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Institute of Medicine: Delivering High-Quality Cancer Care: Charting a New Course For a System in Crisis; Part III: The Workforce Caring for Patients with Cancer

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Introduction

Welcome to part III; as you will recall, part I addressed the current landscape of cancer care and part II addressed patient-centered communication and shared decision-making.  Part IV, to come, will address the evidence base for high quality care.

 

The IOM says that coordinated, experienced professionals should deliver cancer care and that current practice falls far short of this gold standard.  Much of the fourth chapter addresses the current workforce shortages among many of the professionals involved in providing cancer care and why the problem will get worse.  Ironically, some of the drivers of the problem are side effects of changes that are otherwise desirable.  The chapter spends the greatest focus on physicians, but also gives attention to nurses, pharmacists, advanced practitioners (nurse practitioners and physician assistants) and family caregivers.

 

Physicians

The affordable care act is expected to expand insurance coverage to about 25 million people who were previously uninsured; some of these people will surely get cancer at some point in their lives.  Overall, the US will have a shortage of 90,000 physicians in the next 10 years due to the aging and growing population (AAMC, 2011b cited in IOM report).  The IOM cites additional research showing the potential for the physician shortage to grow much worse if we don’t train more doctors.  Further, physicians are being required to spend more and more time on things other than direct patient care such as documentation, compliance, and other paperwork; the IOM estimates that these demands will grow the need for physicians by another 10-15%.  Finally, individual doctors aren’t willing to work as much as they used to.  While doctors who sleep at night may make fewer mistakes and while doctors with fulfilling personal lives may deliver more compassionate care, doctors working fewer hours will also contribute to the shortage.  Beyond simply not working crazy hours, many medical school graduates are working part time or are particularly seeking specialties that require fewer hours or less on-call responsibilities.  Although medical school enrollment has increased 30% over the past five years, the balanced budget act of 1997 froze the number of resident slots and fellowships funded by Medicare.

 

To become an oncologist, a doctor just out of medical school must complete a 3-year residency in internal medicine then a 3-year fellowship in hematology and oncology.  A study commissioned by ASCO and cited in the IOM report makes specific predictions on the shortage of oncologists.   Between now and 2020, the survey expects a 48% increase in cancer incidence and an 81% increase in people living with or surviving cancer (AAMC 2007; Erikson 2007).  During this same time interval, a 14% increase in oncologists is expected.  More than half of currently practicing oncologists will retire by 2020 while the younger oncologists replacing them are expected to work fewer hours each.  The report predicts a resulting shortage of between 2,500 and 4,080 medical oncologists by 2020.  While the best data exist for physician oncologists, this trend is expected to repeat itself with other critical professionals that care for cancer patients.

 

Advanced practitioners (NPs and PAs)

Advanced practice nurses and physician assistants have the potential to help lessen the problem of physician shortages.  Advanced practice nurses (APRNs aka NPs) typically pursue additional graduate training after nursing school while physician assistants (PAs) typically enter PA school with some medical exposure.  The IOM report talks on briefly about each of these two important and related specialties. I realize that the role of these advanced practitioners is controversial in some circles.  For individual patients (and their loved ones) strong feelings sometimes result from personal good (or bad) experiences.  Overall, I think that if these advanced practitioners are well trained in oncology, and if communication and coordination of care is well done, they can dramatically improve the quality of care delivered.  I received part of my training from advanced practitioners and currently collaborate with both an NP and a PA and love doing so.  In addition to improving the quality of care, I think that these practitioners have the potential to address the shortage of oncologists as they can be trained faster and typically receive lower salaries.  As the IOM didn’t write a lot about advanced practitioners, I’ll stop here, but I think that they deserve a lot of attention from the public policy folks whenever they seek to address the shortage problems described by the IOM.

 

Nurses

The title “nurse” applies to a group of professionals with fairly heterogeneous training; stated another way, there or “levels” of nurses with different training and certification.  Licensed practical nurses are trained through 12-18 month programs with vocational/technical schools or community colleges.  Registered nurses (RNs) complete a 4-year bachelor’s degree, a 2-year associate degree program or a 3-year diploma program; they are licensed.  Advanced practice registered nurses have a master’s or PhD in nursing and may practice with more independence than other nurses.  The bureau of labor statistics has predicted that the country will need over one million new nurses by 2020.  In the short term, a number of factors related to economic difficulties have helped avoid a severe nursing shortage.  Older nurses have delayed retirement or returned to the work force.  Part time nurses have switched to full time work.  The number of new nurses has increased more than expected.  But, experts are concerned that these trends will not continue.  Nursing income has fallen relative to other competitive professions.  The baby-boomer generation of nurses will ultimately retire.  Nursing satisfaction has fallen and there is concern that many nurses will switch to other jobs. Nursing schools lack sufficient capacity to train new nurses—a survey (AACN 2012b) showed that 85% of nursing schools have faculty vacancies or need more faculty members, but cannot afford them.  Compounding factors include the requirement to hold a PhD and lower pay in academic positions.  The result is that nursing schools lack the capacity to address the impending nursing shortage.  The problem is particularly dire in oncology because the number of nursing schools with an oncology specialty has drastically fallen in recent years.

 

Palliative Care Practitioners

As we’ve discussed many times before on GRACE, palliative care and hospice care are a critical part of optimal cancer care.  In lung cancer, there’s even data for a survival advantage from early palliative care!  It is therefor disturbing that a study sponsored by the American Academy of Hospice and Palliative medicine (Lupu, 2010) projects a shortage of around 3,000 to 7,000 full time professionals.  As there are only 234 palliative and hospice fellowship positions per year, the field is poorly equipped to train these critical experts.  I have personally witnessed advanced practitioners and pharmacists providing skilled palliative care services and feel that well trained practitioners working closely with physicians will be needed fill the gap.

 

Critical practitioners discussed more briefly in the report

The middle of chapter four of the IOM’s report discusses practitioners tending specifically to patients’ psychosocial needs.  The report describes the training and roles of social workers, psychologists, psychiatrists and chaplains.  The report says that rehabilitation clinicians are not playing a large enough role in cancer care (I think that this is particularly true for our older patients).  Pharmacists can play an important role in the care of cancer patients.

 

Caregivers

The IOM report identifies two primary groups of caregivers to cancer patients—family caregivers and direct care workers.  “Family caregivers” refers to a broad class of relatives, friends, neighbors and other loved-ones who provide unpaid care for patients.  In contrast, direct care workers are paid for their services and include nurse aids, home health aids and personal or home care aids. 

 

The report citers a lot of data from a 2009 study by NAC and AARP that defines the scope of family care provided in the US.  Between 2008 and 2009, 65.7 million people served this role, spending an average of 20 hours each week providing care.  The average time spent in this role was 4.6 years.  The average age of the caregiver has increased to 49 years and the majority are female.  Increasingly, much care is also provided distantly—5 to 7 million Americans work on coordinating care from a distance.  The report discusses both the rewards (such as satisfaction and personal growth) that can come from caregiving as well as the hazards (such as harm to quality of life of the caregiver and distress at the suffering witnessed).  Direct caregivers should be strongly supported, both in terms of how-to counseling and psychosocial support.

 

Direct care workers are not required to undergo any specific training.  Many are racial minorities and many are illegal immigrants.  Pay is poor, often below minimum wage and benefits are frequently not provided; many direct care workers are exempted, by law, from federal minimum wage and overtime laws due to a provision of the Fair Labor Standards Act of 1974.  The work can be strenuous and injuries are common. 

 

Prescriptions

The IOM says that we need to recruit and retain an skilled workforce of greater size.  The report discusses challenges to the retention of trained professionals.  Cancer care can be emotionally draining and this can lead to high burnout.  High patient volumes, mandated shorter patient visits, increasing paperwork and unpredictable schedules make the problem worse.  Physicians report that their duties to their patients frequently interfere with their family and personal lives, leading to feelings of guilt and personal dissatisfaction.  Financial concerns including student debt and the long training path required dissuade many qualified people from training in oncology.  Recruitment of racial and ethnic minorities has been challenging.  The report briefly discusses existing programs to address recruitment problems including loan forgiveness, early exposure to oncology and minority recruitment.  Retention efforts can include training programs, educational-assistance programs, orientation, coaching, mentoring programs, and flexible work schedules.  I will add an additional thought of my own—counseling.  A psychiatrist friend of mine described to me the therapy that is mandatory as part of psychiatry training and told me that many of his colleagues pursue lifelong therapy to help cope with the emotional demands of the profession.  Perhaps counseling should be a core part (as opposed to something simply available) of oncology training.  And, if we either made ongoing counseling mandatory (or maybe at least free) we might be able to retain more oncology professionals, while simultaneously increasing the compassion of care provided by those retained.

 

The report appropriately spends pages discussing the issue of coordination of care.  I have witnessed the harm that can arise from poorly coordinated care and I have witnessed the power of properly coordinated care.  We need more inter-professional education. We need to modify systems processes to promote coordinated and interdisciplinary care.  We need to adjust our reimbursement policies and eliminate scope or practice barriers to team-based care.   Telemedicine may bring services to patients that are not available locally.  We must facilitate records sharing while still respecting patient privacy.

 

Stay tuned for part IV: The Evidence Base for High-Quality Cancer Care. 


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