7

Preparing the Workforce
1

CHAPTER SUMMARY

Psychosocial health services are delivered by a wide variety of providers, including specialists in medical, nursing, and social work oncology; other physicians, nurses, and social workers; and a range of additional mental health professionals, such as psychologists and counselors. Although it is not possible to estimate the optimal supply of this workforce (individually or in the aggregate) to meet the nation’s need for psychosocial health services for people diagnosed with cancer, it is clear that there currently exists a large health care workforce that routinely encounters and cares for this population and can deliver these services.

Institutions concerned with the preparation of this workforce address psychosocial issues in their standards for educational accreditation and licensure. However, many of these standards are brief and general, and there are limited systems in place to collect data on how these educational standards are translated into hours, methods, or content of such instruction or the resulting skills of the workforce. Consequently, it is not possible to know with certainty the characteristics of the education on psychosocial issues these health care providers receive, or their resulting competency in assessing and addressing psychosocial health needs.

To remedy educational contributions to inadequate provision of psychosocial health care, the committee recommends that educational accrediting organizations, licensing bodies, and professional societies examine their standards and licensing and certification criteria, and develop them as fully as possible in accordance with a model that integrates biomedical

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1Although (as discussed in Chapters 2 and 6) families and other informal caregivers provide substantial amounts of psychosocial health services, this chapter addresses the paid, professional workforce.



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7 Preparing the Workforce1 CHAPTER SUMMARY Psychosocial health serices are deliered by a wide ariety of proid- ers, including specialists in medical, nursing, and social work oncology; other physicians, nurses, and social workers; and a range of additional mental health professionals, such as psychologists and counselors. Al- though it is not possible to estimate the optimal supply of this workforce (indiidually or in the aggregate) to meet the nation’s need for psychosocial health serices for people diagnosed with cancer, it is clear that there cur- rently exists a large health care workforce that routinely encounters and cares for this population and can delier these serices. Institutions concerned with the preparation of this workforce address psychosocial issues in their standards for educational accreditation and licensure. Howeer, many of these standards are brief and general, and there are limited systems in place to collect data on how these educational standards are translated into hours, methods, or content of such instruc- tion or the resulting skills of the workforce. Consequently, it is not possible to know with certainty the characteristics of the education on psychosocial issues these health care proiders receie, or their resulting competency in assessing and addressing psychosocial health needs. To remedy educational contributions to inadequate proision of psy- chosocial health care, the committee recommends that educational accred- iting organizations, licensing bodies, and professional societies examine their standards and licensing and certification criteria, and deelop them as fully as possible in accordance with a model that integrates biomedi- cal and psychosocial care. The education of the health care workforce 1 Although (as discussed in Chapters 2 and 6) families and other informal caregivers provide substantial amounts of psychosocial health services, this chapter addresses the paid, profes- sional workforce. 2

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2 CANCER CARE FOR THE WHOLE PATIENT in psychosocial health needs and serices could also be improed by a public–priate collaboration aimed at (1) identifying and supporting the implementation of strategies for collecting better information about curricular content and methods addressing psychosocial health care; (2) identifying, refining, and broadly disseminating information to health care educators about workforce competency models and curricula releant to proiding psychosocial health serices; () further deeloping faculty skills to teach psychosocial health care using eidence-based teaching strategies; and () strengthening accreditation standards pertaining to psychosocial health care in education programs and health care organizations. A LARGE AND DIVERSE WORKFORCE Currently, a large and diverse workforce either comes into contact with cancer patients and their families through the provision of cancer care or exists as a potential resource for these individuals. This considerably di- verse workforce comprises distinct, although at times overlapping, sectors, including (1) clinicians who are involved principally in the provision of bio- medical health care services; (2) mental health and counseling profession- als; and (3) providers of other psychosocial services, such as information, logistical or material support, and financial assistance. This latter sector includes a large volunteer and peer support component. A wide variety of licensed providers deliver some psychosocial health services: allopathic physicians (such as those practicing oncology, internal medicine, family medicine, pediatric hematology-oncology, and pediatrics), nurses, mental health professionals (such as psychiatrists, clinical psy- chologists, counselors, social workers, and pastoral counselors), and other social workers. Some of these providers deliver care exclusively to people diagnosed with cancer on the basis of their specialization in oncology or employment in programs devoted to serving these individuals. Others pro- vide care to people diagnosed with cancer as just one segment of their total patient populations. For example, a previous Institute of Medicine (IOM) report, From Cancer Patient to Cancer Surior: Lost in Transition, notes that primary care physicians provide the greatest amount of ambulatory cancer care in the United States (IOM and NRC, 2005). Tables 7-1 and 7-2 provide estimates of the numbers of selected pro- viders of various types who serve cancer patients and can play a role in either providing or ensuring the provision of psychosocial health services. Table 7-1 shows the number of physicians in various specialties certified by the American Board of Medical Specialties (ABMS)2 or with membership in 2 Initial certification, a process that evaluates the training, qualifications, and competence of physician specialists at the outset of their careers, is a major focus of ABMS and its Member Boards (Horowitz et al., 2004). Nearly 85 percent of licensed U.S. doctors are certified by at least one ABMS member board (ABMS, 2007).

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2 PREPARING THE WORKFORCE TABLE 7-1 Estimates of the Supply of Selected Physician Types Available to Provide or Ensure the Provision of Psychosocial Health Services Type of Physician Specialty Credential or Membership Status Amount Board certifieda (2006) Internal 186,868 Member of American College of Physiciansb (2006) Medicine 120,000 Board certifiedc (2006) Family 66,421 Member of American Academy of Family Physiciansd (2006) Medicine 94,000 Board certifiede (2005) Pediatrics 84,826 Member of American Academy of Pediatricsf (2006) 60,000 Board certifiedg (2005) Psychiatry 43,850 Member of American Psychiatric Associationh (2006) 35,000 Board certifieda (2006) Medical 10,016 Member of American Society of Clinical Oncologyi (2006) Oncology 20,000 Board certifiede (2006) Pediatric 1,884 Hematology- Member of American Society of Pediatric Hematology/ 1,000 Oncologyj (2006) Oncology NOTE: Estimates of board-certified physicians are based on the number of valid certificates issued, and may not accurately reflect the number of currently practicing physicians in the United States. Also, because provider types may be credentialed as well as licensed or hold more than one credential, the numbers in each category are not mutually exclusive. SOURCE: Numbers of board-certified physicians come from the aAmerican Board of Internal Medicine (ABIM, 2006a); cAmerican Board of Family Medicine (ABFM, 2006c); eAmerican Board of Pediatrics (ABP, 2006b); and gAmerican Board of Psychiatry and Neurology, Inc. (ABPN, 2006b). Professional organization membership comes from the bAmerican College of Physicians (ACP, 2006); dAmerican Academy of Family Physicians (AAFP, 2006); fAmerican Academy of Pediatrics (AAP, 2006); hPersonal communication, Lisa Corchado, American Psychiatric Association, September 4, 2007; iAmerican Society of Clinical Oncology (ASCO, 2006); and jAmerican Society of Pediatric Hematology/Oncology (ASPHO, 2006). related professional societies. Table 7-2 shows the numbers of other health care personnel—generally those licensed and credentialed by relevant pro- fessional societies. In addition to these licensed professionals, there are a host of other employed providers of psychosocial services that constitute a large and critical sector of the health care workforce. This sector includes individu- als with bachelor’s degrees, high school diplomas, or lesser education who are involved in diverse caregiver roles. They may provide information, transportation, financial advice, or case management, or may function as navigators in systems of care. They may also provide in-home support for activities of daily living and other services. Virtually no data or information is available about the numbers of these individuals or their characteristics, training, or performance. Finally, complementing the employed workforce

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2 CANCER CARE FOR THE WHOLE PATIENT TABLE 7-2 Estimates of the U.S. Supply of Selected Nonphysician Providers Available to Provide or Ensure the Provision of Psychosocial Health Services Type of Provider Licensure or Credential Status Number Licenseda Registered (as of 2004) 2,909,357 nurses (RNs) RN with advance practice preparation and credentials in 2,573 oncologya (2004) Member of Oncology Nursing Societyb (2006) 33,000 Oncology Certified Nurse (OCNs)c (2006) 21,195 Advanced Oncology Certified Nurse (AOCN)c (2006) 1,381 Certified Pediatric Oncology Nurse (CPONs)c (2006) 1,261 Advanced Oncology Certified Nurse Practitioner (AOCNP)c 313 (2006) Advanced Oncology Certified Clinical Nurse Specialist 128 (AOCNS)c (2006) RN with advance practice preparation and credentials in 19,693 psychiatry/mental healtha (2004) Clinical nurse specialists in adult psychiatric and mental healthd 6,851 (2007) Clinical nurse specialist in child and adolescent mental healthd 988 (2007) Family psychiatric and mental health nurse practitionerd (2007) 635 Adult psychiatric and mental health nurse practitionerd (2007) 1,750 Employed social workere (2004) Social 562,000 workers Social worker employed in mental health and substance abuse 116,000 servicese (2004) Social worker employed in medical and public healthe (2004) 110,000 Social worker employed in child, family, and school social 272,000 servicese Licensed social workerf (2004) 310,000 Member of National Association of Social Workersg (2006) 149,621 Member of Association of Oncology Social Workh (2007) 1,000 Member of Association of Pediatric Oncology Social Workersi 303 (2006) Certified by the Board of Oncology Social Work Certificationj 236 (2007) Licensedk (2004) Psychologists 179,000 Member (worldwide) of American Psychological Association 148,000 (APA)l (2006) Member of APA Health Divisionm (2006) 532 Licensedn (2004) Mental 96,000 health counselors Certifiedo (2006) Pastoral 3,000 counselors NOTE: Estimates are based on the number of valid licenses or certificates issued, and may not accurately reflect the number of currently practicing providers in the United States. Because

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2 PREPARING THE WORKFORCE TABLE 7-2 Continued provider types may be credentialed as well as licensed or hold more than one credential, the numbers in each category are not mutually exclusive. SOURCES: Number of providers and professional organization membership comes from the aHealth Resources and Service Administration (HRSA, 2006); bOncology Nursing Society (ONS, 2006); cOncology Nursing Certification Corporation (ONCC, 2006); dPersonal com- munication, Todd Peterson, American Nurse Credentialing Center, September 10, 2007; eU.S. Department of Labor (BLS, 2006d); fCenter for Health Workforce Studies and NASW Center for Workforce Studies (2006); gNational Association of Social Workers (NASW, 2006); hPer- sonal communication, Ethan Gray, Association of Oncology Social Work, September 4, 2007; iAssociation of Pediatric Oncology Social Workers (Personal communication, D. Donelson, APOSW, November 15, 2006); jPersonal communication, Kim Day, Board of Oncology Social Work Certification, September 5, 2007; kU.S. Department of Labor (BLS, 2006c); lAmerican Psychological Association (APA, 2006a); mPersonal communication, Wendy Williams, Ameri- can Psychological Association, September 5, 2007; nU.S. Department of Labor (BLS, 2006a); and oAmerican Association of Pastoral Counselors (AAPC, 2006). are numerous volunteers who also provide information, support, and other forms of assistance. Again, there is little information available about the size, nature, preparation, and functioning of this important sector of the health care workforce. This mix of different disciplines and licensed, unlicensed, and informal caregivers contributes to the difficulty of determining whether the number of workers is adequate to provide psychosocial health services. Ideally, one might want to estimate carefully the level of need for these services and then attempt to predict accurately the necessary workforce supply to meet that need. However, experts in health care workforce issues note decades of failure of efforts to estimate the size, composition, and distribution of the nation’s health care workforce (Grumbach, 2002; Snyderman et al., 2002). Even in countries with centrally managed, universal health care systems, progress in medical technology and changes in the organization of care can create large forecasting errors. Predicting workforce supply in the United States is further complicated by the fact that demand for services is not tightly controlled, and the distribution of the workforce is neither controlled nor actively shaped through reimbursement mechanisms (Reinhardt, 2002). To complicate the matter, data on health professions are not collected in a routine, standardized fashion across the multiple disciplines (Hoge et al., 2007), and the dramatic growth in selected disciplines, such as clinical psychology and counseling, has reshaped the composition of the health care workforce. Another limitation on a forecasting effort is that the same function (e.g., care coordination, case management, or patient navigation) may be carried out by different types of professionals, paraprofessionals,

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2 CANCER CARE FOR THE WHOLE PATIENT or volunteers in different organizations or systems. Thus, workforce needs are heavily influenced at the local level by the assignment of functions to providers. For these and other reasons discussed in Appendix B, the de- velopment of estimates of the overall workforce capacity required to meet psychosocial health needs through modeling or other methods was not a feasible activity for this study. Nonetheless, shortages and maldistribution of a variety of psychoso- cial health care providers, such as nurses and mental health clinicians is a long-recognized problem. In 1999, the Surgeon General’s report on mental health stated: “The supply of well-trained mental health professionals is in- adequate in many areas of the country, especially in rural areas. Particularly keen shortages are found in the numbers of mental health professionals serving children and adolescents with serious mental disorders, and older people” (DHHS, 1999:455). Echoing this statement, in 2003 the President’s New Freedom Commission on Mental Health reported: “In rural and other geographically remote areas, many people with mental illnesses have inad- equate access to care [and] limited availability of skilled care providers . . .” (New Freedom Commission on Mental Health, 2003:51). Shortages in the nursing workforce also have been well documented (HRSA, 2004). And the American Association of Medical Colleges estimates that the growing need for cancer care will soon outstrip the supply of oncologists, and predicts a shortage by 2020 (Erikson et al., 2007). WORKFORCE EDUCATION IN BIOPSYCHOSOCIAL APPROACHES TO CARE In addition to its numbers, the capacity of the health care workforce is determined by its knowledge, skill, and overall ability to deliver psy- chosocial health services. As described in previous chapters, this ability is influenced in part by how work in clinical practices is designed (Chapters 4 and 5) and how incentives from payers and oversight organizations operate (Chapter 6). However, the content and methods of professional education and training also affect the workforce’s understanding and appreciation of the interrelatedness of biological, psychological, and social factors in influencing health, as well as its knowledge and skill in detecting and responding to adverse psychosocial stressors. Although most professions have developed educational standards addressing psychosocial issues, it is unclear how these standards have been translated into educational curricula and more important, whether they create the competencies needed in the health care workforce to meet psychosocial health needs effectively. Professional education should prepare licensed clinicians to recognize and address psychosocial health needs just as they do biomedical needs. The education of mental health and social service professionals should

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2 PREPARING THE WORKFORCE also impart knowledge of and skills in addressing the effects of general medical illnesses on mental health and comorbid mental illnesses and on social needs. While the biopsychosocial model of health care has long been advocated (Engel, 1977), the extent to which this model is adequately implemented in educational curricula is unclear. Licensing and continuing education requirements and credentialing standards pertaining to psycho- social factors also are unclear and appear to be limited, with variations across professions. Physicians Education, training, and licensing requirements to practice medicine in the United States typically include graduating from college with an under- graduate degree; receiving an additional 4 years of undergraduate education at a medical school; passing a licensing examination; and completing up to 8 years of residency training, depending on a physician’s chosen specialty (BLS, 2006b). Undergraduate Medical Education The IOM committee that authored the 2004 IOM report Improing Medical Education: Enhancing the Behaioral and Social Science Con- tent of Medical School Curricula found that “existing national databases provide inadequate information on behavioral and social science content, teaching techniques, and assessment methodologies. This lack of data im- pedes the ability to reach conclusions about the current state and adequacy of behavioral and social science instruction in U.S. medical schools.” The committee recommended that the “National Institutes of Health’s Office of Behavioral and Social Sciences Research should contract with the Associa- tion of American Medical Colleges to develop and maintain a database on behavioral and social science curricular content, teaching techniques, and assessment methodologies in U.S. medical schools. This database should be updated on a regular basis” (IOM, 2004a:7). This recommendation has not been implemented.3 Accreditation of medical schools is conducted by the Liaison Commit- tee on Medical Education (LCME), sponsored jointly by the Association of American Medical Colleges (AAMC) and the American Medical As- sociation. Although LCME accreditation is “voluntary,” it is required for “schools to receive federal grants for medical education and to participate in federal loan programs” (LCME, 2006b). Box 7-1 displays LCME ac- creditation standards that address psychosocial health services. The stan- 3 Personal communication, M. Brownell Anderson, AAMC, November 9, 2006.

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20 CANCER CARE FOR THE WHOLE PATIENT BOX 7-1 LCME Undergraduate Medical Education Accreditation Standards That Address Psychosocial Health Services ED-7. It [the curriculum] must include current concepts in the basic and clinical • sciences, including therapy and technology, changes in the understanding of disease, and the effect of social needs and demands on care. ED-10. The curriculum must include behavioral and socioeconomic sub- • jects, in addition to basic science and clinical disciplines. ED-13. Clinical instruction must cover all organ systems, and include the • important aspects of preventive, acute, chronic, continuing, rehabilitative, and end-of-life care. ED-19. There must be specific instruction in communication skills as they • relate to physician responsibilities, including communication with patients, families, colleagues, and other health professionals [emphasis added]. SOURCE: LCME, 2006a. dards intentionally are broad in scope to afford schools flexibility in the way they meet them.4 Each medical school defines its own curricular objectives (LCME, 2006a). In 1996, however, AAMC initiated the Medical School Objectives Project (MSOP) (AAMC, 1998) “to reach general consensus within the medical education community on the skills, attitudes, and knowledge that graduating medical students should possess” (AAMC, undated). The MSOP guidelines state, in part, that graduates must demonstrate “knowledge of the important non-biological determinants of poor health and of the eco- nomic, psychological, social, and cultural factors” that contribute to the development or continuation of ill health (AAMC, 1998:8). Yet neither the LCME standards nor the MSOP guidelines specify explicitly how to teach these subjects, how many hours should be devoted to their study, or what topics related to psychosocial health services should be covered. The extent to which the MSOP guidelines are being fulfilled is unclear. A national survey of U.S. medical schools5 conducted between 1997 and 1999 found that the concepts and measurement of such psychosocial factors as stress and social support were taught by 80 to 93 percent of schools (most often in required courses), but that psychosocial topics repre- sented on average 14 percent of curricula (range from 1 to 60 percent), and 4 Personal communication, Robert Eaglen, PhD, LCME/AAMC, October 10, 2006. 5 46 percent response rate.

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21 PREPARING THE WORKFORCE only 37 percent had a written curriculum on these topics. Student interest in and appreciation of the subject was mixed. About 50 percent of medical schools endorsed less than 40 hours of total instruction in psychosomatic/ behavioral medicine out of the 7,000–8,000 hours in the average medical school curriculum. The researchers concluded that the degree of coverage of the subject in undergraduate medical education appeared variable, but generally was unknown and difficult to assess (Waldstein et al., 2001). AAMC’s online Curriculum Management and Information Tool (CurrMIT) currently serves as the database for tracking teaching techniques and assess- ment methodologies for these topics.6 Although CurrMIT aids in analyzing curricular content, it is a voluntary system. About one-third of accredited U.S. medical schools are not actively entering data into the system. Further, medical schools that participate have flexibility in data entry, and as a re- sult, the data submitted vary in detail from school to school.7 As reported above, a 2004 IOM report found that existing national databases provide inadequate information on behavioral and social science content, teaching techniques, and assessment methodologies in U.S. medical schools. Medical students’ clerkship experiences and opinions reflect some satis- faction with current education and training in psychosocial health services (Yuen et al., 2006). In the 2006 Medical School Graduation Questionnaire, 86.5 percent of students reported receiving “appropriate” instruction in behavioral sciences (AAMC, 2006b).8 Yet some medical students, residents, and practicing physicians have reported inadequate medical education on the role of psychosocial factors in health (Astin et al., 2005, 2006), which is related to clinicians’ attention to psychosocial issues in their practices (Astin et al., 2006). Medical Licensure To practice legally as a physician, medical students must pass the three-step U.S. Medical Licensing Examination (USMLE). Step 1 of the exam (usually taken after the second year in medical school) assesses basic science knowledge according to general principles and individual organ systems. Approximately 10–20 percent of Step 1 addresses “behavioral considerations affecting disease treatment and prevention, including psy- chosocial, cultural, occupational and environmental” (USMLE, 2006:7). Box 7-2 shows the subtopics in the Step 1 exam that address psychosocial 6 Personal communication, M. Brownell Anderson, AAMC, November 9, 2006. 7 Personal communication, Robby Reynolds, AAMC, October, 23, 2006. 8 In the 200 All Schools Report, the question was, “Do you believe that the time devoted to your instruction in the following areas was inadequate, appropriate, or excessive?” (n= 11,417); 9.2 and 4.4 percent, respectively, rated the time as “inadequate” or “excessive” (AAMC, 2006b).

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22 CANCER CARE FOR THE WHOLE PATIENT BOX 7-2 General Principles of Gender, Ethnic, and Behavioral Considerations for USMLE Step 1 Psychologic and social factors influencing patient behavior: • personality traits or coping style, including coping mechanisms • psychodynamic and behavioral factors, related past experience • family and cultural factors, including socioeconomic status, ethnicity, and gender • adaptive and maladaptive behavioral responses to stress and illness • interactions between the patient and the physician or the health care system • patient adherence, including general and adolescent SOURCE: FSMB and NBME, undated-a. health services. However, such test questions would most likely be woven together with questions dealing with chronic diseases instead of making up a separate section devoted to psychological and social factors.9 Similarly, Step 2 of the exam (usually taken after the fourth year of medical school) does not explicitly cover psychosocial health services, but a “broad spectrum of cases reflecting common and important symptoms and diagnoses” (USMLE, 2006:9). It tests clinical knowledge and communica- tion and interpersonal skills using standardized patients.10 Approximately 15–20 percent of the exam addresses “promoting preventive medicine and health maintenance,” as in the assessment of risk factors and application of preventive measures, and approximately 15–25 percent addresses “applying principles of management,” as in the care of people with chronic and acute conditions in ambulatory and inpatient settings (USMLE, 2006:8). Step 3 of the exam may cover psychosocial health services since “test items and cases reflect the clinical situations that a general, as yet undifferentiated, physician might encounter within the context of a specific setting” (FSMB and NBME, undated-b). 9 Personal communication, G. Dillon, National Board of Medical Examiners, October 10, 2006. 10 USMLE Step 2 assesses whether candidates can “apply medical knowledge, skills, and understanding of clinical science essential for the provision of patient care under supervision and includes emphasis on health promotion and disease prevention” (USMLE, 2006:2).

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2 PREPARING THE WORKFORCE Graduate Medical Education Medical school graduates seeking to receive board certification or enter independent practice must complete graduate medical education (GME, or residency training programs) of up to 8 years in length, depending on their specialty. Recognizing that the current teaching models focus more on accommodating biomedical content than on improving patient care (Leach, 2001), the Accreditation Council for Graduate Medical Education (ACGME), which accredits residency programs and sets their curricular standards, developed the Outcome Project (ACGME, 2007a)—a long-term effort to enhance the effectiveness of residency education and accreditation by increasing the emphasis on outcomes. The desired outcomes are fo- cused on demonstrated competencies among physicians in training. Box 7-3 shows the “minimum language” version of the six general competencies endorsed by ACGME in 1999. Internal Medicine Residency and Medical Oncology Subspecialty The American Board of Internal Medicine (ABIM) requires candidates for BOX 7-3 General Competencies of the ACGME Outcome Project 1. Patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health 2. Medical knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the ap- plication of this knowledge to patient care 3. Practice-based learning and improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care 4. Interpersonal and communication skills that result in effective informa- tion exchange and teaming with patients, their families, and other health professionals 5. Professionalism, as manifested through a commitment to carrying out profes- sional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population 6. Systems-based practice, as manifested by actions that demonstrate an aware- ness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value [emphasis added] SOURCE: ACGME, 2007a.

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1 CANCER CARE FOR THE WHOLE PATIENT Interactive, multicomponent education postlicensure The Individual Can- cer Assistance Network (ICAN) initiative of the National Association of Social Workers, CancerCare, the American Psychosocial Oncology Society (APOS), and Bristol-Meyers Squibb Foundation uses interactive strategies to train social workers and other mental health professionals to provide “cancer-sensitive” counseling to individuals with cancer. ICAN’s 8-hour face-to-face, interactive, experiential training program comprises discus- sion and knowledge- and skill-building activities encompassing clinicians’ monitoring of their own attitudinal and emotional responses to cancer; psy- chosocial issues relevant to cancer patients, including stress management, coping, quality-of-life concerns, grief, and hope; and ongoing case consulta- tion support. Skill-building activities address biopsychosocial assessment, counseling methods, relaxation techniques, collaborative care, and resource utilization. Evaluations of the ICAN program found that participants rated the program highly with respect to increasing their knowledge and mak- ing them better prepared to serve cancer patients (Blum et al., 2006). As of the end of 2006, more than 20,000 people from at least 68 countries had taken the online courses offered by APOS and NASW; 75 percent of these participants had taken and passed the continuing education credit exams; and more than 400 social workers had participated in the day-long in-person training sessions hosted by NASW state chapters. Most recently, the ICAN program implemented a train-the-trainer format, and 20 par- ticipants were trained to deliver the curriculum to at least 20 colleagues in their communities.24 Interdisciplinary, experiential, statewide education In response to a study revealing a high level of unmet psychosocial needs among cancer patients in the state, Pennsylvania’s Cancer Control Program commissioned the development of a statewide continuing education program for health pro- fessionals working with cancer patients (Barg et al., 1993). Priorities of the program were to (1) enhance provider knowledge about psychosocial services, as well as pain and symptom control; (2) develop and distribute consumer guides to community resources to increase the use of existing support services; and (3) increase effective provider communication with patients and their families. Responsibility for curriculum content, methods, and implementation was shared by the University of Pennsylvania, Univer- sity of Pittsburgh, Hershey Medical Center, and Lehigh Valley-Allentown Cooperative Cancer Center. The 3-day curriculum for health professionals was delivered at more than 20 sites across the state, and involved transmit- ting knowledge and using experiential educational strategies such as role 24 Personalcommunication, Patricia Doykos Duquette, PhD, Bristol-Myers Squibb Founda- tion, New York, December 14, 2006.

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1 PREPARING THE WORKFORCE playing, exercises in communication and problem solving, and analysis of ethical dilemmas. An interdisciplinary approach to care was modeled through the use of teams, comprising a nurse and social worker, to de- liver the continuing education program. The majority of participants were nurses, complemented by social workers, nutritionists, clergy, and pharma- cists. Evaluation revealed measurable changes in psychosocial assessments, interventions, and referrals taking place at attendees’ workplaces. Learning collaborative In conjunction with The Robert Wood Johnson Foundation, the American Association of Medical Colleges launched an Academic Chronic Care Collaborative to improve care of persons with chronic conditions who receive their care in academic health systems and to ensure that clinical education occurs in an exemplary clinical environment. Teams from 22 academic medical centers are participating in the initiative and have reported significantly enhanced clinical processes and outcomes for persons with diabetes, chronic obstructive pulmonary disease, and childhood asthma. In addition, their redesign of resident training produced new evidence-based approaches to trainees’ experiences and evaluation, as well as new insights into how to revitalize primary care in these settings (AAMC, 2006a). CONCLUSIONS AND RECOMMENDATION The committee concludes that the health care workforce’s attention to psychosocial needs may be inadequate for a number of reasons. As discussed in other chapters, practice environments may not be designed or organized to support efforts to identify and meet these needs. Policies of insurers and others also may create disincentives to attend to psycho- social health care. However, health professions education and training shape clinicians before they enter the workforce and are key determinants of clinicians’ attitudes, knowledge, and skills. Continuing education and maintenance-of-competency initiatives also help as new knowledge and care methods develop. Thus, professional education and training should not be ignored as a factor influencing the practices of health care providers. With respect to workforce training and development, the committee identifies the following factors as possible impediments to the provision of psychosocial health services: • lack of clarity about the competencies the workforce should opti- mally possess to provide the services; • the absence of well-developed curricula built around clearly defined competencies;

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20 CANCER CARE FOR THE WHOLE PATIENT • inadequate numbers of faculty qualified to train and mentor stu- dents in psychosocial skills; and • insufficient specificity in accreditation and licensing standards re- garding competencies in and curricula on psychosocial care. Moreover, the lack of information systems to track developments in edu- cation and training hampers the identification of effective educational ap- proaches. Significant efforts are needed to ensure appropriate education and training of practitioners. Educational accrediting organizations, licensing bodies, and professional societies should examine their standards, licensing, and certification criteria with an eye to developing them as fully as possible in accordance with the standard of care set forth in this report. The com- mittee further makes the following recommendation. Recommendation: Workforce competencies. a. Educational accrediting organizations, licensing bodies, and pro- fessional societies should examine their standards and licensing and certification criteria with an eye to identifying competencies in delivering psychosocial health care and developing them as fully as possible in accordance with a model that integrates biomedical and psychosocial care. b. Congress and federal agencies should support and fund the estab- lishment of a Workforce Development Collaborative on Psycho- social Care during Chronic Medical Illness. This cross-specialty, multidisciplinary group should comprise educators, consumer and family advocates, and providers of psychosocial and biomedical health services and be charged with – identifying, refining, and broadly disseminating to health care ed- ucators information about workforce competencies, models, and preservice curricula relevant to providing psychosocial services to persons with chronic medical illnesses and their families; – adapting curricula for continuing education of the existing work- force using efficient workplace-based learning approaches; – drafting and implementing a plan for developing the skills of faculty and other trainers in teaching psychosocial health care using evidence-based teaching strategies; and – strengthening the emphasis on psychosocial health care in edu- cational accreditation standards and professional licensing and certification exams by recommending revisions to the relevant oversight organizations. c. Organizations providing research funding should support assess- ment of the implementation in education, training, and clinical

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21 PREPARING THE WORKFORCE practice of the workforce competencies necessary to provide psy- chosocial care and their impact on achieving the standard for such care. The committee proposes a sequence of three steps to foster both immediate and increasing attention to this workforce need. First, to catalyze the process, the National Institutes of Health (NIH) and other components of the Department of Health and Human Services (DHHS) should jointly convene a meeting of stakeholders in psychoso- cial health care to identify, summarize, and develop a distribution plan regarding currently available competencies, curricula, and model training approaches. This group should also develop the recommended member- ship and 2-year work plan for the proposed Workforce Development Collaborative. As a second step, DHHS should establish a full-time managerial posi- tion within its Health Resources and Services Administration (HRSA) with responsibility for improving the provision of psychosocial health services to individuals with chronic medical illnesses and their families. This individual should convene a multiagency federal working group to coordinate federal efforts on this agenda. At a minimum, the group should include represen- tatives from HRSA, the Office of Behavioral and Social Sciences Research (OBSSR) within NIH, the Centers for Medicare and Medicaid Services (CMS), the Agency for Healthcare Research and Quality (AHRQ), and the Substance Abuse and Mental Health Services Administration (SAMHSA). The third step in this process should involve appropriation or alloca- tion of federal funds to establish and support the operation of the Work- force Development Collaborative. Once convened, the Collaborative would pursue activities to further develop competencies and curricula, improve the skills of faculty, and influence the strengthening of accreditation standards. The Collaborative should give consideration to using small “challenge grants” to stimulate competency and curriculum development, following the model being used by the Picker Institute (http://www.pickerinstitute. org) to stimulate best practices in graduate medical education on patient- centered care. Congressional action and support for these recommended steps would be optimal, providing robust support for fully realizing the objectives iden- tified. However, action on these recommendations can and should be taken by the federal agencies even in the absence of congressional action. Moreover, action can be taken independently by educational leaders in the private sector as described in recommendation a above: a. Educational accrediting organizations, licensing bodies, and professional societies should examine their standards and licensing and certification

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