Demographics and clinical practice setting of respondents from India and other to a medical oncology workload survey

Clinical practice setting

About 59% (48/82) of Indian MOs reported working exclusively in the private health system; 23% (15/65) of MOs in other LMICs worked exclusively in the private system (P < 0 class="i" xss=removed>P < 0>50 beds compared to 28% (27/65) of MOs at other LMICs (P = 0.001). Despite having substantially more inpatient beds, the number of chemotherapy-prescribing physicians at Indian centers was not greater than that of other LMICs: 21% (17/82) of Indian MO worked at centers that had >10 chemotherapy physicians versus 32% (21/65) in other LMICs (P = 0.233). Indian MOs reported access to onsite radiation (84%, [69/82] vs. 74% [48/65] P = 0.124) and palliative care (72% [59/82] vs. 69% [45/65], P = 0.719) that was comparable to other LMICs. However, Indian MOs were less likely to have chemotherapy pharmacists (54% [44/82] vs. 75% [49/65] P = 0.007) than MOs at other LMICs.

Seventy-eight percent (64/82) and 85% (55/65, P = 0.314) of MOs in India and other LMICs supervise trainees. Two-thirds of respondents in both groups reported having MO training programs at their own centers. Clinics notes were hand-written by a majority of MOs in India and other LMICs (73% [60/82] vs. 92% [60/65], P = 0.003). The availability of service extenders in India was comparable with that of other LMICs.

Delivery of clinical care

Compared to other LMICs, Indian MOs worked more days (median 6 vs. 5, P < 0 xss=removed href="https://www.thieme-connect.com/products/ejournals/html/10.4103/ijmpo.ijmpo_66_18#TB_2" xss=removed>Table 2]. Indian MOs have a median of 3 weeks' annual vacation compared to 4 weeks at other LMICs (P = 0.017). MOs in India and other LMICs had a median of 2 weeks' annual conference leave. MOs in India reported being on-call a median of 5 nights per month. Seventy-one percent of Indian MOs (41/58) and 43% (18/42) of other MOs reported being on-call every night. The proportion of time that Indian MOs spend on clinical duties (mean 67%), research (mean 11%), teaching (mean 10%), and administration (9%) is consistent with MOs in other LMICs. Sixty percent (49/82) of Indian MOs and 68% (44/65) of other LMICs reported treating all tumor sites.

Delivery of clinical care and clinical volumes* reported by respondents from India and other low-middle income countries to a medical oncology workload survey

Clinical volumes

The median number of new consults per year among Indian MOs was 475 compared to 350 for other LMICs (P = 0.032) [Table 2]. Twenty-four percent (20/82) of Indian MOs reported seeing >1000 new consults per year. The proportion of MO seeing very low volumes was much greater among other LMICs; 24% (15/62) of MOs in other LMICs and 2% (2/82) of Indian MOs reported <100 class="i" xss=removed>P < 0 xss=removed xss=removed xss=removed>

The median number of patients seen in a full-day clinic was 35 in India and 25 in other LMICs (P = 0.003). Twenty-six percent (22/82) of Indian MOs reported seeing >50 patients per day. Indian MOs reported spending 25 min with a new patient and 7.5 min with a chemotherapy treatment patient; this was less than that reported by MOs in other LMICs (P = 0.018 and P < 0>

Satisfaction, barriers, and challenges

The median job satisfaction score on a 10-point Likert scale (higher scores represent higher satisfaction) was 8 in India and 7 in other LMCs (P = 0.057). The most common barriers to clinical care reported by MOs from India included: patients being unable to pay for care (60%, 35/82), limited access to new treatments (42%, 34/82), high clinical volumes (39%, 32/82), insufficient time for reading (32%, 26/82), and a shortage of oncologists (22%, 18/82).

Discussion

In this study, we describe workload, infrastructure, and delivery of care among Indian medical oncologists. For comparative purposes, we also present data from 21 other LMICs. Several important findings have emerged. First, more than half of the Indian MO respondents work exclusively in the private health system; this is far greater than that of other LMICs or HICs. Second, the median number of new patients reported per year was 475 compared to 350 in other LMICs and 175 in HICs. One-quarter of Indian MO respondents see >1000 new cases annually. Moreover, Indian MOs work at centers with large inpatient services. This volume of inpatient work (which may not be captured by annual consultations) suggests potentially even greater workload for Indian MOs compared to other countries. Third, compared to other LMICs, Indian MOs work more hours and days per week and have less annual leave for vacation. Finally, the greatest challenges to clinical care reported by Indian MOs are limited financial means of patients, limited access to new therapies, and high clinical volumes.

We have recently reported the first global analysis of MO workload and available infrastructure.[6] In our global analysis, we found striking differences in workload and delivery of clinical care between LMICs, UMICs, and HICs. Annual case volume in LMICs (median consults 425, 40% of respondents seeing >500 consults) was substantially higher than that of UMICs (175, 14%>500) and HICs (175, 7%>500) (P < 0>500 annual consultations), India (475, 43% >500), Turkey (475, 27%>500), LMIC Africa (375, 37% >500), Italy (325, 32% >500), and China (275, 22% >500).

To the best of our knowledge, this is the first country-specific report of MO workload in a low-resource setting. We are aware of three contemporary studies that describe oncologist workload in HICs. Balch et al. have described practice data for 589 hematologists/oncologists in the United States.[4] The median annual consult load was ~260 for outpatients but rose to 350 per oncologist if hospital inpatients were included. Blinman et al.[5] described an annual new consult workload of 280 among 94 Australian MOs, and a survey by the New Zealand Working Group of 32 MOs reported an annual consult load of 220.[3]

The finding that more than half of the Indian MO respondents work exclusively in the private sector has significant implications. The vast majority of Indian patients come from low-middle socioeconomic strata, and due to their limited ability to pay, they seek treatment at government institutions. This suggests that there may be even greater workload among MOs within India's public system. The median workload for those in the public system (n = 22) was 451–500 new consults; for the private system (n = 48) the median was 401–450; and for those who indicate both (n = 11), the median was 501–600 new consults per year. It is also notable that physician salaries are known to be considerably lower in public hospitals compared to the private sector. Moreover, a substantial volume of MO care in India is delivered in the inpatient setting. This relates to the vast distances patients travel for cancer care and the sparse cancer services available in district hospitals. Our data demonstrate that relatively fewer MOs work at these much larger inpatient centers compared to other LMICs and HICs; accordingly, our results likely underestimate the total relative clinical workload of Indian MOs.

The study results suggest that there are urgent needs within Indian MO centers to expand palliative care services and develop capacity in systemic therapy pharmacy. The responsibility of safely delivering chemotherapy in India often falls on the MO rather than a trained pharmacy team. This further adds to MO workload and can potentially lead to errors in chemotherapy planning and administration. Delivery of safe and high-quality care in this workload environment may be further compromised by nightly on-call duties and having fewer minutes per patient in the outpatient department. Task shifting and task sharing could be options wherein some of the work of oncologists are managed by physician assistants, nurses, and pharmacists.

The barriers to care reported by Indian MOs offer important insights for future planning. Concern regarding patient inability to pay for care highlights the need for central and state governments to invest in publically accessible and affordable cancer care. This may also partially address the second most reported barrier to care regarding access to new systemic therapies. Finally, it is worth noting that treatment recommendations are generally based on the research conducted in high-income settings which may not be applicable in India due to important differences in disease presentation, biology, and health system capacity. The implementation of research is further limited due to the high costs of all the novel agents. This has two implications – first, there needs to be a robust health technology assessment mechanism to identify systemic therapies which have “value” and second, this confers the responsibility of context- and resource-specific research to MOs within India. Given the staggering clinical workload of Indian MOs, it is therefore not surprising that only 11% of their time is dedicated to research. For the Indian cancer system to identify and implement unique solutions to its unique challenges, there needs further investment in resources and time to facilitate research by Indian MOs. The concept of “protected time” for research, which might be associated with short-term pain, might result in long-term rewards by identifying cost-effective treatment alternatives.

Our study results should be considered in light of important methodologic limitations. Because we do not know the number of potential respondents that received the survey, we are not able to determine a response rate. Moreover, due to potential selection (volunteer) bias, it is possible that our results are not generalizable to all Indian MOs. While our survey was distributed to all members of the ISMPO, this includes only an estimated 60% of all practicing MOs in India. Current estimates suggest that there are approximately <350>

Conclusions

This study offers insight into MO workload and delivery of clinical care in India. The clinical volumes and workload of Indian MOs are substantially greater than peers in HICs and other LMICs. With more than half of the Indian MO respondents working exclusively in the private sector (where care is not accessible for the majority of Indian patients), future health human resource planning needs to carefully consider how to equitably expand access to MO care. More granular state-level analyses of workload and alternative models of care are urgently needed.

Conflict of Interest

There are no conflicts of interest.

Acknowledgments

Dr. Booth is supported as the Canada Research Chair in Population Cancer Care. Professor Sullivan acknowledges the support of the NCI Centre for Global Health. Dr. Seruga acknowledges the support of the Slovenian Research Agency.

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