When the nation's top medical research institute recently announced a growing crisis in cancer care, it cited workforce challenges as a major contributor. The Institute of Medicine warned in a 2013 study, "Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis," that the number of clinicians and other professionals specializing in oncology "may soon be too small to care for the growing population of individuals diagnosed with cancer."
"Workforce shortages among many of the professionals involved in providing care to cancer patients are growing," it added, "and training programs lack the ability to rapidly expand."
The cancer care crisis is the latest example of a perfect storm of events shaking the health care workforce and the hospitals, health systems, clinics and practices in which they work. America's health care system is facing:
- clinician shortages;
- an aging population needing more care;
- millions of newly insured patients as a result of the Affordable Care Act;
- market and regulatory forces demanding cost-containment and improved quality;
- rapid advancements in technology;
- new models of care delivery, reimbursement and compensation.
The IOM study found serious and growing shortages in key positions of cancer care. In addition, our education system, including residency and medical education programs, are not expanding offerings quickly enough — or are not expanding them at all, in some cases — to fill the void with new oncology clinicians. Although new team-based care models show the best patient outcomes and improved productivity, there are many obstacles to team-based care, according to the IOM report. And the fast pace of cancer research, new technology and breakthrough treatments is outstripping the ability to train health care workers to use this knowledge properly.
Oncology Faces Acute Shortages
The main cause of the cancer care crisis is found in demographics: Our population is getting older, and older people are much more likely to get cancer. The 65-and-older demographic includes the majority of cancer diagnoses, cancer deaths and cancer survivors. Today, more than 1.6 million new cases of cancer are diagnosed each year. By 2030, that number is expected to rise to 2.3 million. At the same time, the cost of cancer care is rising more rapidly than the rest of health care. Our health care system simply cannot keep up with the pace of these factors, and that's what constitutes the crisis.
While growing clinician shortages are a problem for health care in general, current and projected shortages in cancer care are particularly worrisome. The IOM study included the following examples:
- From today to 2020, cancer incidence will grow 48 percent, but the supply of oncologists will increase by only 14 percent.
- Half of oncologists are age 50 or older and nearing retirement. Younger oncologists are working fewer hours than older ones.
- The number of geriatricians does not meet the needs of the older population, and that problem is getting worse in part due to lack of interest in this specialty.
- Of more than 1 million registered nurses with a specialty certification, only 1.2 percent are certified in oncology.
- Of approximately 250,000 advanced practice registered nurses, only 2.6 percent are certified in oncology.
- Only one residency program in oncology exists for physician assistants.
- A shortage exists of up to 7,000 physicians specializing in palliative medicine.Nationwide, there are only 235 palliative medicine fellowship slots.
- There are only 428 certified oncology social workers.
To address these critical shortages, hospitals and health systems will need recruitment and retention strategies designed specifically for cancer care professionals. A particular irony of cancer care, according to the IOM study, is that while oncology careers can sometimes provide tremendous job satisfaction, they can also lead to acute dissatisfaction and extreme stress.
Cancer care professionals develop relationships with patients and their families and often administer treatments that achieve remission and prolong life. But they also may find that treatments are of limited value and then must make end-of-life decisions with patients and families — sometimes with the same patients whose lives they managed to prolong a few years before. It's not surprising that burnout and stress are high in oncology jobs.
Team-Based Care vs. Silos
One of the most promising workforce developments in oncology may be team-based care. Team-based care is a workforce management and care delivery model that's advancing throughout health care, but has particular value in cancer care. Because cancer care is multidimensional, with many fields of workers involved in treating the disease course and its impacts, a team approach is clearly befitting to this disease.
However, according to the IOM study, creating effective cancer care teams is a challenge for most health systems: "Establishing effective care teams requires time and effort, and there are few incentives for health care clinicians to make this investment. The health care system often lacks the experience and expertise to form clinical teams, and the ‘siloed' nature of the professionals involved in care creates cultural barriers. Additionally, the health care infrastructure and reimbursement systems are not set up to support team-based care."
Team-based care can be important for both patients and oncology workers. According to many studies, it improves the quality and outcome of cancer care, which obviously benefits patients, but also workers who are dealing with a deadly disease on a daily basis. Team-based care leads to better coordination and communication among clinicians. The principles of team-based care — shared goals, clear roles, mutual trust, effective communication, and measurable processes and outcomes — individually impact the work of oncology professionals in a positive way while collectively improving patient outcomes.
The IOM study recommends education on interprofessional collaboration to teach clinicians how to work in teams, calling collaborative care one of the key competencies for health professionals in the 21st century. Today's health education reflects the all-too-common silo approach, in which professions are isolated from each other in separate degree programs with little or no overlap.
The study also recommended that all members of cancer care teams be certified or credentialed, with competencies that include patient-centered communication, working in teams, information technology that improves care delivery, accessibility and affordability of cancer care and, of course, the new and established clinical and disease research.
Engaging the Cancer Care Workforce
In the national discussion about the transformation of our health care system, workforce issues are rarely debated. Yet, nearly all aspects of the massive changes under way directly involve health care professionals. Therefore, to address the challenges of the health care transformation, the workforce must be engaged. Similarly, in the cancer care crisis, many solutions, from improving communication with patients and families to creating coordinated patient care, require engagement and innovative management of the oncology workforce. When it comes to creating positive change in health care, workforce considerations need to come first.
Marcia Faller, R.N., Ph.D., is the chief clinical officer of AMN Healthcare and is based in its San Diego headquarters.