Burnout. We define, measure, and talk about it endlessly but do little to fix it. Unchecked, it can lead to medical mistakes, career dissatisfaction, early retirement, provider suicide, and excess costs. With the recent pandemic, the public has become more aware of it, but action to fix it is still lagging.
Feeling underappreciated, feeling one’s work is meaningless, feeling powerless to make changes, and feelings of moral injury are but a few recognized contributors to burnout.
The increasing clerical burdens placed on physicians with electronic medical records add an average of two hours to the physician’s workday. This longer workday and the accessibility of work from a home computer means that work intrudes into home life.
Typing on the computer throughout the visit degrades the human connection with your patient. In high-volume assembly line medicine, many are forced to practice, and the sense of powerlessness that arises as more physicians are employed and cannot influence their work conditions causes burnout.
The frustration of spending more time with administrative tasks such as preauthorizations for standard therapies or additional coding to capture higher level reimbursements causes burnout.
And there’s the realization that many of these additional tasks that have been dumped in the lap of doctors are nonmedical functions.
The role of an increasing number and variety of quality measures as contributors to burnout is newly recognized. The rollout of quality measures that are often not dependent on physician performance, coupled with the fact that these quality measures are tied to physician salary and bonus, is intrinsically unfair and contributes to burnout.
These quality measures may be based on CMS measures, QOPI scores, or HCAHPS surveys. But each is often operationalized by tying a physician’s salary or bonus to their cumulative scores. Financial incentives can work to modify behavior, but when the incentive (or punishment) is the result of someone else’s actions, it can backfire and cause frustration and futility. I will focus on two and point out how they impact job satisfaction and how they can be altered to reduce their impact on burnout.
Death within 14 days of treatment is viewed as a sign of poor clinical judgment by an oncologist and results in a demerit. That is fair if the doctor is oblivious to the patient’s decline or generating revenue by treating a hopeless patient. But how about high-risk diseases like acute leukemia or high-risk treatments like CAR-T therapy, where the goal is a cure, the treatment is arduous, and death may result from curative efforts?
Or how about when the patient that is told further treatment is ill-advised but chooses to continue treatment but dies? Applied to these scenarios, the quality measure is unfair. And don’t forget, the delivery of bad news has been shown to lower your patient satisfaction score.
So dealing with the scenario of the patient who is not responding to treatment and whose condition is declining, you can receive a QOPI demerit, an HCAHPS demerit — or both! This situation repeats almost daily in oncology practice.
OP-35 measures ER visits or hospitalizations within 30 days of treatment for cancer. Sure, the oncologist should take care of urgent complications of cancer treatment, saving the patient and the system an unnecessary ER visit. The search is crude: patient name, cancer treatment date, ER visit. And there is no filtering of data. The result is that a patient with monthly cancer treatment who has coronary artery disease and periodically presents to the ER with chest pain will always represent a demerit for an oncologist. A patient with symptoms related to chemo who is offered a work-in appointment and refuses it but later goes to the ER will also count as a demerit even though the oncologist has offered a work-in appointment!
Receiving demerits for factors outside of your control will cause burnout.
Since these scenarios reflect unintended consequences of well-intentioned quality measures, commitment to try to reduce burnout requires just-in-time cooperation to enact immediate changes to the quality measures.
While it may not have been intended that these measures be used punitively, CMS and ASCO cannot absolve themselves of blame by pointing at overzealous hospital administrators. After all, the threat to hospitals of financial consequences for noncompliance with these measures is real.
These measures could easily be improved to be more reflective of what I believe they were intended to measure. Death within 14 days of treatment is meant to assess the oncologist’s ability to recognize their patient’s downward clinical trajectory and discontinue futile or harmful therapy.
Requiring documentation of a goals-of-care discussion followed by goal-concordant care seems a better way to achieve this aim. For OP-35, refine the filters so the search is for diagnoses that are associated with treatment (i.e., fever, treatment-related pain or dehydration) and exclude those patients who were offered a work-in appointment but refused it. Agility in responding to burnout measures is going to be critical moving forward.
In today’s health care system, we are asking doctors to see more patients in less time each day. We’re asking them to address their smoking, distress, and non-cancer pain at each visit. All of this while also addressing the primary reason for their visit, seeing new patients sooner, jumping through hoops surrounding narcotic prescriptions, adding more refined coding to allow higher billing rates, convincing the patients’ insurance company to preauthorize drugs and treatments faster, working late into the night to complete all your clerical tasks while avoiding unnecessary patient ER visits, and making sure that patients are referred to hospice in a timely manner. And be prepared for demerits and financial consequences no matter how hard you try.
No wonder doctors feel like hamsters running on an exercise wheel to nowhere. And this sense of futility is driving burnout. How much patient care will you get out of docs who have moved on to nonclinical jobs, retired early, or committed suicide due to burnout? The time for rumination and hand wringing is over! It is time for medical organizations to cooperate, take prompt action, and avert a health care crisis by protecting one of their most precious health care resources.
Banu Symington is a hematology-oncology physician.
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