Amy Hanley

Burnout and Career Satisfaction Among US Oncologists

PURPOSE To evaluate the personal and professional characteristics associated with career satisfaction and burnout among US oncologists. METHODS Between October 2012 and March 2013, the American Society of Clinical Oncology conducted a survey of US oncologists evaluating burnout and career satisfaction. The survey sample included equal numbers of men and women and represented all career stages. RESULTS Of 2,998 oncologists contacted, 1,490 (49.7%) returned surveys (median age of respondents, 52 years; 49.6% women). Among the 1,117 oncologists (37.3% of overall sample) who completed full-length surveys, 377 (33.8%) were in academic practice (AP) and 482 (43.2%) in private practice (PP), with the remainder in other settings. Oncologists worked an average of 57.6 hours per week (AP, 58.6 hours per week; PP, 62.9 hours per week) and saw a mean of 52 outpatients per week. Overall, 484 oncologists (44.7%) were burned out on the emotional exhaustion and/or depersonalization domain of Maslach Burnout Inventory (AP, 45.9%; PP, 50.5%; P = .18). Hours per week devoted to direct patient care was the dominant professional predictor of burnout for both PP and AP oncologists on univariable and multivariable analyses. Although a majority of oncologists were satisfied with their career (82.5%) and specialty (80.4%) choices, both measures of career satisfaction were lower for those in PP relative to AP (all P < .006). CONCLUSION Overall career satisfaction is high among US oncologists, albeit lower for those in PP relative to AP. Burnout rates among oncologists seem similar to those described in recent studies of US physicians in general. Those oncologists who devote the greatest amount of their professional time to patient care seem to be at greatest risk for burnout.

Projected Supply of and Demand for Oncologists and Radiation Oncologists Through 2025: An Aging, Better-Insured Population Will Result in Shortage

PURPOSE The American Society of Clinical Oncology (ASCO) published a study in 2007 that anticipated a shortage of oncologists by 2020. This study aims to update and better assess the market for chemotherapy and radiation therapy and the impact of health reform on capacity of and demand for oncologists and radiation oncologists. METHODS The supply of oncologists and radiation oncologists, by age, sex, and specialty, was projected through 2025 with an input-output model. The Medical Expenditure Panel Survey, commercial claims, and Medicare claims were analyzed to determine patterns of use by patient characteristics such as age, sex, health insurance coverage, cancer site, physician specialty, and service type. Patterns of use were then applied to the projected prevalence of cancer, using data from the SEER Program of the National Cancer Institute. RESULTS Beginning in 2012, 16,347 oncologists and radiation oncologists were active and supplying 15,190 full-time equivalents (FTEs) of patient care. Without consideration of the Affordable Care Act (ACA), overall demand for oncologist services is projected to grow 40% (21,255 FTEs), whereas supply may grow only 25% (18,997 FTEs), generating a shortage of 2,258 FTEs in 2025. When fully implemented, the ACA could increase the demand for oncologists and radiation oncologists by 500,000 visits per year, increasing the shortage to 2,393 FTEs in 2025. CONCLUSION Anticipated shortages are largely consistent with the projections of the ASCO 2007 workforce study but somewhat more delayed. The ACA may modestly exacerbate the shortage. Unless oncologist productivity can be enhanced, the anticipated shortage will strain the ability to provide quality cancer care.

Satisfaction With Work-Life Balance and the Career and Retirement Plans of US Oncologists

PURPOSE To evaluate satisfaction with work-life balance (WLB) and career plans of US oncologists. METHODS The American Society of Clinical Oncology conducted a survey of US oncologists evaluating satisfaction with WLB and career plans between October 2012 and March 2013. The sample included equal numbers of men and women from all career stages. RESULTS Of 2,998 oncologists contacted, 1,490 (49.7%) returned surveys. From 1,117 oncologists (37.3% of overall sample) completing full-length surveys, we evaluated satisfaction with WLB and career plans among the 1,058 who were not yet retired. The proportion of oncologists satisfied with WLB (n = 345; 33.4%) ranked lower than that reported for all other medical specialties in a recent national study. Regarding career plans, 270 oncologists (26.5%) reported a moderate or higher likelihood of reducing their clinical work hours in the next 12 months, 351 (34.3%) indicated a moderate or higher likelihood of leaving their current position within 24 months, and 273 (28.5%) planned to retire before 65 years of age. Multivariable analyses found women oncologists (odds ratio [OR], 0.458; P < .001) and those who devoted greater time to patient care (OR for each additional hour, 0.977; P < .001) were less likely to be satisfied with WLB. Satisfaction with WLB and burnout were the strongest predictors of intent to reduce clinical work hours and leave current position on multivariable analysis. CONCLUSION Satisfaction with WLB among US oncologists seems lower than for other medical specialties. Dissatisfaction with WLB shows a strong relationship with plans to reduce hours and leave current practice. Given the pending US oncologist shortage, additional studies exploring interactions among WLB, burnout, and career satisfaction and their impact on career and retirement plans are warranted.

Association Between Geographic Access to Cancer Care, Insurance, and Receipt of Chemotherapy: Geographic Distribution of Oncologists and Travel Distance

PURPOSE Geographic access to care may be associated with receipt of chemotherapy but has not been fully examined. This study sought to evaluate the association between density of oncologists and travel distance and receipt of adjuvant chemotherapy for colon cancer within 90 days of colectomy. PATIENTS AND METHODS Patients in the National Cancer Data Base with stage III colon cancer, diagnosed between 2007 and 2010, and age 18 to 80 years were selected. Generalized estimating equation clustering by hospital service area was conducted to examine the association between geographic access and receipt of oncology services, controlling for patient sociodemographic and clinical characteristics. RESULTS Of 34,694 patients in the study cohort, 75.7% received adjuvant chemotherapy within 90 days of colectomy. Compared with travel distance less than 12.5 miles, patients who traveled 50 to 249 miles (odds ratio [OR], 0.87; P=.009) or ≥250 miles (OR, 0.36; P<.001) had decreased likelihood of receiving adjuvant chemotherapy. Density level of oncologists was not statistically associated with receipt of adjuvant chemotherapy (low v high density: OR, 0.98; P=.77). When stratifying analyses by insurance status, non-privately insured patients who resided in areas with low density of oncologists were less likely to receive adjuvant chemotherapy (OR, 0.85; P=.03). CONCLUSION Increased travel burden was associated with a decreased likelihood of receiving adjuvant chemotherapy, regardless of insurance status. Patients with nonprivate insurance who resided in low-density oncologist areas were less likely to receive adjuvant chemotherapy. If these findings are validated prospectively, interventions to decrease geographic barriers may improve the timeliness and quality of colon cancer treatment.

Results of the ASCO Study of Collaborative Practice Arrangements.

PURPOSE ASCO projects a shortfall of oncologists in the next decade. The study was designed to address the workforce shortage by exploring collaborative oncology practice models that include nonphysician practitioners (NPPs). METHODS ASCO contracted with Oncology Metrics, a division of Altos Solutions, to conduct a national survey of NPP integration and identify collaborative practice models and services provided by NPPs, as the first phase of the ASCO Study of Collaborative Practice Arrangements. Results of the national survey were used to identify practices for the next phase, in which selected practices participated in a more detailed data survey and satisfaction surveys. Focus groups or interviews were conducted with NPPs to collect additional subjective information to inform the project. RESULTS The incident-to practice model was the predominant model. Satisfaction was universally high for patients and generally high for physicians and NPPs. In virtually all cases (98%), patients recognized they were seeing an NPP rather than a physician. Practices in which the NPP worked with all practice physicians showed significantly higher productivity than those practices in which the NPP worked exclusively with a specific physician or group of physicians. CONCLUSION The use of NPPs in oncology practices increases productivity for the practice and provides high physician and NPP satisfaction. Patients were aware when care was provided by an NPP and were very satisfied with all aspects of the collaborative care that they received. The integration of nonphysician practitioners into oncology practice offers a reliable means to address increased demand for oncology services without adding physicians.

American Society of Clinical Oncology National Census of Oncology Practices: Preliminary Report

In response to reports of increasing financial and administrative burdens on oncology practices and a lack of systematic information related to these issues, American Society of Clinical Oncology (ASCO) leadership started an effort to collect key practice-level data from all oncology practices in the United States. The result of the effort is the ASCO National Census of Oncology Practices (Census) launched in June 2012. The initial Census work involved compiling an inventory of oncology practices from existing lists of oncology physicians in the United States. A comprehensive, online data collection instrument was developed, which covered a number of areas, including practice characteristics (staffing configuration, organizational structure, patient mix and volume, types of services offered); organizational, staffing, and service changes over the past 12 months; and an assessment of the likelihood that the practice would experience organizational, staffing, and service changes in the next 12 months. More than 600 practices participated in the Census by providing information. In this article, we present preliminary highlights from the data gathered to date. We found that practice size was related to having experienced practice mergers, hiring additional staff, and increasing staff pay in the past 12 months, that geographic location was related to having experienced hiring additional staff, and that practices in metropolitan areas were more likely to have experienced practice mergers in the past 12 months than those in nonmetropolitan areas. We also found that practice size and geographic location were related to higher likelihoods of anticipating practice mergers, sales, and purchases in the future.

Who Does Not Receive Treatment for Cancer

PURPOSE Little has been published on nontreatment of cancer, yet the National Cancer Data Base (NCDB) indicates that 9.2% of patients receive no first course of treatment. Because the NCDB is limited to accredited cancer programs, there is potential for the actual rate to differ. We sought to understand the rate and characteristics of patients with cancer who receive no first course of treatment in a more population-representative data source. MATERIALS AND METHODS The Iowa Cancer Registry (ICR) strives to capture 100% of newly diagnosed cancer cases among Iowa residents, regardless of where they are diagnosed or treated. RESULTS In the ICR from 2004 to 2010, 12.3% of newly diagnosed patients with cancer did not receive a first course of treatment, which is 48% higher than the NCDB data for the state of Iowa (8.3%) during the same time period. Logistic regression indicated that nontreatment was more common in certain cancers (ie, small-cell and non-small-cell lung/bronchial cancers and low-grade non-Hodgkin lymphoma), advanced stages, older patients, those receiving treatment recommendations at nonaccredited cancer programs, and patients who never consulted an oncologist, radiation therapist, or surgeon. Distance to treatment facilities was not related to nontreatment. CONCLUSION The rate of nontreatment varies by cancer type and stage and is higher in patients receiving initial treatment recommendations in nonaccredited cancer programs than in accredited cancer programs. This pattern seems to be correlated with patient characteristics but also may be related to provider and facility characteristics available to people locally that influence both patient and provider decision making.

Oncology Workforce: Results of the ASCO 2007 Program Directors Survey

The supply of oncologists is projected to increase by 14%, but the demand for oncology visits is projected to increase by 48% because of a growing aging population and an increase in the number of cancer survivors. Multiple strategies must be implemented to ensure continued access to quality cancer care, such as increasing the number of oncology training positions.

The Study of Collaborative Practice Arrangements: Where Do We Go From Here?

In 2007 ASCO published their workforce study, Forecasting the Supply of and Demand for Oncologists, which gave ASCO its first look at the future of oncology care delivery in the United States. The view was bleak, with the supply and demand curves painting an austere picture of oncology by 2020. The study predicted a demand increase of 9.4 to 15.1 million oncologist visits. This increase would create a visit deficit that translates into a predicted shortage of between 2,550 and 4,080 oncologists by the end of this decade. To address such a significant shortfall in an already strained medical system will require a multifaceted approach. Substantially increasing the supply of oncologists would not be possible in the current medical system, so a transformation of oncology practice models emerged as the most likely strategy to address expected demands in oncology services. It has been suggested by many in the oncology community that expanded use of nurse practitioners and physician assistants, jointly known as nonphysician practitioners (NPPs), could effectively extend the supply of oncologist services, for both active oncology treatment and care for the growing number of cancer survivors. Better integration of NPPs could also improve practice quality and efficiency and, by better balancing workload and skills, may increase professional satisfaction for providers. ASCO’s first glimpse into this opportunity stemmed from a 2006 survey of oncologists. The survey reported that 56% of oncologists worked with NPPs and that oncologists who employed NPPs in their practices reported higher visit rates than those who did not. In addition, the majority of oncologists believed that NPPs benefited their practices by enhancing efficiency, improving patient care, and increasing physicians’ professional satisfaction. ASCO’s Workforce Advisory Group, a volunteer group tasked with creating and managing workforce initiatives to address the impending shortage, sought to study the use of NPPs in a more systematic fashion. The Advisory Group was concerned that the only ASCO report on the inclusion of NPPs was based on survey results from oncologists and that actual data on practice efficiency and satisfaction of all stakeholders, including oncologists, NPPs, and patients, were lacking. The Advisory Group wanted to be proactive in providing guidance for members’ practices, with the basic tenet that if collaborative practices that use NPPs could be modeled for efficiency and satisfaction, ASCO recommendations should be data driven and evidence based. To establish data on practices that use NPPs, ASCO partnered with Oncology Metrics, a division of Altos Solutions, in 2009 to conduct the ASCO Study of Collaborative Practice Arrangements. The aim of the study was to determine how using NPPs could benefit both oncology practices and patients, and to identify optimal arrangements for practices looking to make such expansions. From the outset, the study sought to evaluate the economics and satisfaction levels in community clinical practices rather than practices in academic centers. This was based on the assumption that academic practices have confounding factors that would influence NPP collaboration models and efficiency. This study used not only survey results, but also quantifiable, practice-derived data. The results of the study, published in Journal of Oncology Practice, provide compelling data from the perspective of professional satisfaction, patient satisfaction, and practice efficiency demonstrating that increased inclusion of NPPs in community-based practices will benefit all oncology care stakeholders. Several conclusions can be drawn from this study: Collaborative oncology practices are associated with a high degree of satisfaction for professionals and patients. Those practices in which an NPP is employed have both high physician and NPP satisfaction with their collaborative practice model. Critical to the practices is that patients know when they are being treated by an NPP rather than a physician, and, in addition, they are very satisfied with the care they receive in the collaborative practice. This study provides definitive proof that physician-NPP care teams are well accepted by patients with cancer, alleviating physician concerns that patients will react negatively to the introduction of NPPs into their care. Productivity of all professionals is enhanced when NPPs works with multiple physicians rather than just one oncologist. The concept of NPPs working with just one physician rather than multiple physicians would seem to be too subtle to affect practice activity. However, the study demonstrated that practices in which NPPs worked with all physicians had a 19% greater numbers of encounters per full-time equivalent physician in the 6-month observation period compared with practices that used a one-to-one NPP-physician arrangement. Though not included in the publication, the results were similar when productivity was assessed by either patient encounters or relative value units (Shuster S, personal communication, June 4, 2011). It is hard to envision another practice modification that affects practice productivity to such a degree. JOURNAL OF CLINICAL ONCOLOGY E D I T O R I A L S VOLUME 29 NUMBER 27 SEPTEMBER 2

Where do patients with cancer in Iowa receive radiation therapy

PURPOSE Multiple studies have shown survival benefits in patients with cancer treated with radiation therapy, but access to treatment facilities has been found to limit its use. This study was undertaken to examine access issues in Iowa and determine a methodology for conducting a similar national analysis. PATIENTS AND METHODS All Iowa residents who received radiation therapy regardless of where they were diagnosed or treated were identified through the Iowa Cancer Registry (ICR). Radiation oncologists were identified through the Iowa Physician Information System (IPIS). Radiation facilities were identified through IPIS and classified using the Commission on Cancer accreditation standard. RESULTS Between 2004 and 2010, 113,885 invasive cancers in 106,603 patients, 28.5% of whom received radiation treatment, were entered in ICR. Mean and median travel times were 25.8 and 20.1 minutes, respectively, to the nearest facility but 42.4 and 29.1 minutes, respectively, to the patients chosen treatment facility. Multivariable analysis predicting travel time showed significant relationships for disease site, age, residence location, and facility category. Residents of small and isolated rural towns traveled nearly 3× longer than urban residents to receive radiation therapy, as did patients using certain categories of facilities. CONCLUSION Half of Iowa patients could reach their nearest facility in 20 minutes, but instead, they traveled 30 minutes on average to receive treatment. The findings identified certain groups of patients with cancer who chose more distant facilities. However, other groups of patients with cancer, namely those residing in rural areas, had less choice, and some had to travel considerably farther to radiation facilities than urban patients.