equally seems to be a valid solution. Again, referring to my experience, most physicians and APPs are anxious to decant as much of this workload as possible. Open and honest conversations with the team about an equal and economic division of this workload is important. Maybe more staff is necessary, although this is a viewpoint unpopular with practice managers. Making the indirect care process more efficient or outsourcing where possible may also be necessary. In the end, we may have to accept that the changing face of medicine will require continuing increases in the demands of the indirect-care workload.

When we chose to practice oncology, or shortly thereafter, we all became aware of the emotional stress that accompanies our relationships with our patients, and we all have to find ways to cope with this stress. We should be able to admit when we are reaching our maximum capacity, which varies based on a number of other influences. These other influences include the quality of the relationship that exists between team members, particularly between physician, APP and nurse. Recognizing and encouraging each team member to practice at the top of their license or training is economic and helps create a satisfying career. Take the challenge and independently have each team member place an X on the APP physician spectrum where they feel the team resides (see Image). You may be surprised what your colleagues think.

I would propose that a progressive approach balancing the tandem model and the autonomous model based on mutual and earned trust and respect from all parties is the correct model. As experience increases, the team moves toward the autonomous end of the spectrum but, just as it should never be purely autonomous, it should likewise never be purely tandem. Satisfaction lies in the mutual flexibility that the spectrum provides. Burnout among all team members stems, in part, from inflexibility.

References:

Neumann JL, et al. Biol Blood Marrow Transplant. 2017;doi:10.1016/j.bbmt.2017.11.015.

Tetzlaff ED, et al. J Oncol Pract. 2017;doi:10.1200/JOP.2017.025544.

For more information:

Mark Hyde, PhD, PA-C, is the director of advanced practice at the Huntsman Cancer Institute at The University of Utah. He can be reached at mark.hyde@hci.utah.edu. Hyde acknowledges that Julie O’Brien, APRN, and Staci Oldroyd helped edit and review this article.

Disclosure: Hyde reports no relevant financial disclosures.

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