Provider burnout hinders cancer care quality

Clinician burnout is a frequent problem in clinical oncology. It can affect oncologists’ effective communication with patients, the quality of care delivered, and the physical and emotional well being of caregivers-creating retention and turnover challenges for cancer centers.

During the American Society of Clinical Oncology (ASCO) 2016 Annual Meeting in Chicago, attendees heard more about provider burnout during the June 6 session, “Curing Burnout in Oncology: Mindful Self-Compassion, Communication, and Practice.”

HlubockySession presenter Fay J. Hlubocky, PhD, of the University of Chicago, department of medicine, section of hematology/oncology, recently spoke to Managed Healthcare Executive (MHE) about burnout in healthcare professionals.

MHE: How does healthcare provider burnout affect providers, their patients, and the centers that employ them?

Hlubocky: Healthcare clinician burnout greatly impacts all parties leading to potential significant undesirable consequences for all involved. For the clinician, unaddressed burnout causes personal and professional consequences that affect the individual’s physical and emotional health. Feelings of emotional exhaustion or cynicism are important core signs. Professionally, clinician burnout contributes to diminished quality care, reduced satisfaction, and a poor sense of overall accomplishment. Work-life balance is affected.

Patients may find it a challenge to communicate effectively with these clinicians, which greatly influences the quality of the clinician-patient relationship. From an organizational perspective, clinician wellness is essential to the success, sustainability, productivity, and financial strength of group practices and hospitals. Clinician burnout has a powerful effect on the quality of patient care, safety, patient satisfaction as well as contributes to employee turnover, absenteeism, and retention.

For these reasons, addressing clinician burnout and promoting wellness must become a priority to the healthcare community as a whole.

MHE: What are the main factors that contribute to burnout? 

Hlubocky: Many studies have focused on individual contributing factors responsible for clinician development of burnout in healthcare. Individual contributing factors have been defined as internal dispositional risk factors consisting of sociodemographic (for example, age, gender, marital status, trainees) and personality (for example, conscientiousness) characteristics.

However, given the changing healthcare system, recent research equally centers on both individual factors, as well as specific external, environmental, occupational, and organizational risk factors identified as significant contributors driving burnout. Examples of identified external factors include increased time in direct patient care, high occupational demands, lack of control over daily tasks, increased administrative responsibilities, use of electronic health record systems, limited decision-making, unclear job expectations, lack of social support, educational debt, and the evolving medical landscape.

The identification of internal and external contributors is necessary in order to help us promote and tailor both individual and organizational interventions designed to target burnout in clinicians.

Next: How burnout affects oncology care

MHE: Many oncologists struggle with talking to patients about treatment failure and impending death. How does this contribute to burnout, and what can be done about it?

Hlubocky: Communication between cancer patients and oncologists is uniquely complex in oncology, without a doubt. Cancer care providers witness some incredibly difficult situations involving seriously ill patients and distressed family members across the cancer trajectory. These experiences coupled with the responsibility of effectively communicating the complex biomedical information, treatment decision making, prognosis, and end-of-life issues can be challenging.

However, according to research, oncologists who have received specialized communications skill training tailored to address these sensitive topics are less susceptible to developing burnout. Additionally, enhanced communication skills enable oncologists to improve patient understanding of disease and treatment, use time efficiently, and increase overall professional satisfaction.

Therefore, enhanced communication skills tailored for oncology discussions seem to be a protective factor against the development of burnout for some oncologists. It may be due to the fact that this training prepares oncologists for the complexity of cancer communication by providing useful tailored communication strategies for oncologists to cultivate and utilize during these situations.

Several communication programs are available for oncologists. My colleague Anthony Back, MD, and colleagues developed one such program, named Vitaltalk, with the mission of improving the clinician-patient relationship through the use of advanced communication skills training tailored for clinicians charged with discussing end of life and serious illness concerns.

Further research is needed to explore the relationship between enhanced communication skills and their effect on burnout including studying what role individual and organizational factors play.

MHE: What can institutions and administrators do to help reduce the risk of provider burnout?

Hlubocky: There are many solutions. Addressing burnout and promoting clinician wellness are the collective concerns and obligations of both the clinician and organization. Clinicians are incredibly compassionate in the care of their patients, however they tend to forget how to give compassion to themselves. Self-compassion is key.

Prevention is key. Intervention at both the individual level and organizational level is also key. However, an integral part of prevention is awareness. Self-awareness needs to be cultivated in training. Medical and nursing trainees should be informed and prepared early-on in their medical training-in medical or nursing school, in residency, and fellowship-that burnout exists and may likely occur over the course of their professional healthcare oncology career. Trainees should gain awareness of what is burnout, how to recognize signs, and how to adopt healthy coping and wellness strategies for the long-term.

For current practicing clinicians who did not have burnout prevention in their training, using avoidance and “toughing it out” strategies are not useful approaches and will only fuel the existing problem.

However, self-awareness and recognition of unfamiliar frequently occurring symptoms such as exhaustion, irritability, or impatience is the first step to identifying the problem. If the symptoms occur several days of the week, then it is time to seek professional help.

The challenge is to recognize burnout and address it before it is fully established. Additional individual empirically studied resilience-building and wellness strategies found to effectively address and minimize burnout include:

• Regular sleep;

• Physical activity schedule;

• Nutrition;

• Cognitive-behavioral approaches with the inclusion of relaxation techniques;

• Mindfulness-stress reduction; and

• Engagement in professional social support networks.

Recently, an evidence-based, resilience-focused approach has been promoted as a burnout-prevention program for palliative care clinicians tailored to enhance clinicians’ individual skills building and workplace engagement factors. This approach, as well as other resilience- and mindfulness-based programs, is believed to help foster clinician wellness and target burnout directly.

At the organizational level, it is in the interests of any healthcare organization to support efforts promoting clinician wellness as a means to maximize value and improve overall quality of care. Tait Shanafelt, MD, at Mayo Clinic, has proposed that the organization must first recognize and identify institutional contributors responsible for burnout in order to facilitate change. Leadership and administration has a responsibility to:

• Recognize the significance of clinician wellness to achieving its overall mission;

• Identify the prevalence of burnout in their clinicians;

• Assess for burnout over time;

• Proactively involve organizational leaders and clinicians in a mutual concerted effort to meet the organization’s vision;

• Improve the overall practice environment and culture-including flexible schedules; and

• Provide institutional or external and Internet wellness resources to physicians such as Mayo Clinic’s Physician Health Center.

Next: Key ways to mitigate burnout

MHE: How important is communication-communication both between providers and their patients, and between cancer center administrators and providers-in mitigating burnout?

Hlubocky: Communication between all parties is essential and a vital contributor towards addressing burnout in healthcare.

Clinicians should be encouraged to speak with administration regarding concerns pertaining to wellness or the presence of organizational contributors that are responsible for maintaining burnout.

As well, it must be the responsibility of the organization to foster an environment where clinicians are supported and open communication regarding workplace concerns is the norm. Open dialogue is the only way burnout can be prevented at the organizational level. Clinicians should be encouraged to ask for help and understanding from colleagues if an unexpected personal day is needed or a 10-minute break is warranted after engaging in an emotionally distressing encounter with a seriously ill patient.

It is important for clinicians to set appropriate limits and take breaks during the day as needed.

Educational meetings on burnout should be held frequently. Meeting with colleagues to discuss difficult patient cases provides needed social support and feedback.

Scheduling personal time with family, friends and vacations is essential in order to refuel and re-energize. These recommendations must be promoted and encouraged at the organizational level for the long term.

Further, for the clinician, it is absolutely important to have an open dialogue with their patients. By simply listening to a patient who may express frustration at having to wait 15 minutes to see the clinician and normalizing their concerns, such approaches will help to strengthen the clinician-patient relationship.

Clinicians should feel encouraged to tell patients, “It’s a busy day, but now I am here to focus on your needs. Tell me how I can help you.” Simply being aware, fully present, and mindful in the patient encounter will: foster greater confidence and ability to communicate on challenging topics, promote wellness and professional fulfillment.

Moreover, it is important for clinicians to set appropriate boundaries and admit to limitations when it comes to patient outcomes. Unfortunately, the goals of care change relatively quickly for many seriously ill patients so acknowledging that to self and redirecting focus from cure, remission, or disease stabilization to simply being present, mindful, and helpful as patients redirect efforts at symptom management and maintaining a good quality of life will make the clinician less susceptible to burnout and build resilience over time.