Improving the Quality of Palliative Care in Oncology

A Conversation With Arif Kamal, MD, FACP

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Arif Kamal, MD, FACP

High burnout among physicians is not a new story. The new story is that if we do not reverse this trend, we will not be able to deliver high-quality palliative care because clinicians are walking away from the discipline.

—Arif Kamal, MD, FA

Two years ago, ASCO collaborated with the American Academy of Hospice and Palliative Medicine to develop the Virtual Learning Collaborative, a virtual quality improvement program intended to address the complex care needs of patients with advanced cancer and the care quality for all patients with malignancies. The project is modeled after the Quality Improvement Collaborative model developed by the Institute for Healthcare Improvement (IHI). The program includes a series of structured meetings for particiapnts, including small work groups dedicated to particular aspects of palliative care. The website enables communication with others involved in the pilot and hosts a resource library with information about palliative care best practices, and tools to support implementation of  quality improvement science.

Pratice teams from 26 medical oncology practices across the country were invited to pilot test the system. The teams were charged of designing, executing, and evaluating a quality improvement project to optimize one aspect of palliative care for patients with malignancies at their organization. Each practice was able to select the area of palliative care that needs the most attention as defined by local stakeholders. For example, teams have selected projects to address standardizing practices for advance care planning, symptom assessment, and improving referral to palliative care.

At the end of the pilot testing period in June 2015, participants will complete evaluation activities, including interviews for a selected subset of participants. Throughout the project, teams were encouraged to submit data to ASCO’s Quality Oncology Practice Initiative (QOPI). (For more information on ASCO’s Virtual Learning Collaborative, go to

Arif Kamal, MD, FACP, Assistant Professor of Medicine in the Division of Medical Oncology at Duke University Medical Center and Director of Quality and Outcomes for the Duke Cancer Institute, is a co-investigator on the Virtual Learning Collaborative, as well as a member of ASCO’s Quality of Care Committee and ASCO’s Supportive Care Guidelines Advisory Group.

In addition to his work on the Virtual Learning Collaborative, Dr. Kamal is also investigating the rise in burnout among palliative care physicians, a problem that is projected to lead to a loss of over 50% of palliative care clinicians over the next decade, according to the results of a survey1 of 1,241 clinicians conducted by Dr. Kamal and his colleagues. The study found that physician burnout in palliative care is higher—over 62%— than the burnout rate reported in medical oncology—45%. Burnout is most prevalent among younger physicians, those working more than 50 hours per week, and those with fewer colleagues within their practice.

The ASCO Post talked with Dr. Kamal about the implementation of the Virtual Learning Collaborative pilot program and the growing problem of burnout among palliative care physicians and interventions to help prevent it.

Creating a Cooperative Environment

Why did ASCO and the American Academy of Hospice and Palliative Medicine decide to develop the Virtual Learning Collaborative?

The routine integration of palliative care into usual oncology care is an imperative that has been growing over time and was an effort largely led by ASCO. Palliative medicine has now transitioned from providing supplementary “nice to have” care to “must-have” care for patients. And the challenge with that is now that this imperative is in place, every oncology group across the country is struggling with how to implement high-quality palliative care into its routine oncology care.

The onus for developing the Virtual Learning Collaborative was to identify the needs of oncology practices across the country who want to improve their palliative care delivery and to help them understand the components of high-quality palliative care delivery from the perspective of palliative care experts across the country while simultaneously facilitating their knowledge in quality improvement methodology and implementation. The Virtual Learning Collaborative creates a cooperative environment in which physicians can learn from each other, share their challenges, and find solutions.

In our pilot program in 25 community oncology practices nationwide, our main objective is to provide oncologists with the resources, mentoring, and access to national experts in palliative medicine so they can implement a quality-improvement program in their practices. To foster collaboration, participants are organized into small working groups of three teams led by a facilitator who supports shared learning among the teams.

Ultimately, what we are trying to do is make sure that ASCO has a portfolio of quality improvement infrastructure in place that addresses the needs and preferences of all oncology practices.

We are in the process of updating the program and analyzing the results from our feasibility study. We will then use the data to evaluate the impact on palliative care performance measures and determine how to further refine this model to support quality improvement in palliative care and make a decision about launching the program in more oncology practices.

High Burnout Rate

Please talk about your survey of hospice and palliative care clinicians and your findings about their burnout rate. Why did you decide to do the survey?

The impetus for this study was an ongoing debate many of us in palliative medicine were having about whether the burnout rate is higher or lower among palliative care physicians than it is among our nonpalliative care colleagues.

Data show that about 45% of all physicians in the country report high levels of burnout, but studies investigating burnout did not specifically look at palliative medicine physicians. We thought because palliative care physicians have a professional focus on self-care and quality of life, our burnout prevalence would be less than it is in other medical professions.

However, we also knew that palliative care physicians have issues around isolation. Even though palliative care is practiced in two-thirds of all hospitals around the country, most palliative care teams are no bigger than one or two clinicians; this means there isn’t anyone to share the difficulty of talking to another person dying of cancer. There are not many avenues to debrief emotionally, and it can be mentally exhausting. Also, often as palliative care physicians, we do not leave the hospital until after 7:00 PM because we have to meet with patients or family members who work full-time and can’t come in at 5:00 PM; so we get home late and then have to do it again the next day, which can be physically exhausting.

To determine which area of medicine had the highest burnout rate, my colleagues and I approached the American Academy of Hospice and Palliative Medicine to conduct a survey that served two purposes. One was to understand the predictors of burnout among palliative care physicians; and the second was to understand the demographics of palliative care physicians, such as their age, and how much and where they work. In the survey, we asked about their work/life balance, burnout and career satisfaction, and how long they plan on remaining in the field. We were also interested in learning which characteristics of clinicians and their work can be changed and which ones cannot.

What we found is that 62% of all physicians reported high burnout. Younger age, working in smaller organizations, having fewer colleagues near by, as well as working longer hours and on weekends were all predictors of physician burnout.


How will the high rates of burnout among palliative care physicians affect patient care?

High burnout among physicians is not a new story. The new story is that if we do not reverse this trend of high burnout, we will not be able to deliver responsive, high-quality palliative care because clinicians are walking away from the discipline.

In our survey, 25% of palliative care physicians said they would leave the field in 5 years, and 50% said they would leave the field in 10 years.

Efforts to Reduce Burnout

Are there steps being taken to mitigate the issues causing burnout among palliative care physicians?

There are proposals being written into grants to develop interventions to prevent burnout in palliative care physicians. There are also practices already in place to reduce burnout that other disciplines are using, such as mindfulness meditation, but it is unclear whether they will be effective in offsetting burnout in palliative medicine physicians, because a one-size-fits-all approach might not work.

Here at Duke University Medical Center, faculty are invited to a closed-door session each quarter to openly share the issues they face taking care of patients and the emotional reactions, which has been helpful. Other cancer centers have similar in-house programs as well.

What is also helpful is just recognizing that what we do is difficult and that it is hard to separate our own experiences and emotions from the routine delivery of care. ■

Disclosure: Dr. Kamal reported no potential conflicts of interest.


1. Kamal A, Bull J, Wolf S, et al: Prevalence and predictors of burnout among specialty palliative care clinicians in the United States: Results of a national survey. 2014 Palliative Care in Oncology Symposium. Abstract 87. Presented October 25, 2014.


Addressing the evolving needs of cancer survivors at various stages of their illness and care, Palliative Care in Oncology is guest edited by Jamie H. Von Roenn, MD. Dr. Von Roenn is ASCO’s Senior Director of Education, Science and Professional Development Department.