Damage control: The industry is bracing for an oncologist shortage

Collaboration and increased training are among the many proposed solutions.

Oncology became a subspecialty of medicine in the United States in 1972 and has since become a vital component of internal medicine. However, recent data from the American Society of Clinical Oncology’s Workforce Study published in 2007 has shown that by the year 2020 there will be a shortage of between 2,350 and 3,800 oncologists, a problem that will be magnified by a 48% increase in the overall demand for oncology visits.

According to Michael Goldstein, MD, co-chair of ASCO’s Workforce Advisory Group, the impending shortage results from an imbalance between both supply and demand: The demand for oncologists will increase by 48% by 2020 but the number of oncologists will increase only by 14%.

Michael Goldstein, MD, said that the shortage is a complex issue of supply being unable to keep up with increasing demand. Photo by Oran Barber

One of the many factors driving the looming oncology workforce shortage is an increasing population. According to experts, the growing population coupled with the aging baby boomer generation has increased demand for oncology services.

“Cancer is a disease of the elderly,” Douglas W. Blayney, MD, professor of internal medicine, president-elect of ASCO and medical director at The University of Michigan Comprehensive Cancer Center, told HemOnc Today. “As the baby boomer bulge moves through the population there will be more people at risk for getting cancer in spite of all of the progress we’ve made with smoking cessation and early detection. There are just going to be more people with cancer to treat.”

In addition to the aging population, improvements made to current cancer therapies have increased the number of cancer survivors, thus increasing the number of patients in need of critical care.

“Some of the success [in oncology] was encouraged by the increase in the survivorship rate, which is wonderful,” Edward Salsberg, MPA, director at the Center for Workforce Studies at the Association of American Medical Colleges, told HemOnc Today. “But, we have far more to do from the workforce perspective.”

“We now have treatments that work well, and in turn we have more things to do for patients,” Blayney said. “Many of these treatments are complex and have side effects that have to be anticipated and managed, so we need skilled oncologists to deliver and manage these treatments.”

However, “it takes a long time to produce additional physicians because of the 10-year training program,” said Goldstein, who was also a member of ASCO’s Workforce Taskforce and Workforce Implementation Group and is an assistant professor of medicine at Beth Israel Deaconness Medical Center at Harvard University. “The number of people entering medical schools has remained fairly constant; the number of people choosing internal medicine as a specialty has been flat for the last 10 years, and that’s the pool from which oncologists emerge.”

HemOnc Today spoke with several physicians about the factors driving the shortage and how proposed solutions might help curb the problem.

The Workforce Advisory Group’s projected supply of oncologists, as reported in 2007 in The Journal of Oncology Practice, will increase by a mere 14% by 2020 due to an expected limit in the growth of oncology fellowship training positions and an increase in physician retirement.

In response to the projected shortage, ASCO’s Board of Directors approved a five-year strategic plan. Collaboration with nonphysician providers and creativity in training are two of the possible remedies being examined. The Workforce Advisory Group, charged with overseeing the strategic plan, is also working to track oncology workforce trends in real time in order to anticipate problems and react to them in a timely fashion.

According to Goldstein, the plan’s three main goals include the training of oncologists, looking at ways of increasing practice efficiency and establishing a home within ASCO for continuous workforce monitoring. The first issue, training, is designed to provide oncologists with tools to practice in an era of shortage.

“The skill set that oncologists will need in the future may be different than the skill sets that oncologists have needed in the past,” Goldstein said. “Obviously one needs to be well-grounded in science and patient care. In addition, since oncologists are going to be in shorter supply, they are going to act more as team leaders in the future. Therefore, they need to be trained in such areas as communication skills, leadership skills, group dynamics, group psychology — all the things that one expects from a good leader.”

Although the goal of training more oncologists is an important one, the issue of funding may hinder some of the efforts. According to Dean Bajorin, MD, department of genitourinary oncology services at Memorial Sloan Kettering Cancer Center, the number of students being trained and graduating from programs is at a steady 500 per year. However, a downturn in funding available to train oncologists could actually decrease the number of graduates entering the field.

“The funding for fellows is a real patchwork of support across the country,” Bajorin said. “As states have fiscal problems, there’s a possibility that they could pull out some of their funding for their training programs. We’re very concerned about that.”

Collaborating on delivery of care

ASCO’s strategic plan recommends the development of innovative practice models that allow collaboration between practicing oncologists and nonphysician staff.

According to the Workforce Advisory Group’s 2007 analysis, 54% of oncologists already work with nurse practitioners and physician’s assistants. These oncologists, on average, have higher weekly visit rates than those who do not collaborate with NPs and PAs, and their productivity is higher. Therefore, delegating tasks such as assisting with new patient consultations and ordering routine chemotherapy to NPs and PAs could potentially improve efficiency and patient care.

Douglas W. Blayney

Institutions such as The University of Michigan have already begun collaborating to prepare for the future. According to Blayney, nurse practitioners and physician’s assistants are proficient in the daily and weekly symptoms and complications associated with cancer care.

“We’re working very hard with the nurse practitioner and physician assistant pool that we have to develop care models that allow oncologists to work closely and to delegate or collaborate with NPs and PAs,” he told HemOnc Today.

However, quality care remains of crucial importance, according to Goldstein. “The patient experience needs to remain excellent; you want to increase efficiency but you don’t want to do that to the detriment of patient care,” he said. “It’s a very complex issue that needs to look at both the physician side and the patient side as things change.”

In addition, training plays a vital role in the shift toward a collaborative practice. When training oncologists, historically the focus has been on how to best manage tumors, according to Bajorin. Now, strategies to educate fellows on managing practice need to be developed.

“One of the challenges we’ll be working on in the next couple of years is how we can improve our education of fellows so that when they graduate and they’re delivering care, they can utilize the expertise of their local providers in a way that is optimal, not only for care but also for efficiency,” he said.

Special care for survivors

As a result of advanced technology and novel treatment options, about 66% of people diagnosed with cancer are expected to live at least five years after their diagnosis. In addition, according to the CDC, between 1971 and 2005 the estimated number of cancer survivors in the United States rose from about 3 million to 11 million.

Although the advancements made are invaluable achievements, an increase in the number of survivors translates to an increase in the amount of specialized care needed. Patients who survive cancer need a comprehensive team to help treat their physical, emotional and psychological ailments.

“We will have an increase of oncologists, but it will be dwarfed by the increase for demand of oncology services,” Bajorin said. “We’re not going to meet this [shortage] problem by slowly increasing the number of oncologists; we’re going to have to look at it in a more thorough way and look at how we can work with othersubspecialists and local providers to meet the demands so that we can provide the same level of excellence across the country that we do now.”

Another part of ASCO’s strategic plan is to optimize integrated survivorship care by developing partnerships with health care professionals from other disciplines. Creating models that focus on particular topics such as survivorship care and testing their efficacy using pilot projects is another goal.

“Oncologists can’t do all the survivorship care; the demands are going to be too much and the numbers are too great,” Goldstein said. “So some of the survivorship care will be done by nurses, NPs and PAs, and some of it may be done by the patient’s primary care physician once the treatment situation has passed.”

Increasing efficiency with technology

In December 2008, in a radio address on the economy, then President-elect Barack Obama proposed an economic recovery plan that included the universal use of electronic medical records. According to Obama, the use of EMRs would prevent medical mistakes and help save billions of dollars each year.

Physicians and organizations like ASCO are also interested in a more widespread use of EMRs to save time and increase productivity. Based on results of ASCO’s Workforce Study, 43% of physician respondents rated EMRs as having significant potential to improve efficiency and address the impending workforce shortage.

Gabriel Hortobagyi

“The current paper system is tremendously inefficient and leads to errors and prescription mistakes. In addition, it soaks up a huge amount of time,” Gabriel Hortobagyi, MD, FACP, professor of medicine and Nellie B. Connally Chair in Breast Cancer at The University of Texas M.D. Anderson Cancer Center, told HemOnc Today.

However, estimates on the use of EMRs differ. According to preliminary estimates published in December 2008 by the National Center for Health Statistics, 38.4% of physicians surveyed reported using full or partial EMR systems in their office-based practices. The EMR systems did not include billing records.

Also in 2008, a national survey of electronic health records in ambulatory care was published in The New England Journal of Medicine. According to these results, 13% of physicians reported having a basic electronic health record system and 4% reported having an extensive system. Of those with a basic system, 99% reported using all of the functions at least some of the time. Respondents without electronic health records reported that their practice had purchased but not yet implemented a system or that their practice intended to buy a system within the next two years.

The extent to which EMRs will improve productivity remains to be seen; however, ASCO recognizes the use of EMRs as a potential stand-in for other efficiency gains, such as reducing paperwork requirements.

Part-time hours, delayed retirement

More than half of all practicing oncologists are 50 years or older and are likely to retire by the year 2020, according to ASCO’s workforce study. The effects of the anticipated decrease in seasoned oncologists could be quelled by the new generation of physicians; however, their increased interest in quality of life makes this possibility unlikely.

According to the Workforce Study, 60% of oncology fellows surveyed in 2005 rated balancing work and personal life as extremely important in determining their post-training plans. Based on this, the next generation of oncologists may work fewer hours and have a lower lifetime productivity compared with other generations. Hortobagyi’s generation, however, had a different outlook, he said.

“We sort of looked at the choice of medicine as a calling, and most of us entered medicine with the stated inclination that we would never retire and we would continue to work until we dropped dead; many of my colleagues have done so,” he said.

It seems many physicians would prefer to continue working after retirement. The workforce study reported that most active physicians in their 70s work part-time and that 32% of those between the ages of 50 and 64 years would work part-time hours if the opportunity were available at their current practice setting.

To help retain the oncology workforce, ASCO proposes the availability of part-time hours and delayed retirement. However, it is uncertain whether practices are likely to offer part-time hours or whether physicians would be willing to delay their retirement.

Moving forward

Members of ASCO’s taskforce are currently studying various areas of the shortage, as well as possible solutions. According to Bajorin, current studies are examining how practices utilize their manpower and how patients react to collaborative care; results are expected in 18 to 24 months.

“It’s difficult to measure overall the impact of the shortage,” Salsberg said. “There will be changes in practice that will mitigate against the most negative consequences; I expect that people will get services and we may have to change how we deliver services, but hopefully that will not be detrimental to the patient.”

In the meantime, the field of oncology is faced with a looming problem that is likely to affect the health care community as a whole. Shortages in other specialties, as well as nursing, have the potential to complicate the path to solutions.

“If this problem is not unique to oncology but is also relevant to rheumatology and cardiology and pulmonary diseases, etc., we will all be competing for the same pool of general practitioners and nurses, which will limit how much we will be able to accomplish by utilizing those approaches,” Hortobagyi said.

Most experts agree there is no single solution to this multifaceted problem. Increasing public awareness is one approach that, according to Hortobagyi, may give weight to the concerns of the medical community.

“If individuals who are healthy today don’t realize that this might hit them five, 10 or 15 years from now when they need a physician and they won’t be able to find one, then nothing will happen,” he said.

“When physicians go to Congress to ask for more training positions, it’s seen as a self-serving act. If patients or potential patients go to Congress and demand the development of EMR or training more physicians, it might carry more weight.” – by Stacey L. Adams

Should the federal government be more involved in solving the workforce shortage problem?

Telemedicine can extend care to rural areas

The impending oncology workforce shortage has unfavorable consequences for patients in all stages of disease, such as longer appointment wait times and limited access to physicians. However, shortage or no shortage, some patients in rural areas are already at a disadvantage compared with their urban counterparts. “Here at the VA in Minneapolis, if a veteran in Fargo, Sioux Falls or the Black Hills gets leukemia, they need to come all the way to us to be treated, partly because we have the resources and partly because it’s been difficult to attract physicians to rural areas,” Mark Klein, MD, assistant professor of medicine at the Minneapolis VA Medical Center, told HemOnc Today. Klein is a member of the HemOnc Today Editorial Board. Patients in these areas may go undiagnosed and untreated if they have difficulty accessing specialty care, according to an article published in The Journal of Oncology Practice. Additionally, physicians practicing in rural areas may have had minimal experience with treating cancer, especially administering chemotherapy. One way to increase the rural patient’s access to care and reduce the need for trained oncologists in rural areas is telemedicine. Though less personal and less effective than the traditional hands-on physical exam, telemedicine allows physicians to conduct physical exams and consultations via voice and video conferencing. Electronic stethoscopes and peripheral devices allow physicians to hear and see cardiac breath sounds, as well as ear, nose and throat areas. Telemedicine’s role in the solution to the proposed workforce shortage is unknown. However, the technology allows the oncology community to collaborate with nurse practitioners to conduct follow-up visits and oversee chemotherapy administration, therefore decreasing the burden for oncologists. “Telemedicine has the potential to help,” said Edward Salsberg, MPA, director at the Center for Workforce Studies at the Association of American Medical Colleges. “But there are issues with ensuring that the specialist in the distant city has a working relationship with the primary care physician in the rural community; it can’t be done in isolation. The bottom line is that it holds a lot of potential, and we need to look more closely at successful models using telemedicine.”

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