Burnout on the rise among oncology physician assistants
Several studies have shown evidence among oncologists of burnout, characterized by severe emotional exhaustion, depersonalization and a low sense of personal accomplishment resulting from ongoing or extreme workplace stress.
Increased use of nurse practitioners (NPs) and physician assistants (PAs) has been proposed as a means of relieving oncologist workloads.
Now, a study conducted at Fox Chase Cancer Center and presented during the ASCO20 Virtual Scientific Program showed oncology PAs also experience significant levels of burnout.
“With physician burnout, one of the concerns is that physicians are going to leave oncology and there will be a workforce shortage,” Eric D. Tetzlaff, MHS, PA-C, physician assistant in the department of hematology/oncology at the cancer center and lead author of the study, said in an interview with Healio. “If PAs are also burned out, they’re not going to be there to fill the gap.”
Tetzlaff’s study follows a similar national survey of oncology PAs conducted in 2015. He spoke with Healio about the sharp increase in burnout observed since then and what it may mean for clinical practice.
Question: How did you conduct this study?
Answer: We worked with the Association of Physician Assistants in Oncology to survey members of that organization. In 2015, we created several questions of our own but used the Maslach Burnout Inventory to assess burnout. This is considered the gold standard for assessing burnout. It can be used for teachers and other professionals, as well.
Subscales of the survey evaluate contributors to burnout, including emotional exhaustion, depersonalization and a low sense of personal accomplishment. We use the same criteria that other studies have used in oncology, especially those of oncologists, so that we could compare them to some degree. We were interested in how burnout may be changing over time. So, we did this follow-up study, using the same methods we used in 2015. We used the same membership database, adding new members who had joined since the 2015 study, and the Maslach Burnout Inventory, so we had the exact same measure in 2015 and 2019. We also repeated some of the questions we used in 2015 to determine what changes may have occurred over time that could possibly explain any change in burnout.
For the current study we also used the Areas of Worklife Survey, or AWS, which is a conceptual framework for work-life factors that can lead to burnout. The AWS looks at your workload, your sense of being in control, and your personal and organizational values. We could see how well perceptions of one’s workload matched the workload they were given. For example, we found that those whose perception of an appropriate workload did not fit the actual workload had a higher rate of burnout compared with those who thought the workload fit their job expectation. We used the AWS survey as a means of assessing different components of the work setting that may not be consistent with expectations. It gave us an idea of where some of the problems are.
Q: You found that, compared with 34.8% in 2015, 48.7% of oncology PAs reported burnout in 2019. How concerning is this finding?
A: Even in 2015, at 35%, it was a lot. Now, to get closer to 50% is very concerning. This wasn’t just a couple of points on a scale, and it’s concerning not only for those providers, but also for the quality of care. We know in other settings, burnout potentially affects patient care. There also is a risk that PAs will leave the workforce.
Q: Do you have any theories as to why burnout might be increasing?
A: We didn’t identify any changes in the characteristics or role on oncology PAs that would account for the change in burnout between 2015 and 2019. However, the risk factors for burnout that were present in 2015 were still risk factors in 2019. One factor that contributed to burnout was the amount of time PAs spent on patient care. The PAs who were more likely to be burned out were those who spent less time on direct patient care and more time on indirect tasks, such as completing Family and Medical Leave Act paperwork or other administrative tasks. So, in both 2015 and in 2019, those who were burned out were spending less time with patients.
Q. Health care professionals usually pursue the medical field so they can treat patients, not do paperwork. Could this have been a factor?
A: Yes. People go into medicine to help people. They’re interested in the science; they’re compassionate. They want to spend time with patients. When they get into positions where they are spending less time doing the things that are meaningful to them and more time doing things that are mundane, or worse, below the level of their training, burnout can occur. We asked respondents how much time they spent working close to the top of their education and training. The rate of burnout was much higher for people who worked at 75% below their education and training.
Q: To what extent do you think the need for PAs to share oncologists’ workloads might contribute to the problem?
A: We don’t have certainty on that. One of the outstanding questions is, in our attempt to reduce risk for burnout, are we just shifting the burnout to another group? Are some of the tasks that lead to burnout for the oncologists simply being shifted to PAs or NPs? Are these tasks that any of us — PAs, NPs or MDs —should be doing in the first place?
Oncology requires a team approach to providing care, but the team approach to oncology care should not be narrowly thought of as the surgeons, radiation oncologists and medical oncologists. However, the reality is that quality oncology care is delivered by ‘teams of teams’ and there are numerous other providers and teams such as nurses, PAs, NPs, medical assistants and many others who form the team of teams. The interactions between members of a given team in terms of everyone’s role or the interactions between teams can influence the risk for burnout for the individuals and the teams. As we manage burnout, we often focus on certain groups. You see a report on burnout in oncologists, you see my study on burnout in PAs, but what about burnout within the oncology team? I think this is going to be very important to keep in mind going down the road.
For more information:
Eric Tetzlaff, PA, MHS, PA-C, can be reached at 333 Cottman Ave., Philadelphia, PA 19111.