4

The Workforce Caring for Patients with Cancer

Adiverse team of professionals provides cancer care, reflecting the complexity of the disease, its treatments, and survivorship care (C-Change, 2013). The cancer care team includes those with specialized training in oncology, such as oncologists and oncology nurses, other specialists and primary care clinicians, as well as family caregivers and direct care workers. Patients, at the center of the committee’s conceptual framework, are encircled by the cancer care workforce (see Figure S-2), depicting the idea that high-quality cancer care depends on the workforce providing competent, trusted interprofessional care that is aligned with the patients’ needs, values, and preferences. To achieve this standard, the workforce must include adequate numbers of health care clinicians with training in oncology. The members of interprofessional cancer care teams must be coordinated with each other and with the patients’ other care teams (e.g., primary care/geriatrics care teams or other specialty care teams). Additionally, the workforce must have the skills necessary to implement the committee’s conceptual framework for a high-quality cancer care system. The focus on the workforce caring for patients with cancer is consistent with the Institute of Medicine’s (IOM’s) 1999 report on the quality of cancer care, which recognized the importance of cancer care being delivered by coordinated, experienced professionals (IOM and NRC, 1999).

Current practice falls far short of this standard. Workforce shortages among many of the professionals involved in providing cancer care are projected to worsen in the near future, and the educational system lacks the capacity to quickly train new members of the workforce (IOM, 2009b).



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4 The Workforce Caring for Patients with Cancer A diverse team of professionals provides cancer care, reflecting the complexity of the disease, its treatments, and survivorship care (C-Change, 2013). The cancer care team includes those with spe- cialized training in oncology, such as oncologists and oncology nurses, other specialists and primary care clinicians, as well as family caregiv- ers and direct care workers. Patients, at the center of the committee’s conceptual framework, are encircled by the cancer care workforce (see Figure S-2), depicting the idea that high-quality cancer care depends on the workforce providing competent, trusted interprofessional care that is aligned with the patients’ needs, values, and preferences. To achieve this standard, the workforce must include adequate numbers of health care clinicians with training in oncology. The members of interprofessional cancer care teams must be coordinated with each other and with the pa- tients’ other care teams (e.g., primary care/geriatrics care teams or other specialty care teams). Additionally, the workforce must have the skills necessary to implement the committee’s conceptual framework for a high- quality cancer care system. The focus on the workforce caring for patients with cancer is consistent with the Institute of Medicine’s (IOM’s) 1999 report on the quality of cancer care, which recognized the importance of cancer care being delivered by coordinated, experienced professionals (IOM and NRC, 1999). Current practice falls far short of this standard. Workforce shortages among many of the professionals involved in providing cancer care are projected to worsen in the near future, and the educational system lacks the capacity to quickly train new members of the workforce (IOM, 2009b). 153

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154 DELIVERING HIGH-QUALITY CANCER CARE Care is often uncoordinated among the various clinicians and care teams, leaving patients to navigate a fragmented cancer care delivery system. Caregivers are also expected to assume a significant amount of medical tasks without any training or support (Reinhard and Levine, 2012). At the same time, shifting demographics are placing new demands on this delivery system, with the incidence of cancer increasing due to the aging population and cancer survivors living longer (see Chapter 2). Medical advances, such as new chemotherapy regimens that involve less toxic, but more frequent administration, are increasing the volume of can- cer care (IOM, 2009b). In addition, the Patient Protection and Affordable Care Act (ACA)1 is expected to expand health insurance coverage to an estimated 25 million previously uninsured persons, many of whom are likely to require cancer care at some point during their lifetimes (CBO, 2013). A number of studies show that the quality of care is detrimentally impacted by workforce shortages (AHRQ, 2004; Aiken et al., 2010; Blegen et al., 2011; Needleman et al., 2011). Patients can experience delays in di- agnosis and treatment, longer wait times to see a clinician, less frequent interaction with clinical and supportive services, delays in the evalua- tion and management of symptoms, worsening health disparities, and decreased clinical trial enrollment. This chapter assesses the capacity and competence of the workforce to meet the growing need for high-quality cancer care. The first section provides a review of the cancer care team members, including estimates of workforce supply and demand. The next section focuses on strategies for ensuring the quantity and quality of the clinicians on cancer care teams, including the recruitment and retention of clinicians, the importance of team-based cancer care, training the workforce, and telemedicine. The chapter concludes with a discussion of the role of family caregivers and direct care workers in providing cancer care. The committee relied heav- ily on the IOM’s previous research on the health care workforce to derive the evidence base for this chapter, including the National Cancer Policy Forum’s workshop summary on Ensuring Quality Cancer Care Through the Oncology Workforce (2009b) and recent consensus studies addressing the geriatric, nursing, and mental health workforces (IOM, 2008b, 2011a, 2012c). The committee identifies two recommendations to strengthen the workforce that cares for patients with cancer. 1  atient P Protection and Affordable Care Act, Public Law 111-148, 111th Congress (March 23, 2010).

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THE WORKFORCE CARING FOR PATIENTS WITH CANCER 155 Defining the Workforce Caring for Patients with Cancer High-quality cancer care is provided by a diverse team of profes- sionals. This portion of the chapter reviews many of the clinicians who comprise the cancer care team: physicians, nurses, advanced practice reg- istered nurses, physician assistants, palliative care specialists, clinicians providing psychosocial support, spiritual workers, rehabilitation clini- cians, pharmacists, and, for care at the end-of-life, hospice clinicians. Each section describes the general role of the profession in cancer care and the projected workforce supply and demand. Many other professionals are also involved in cancer care teams, such as laboratory personnel, public health workers, and cancer registrars. Annex 4-1 provides a detailed list of professionals involved in cancer care, their general roles on the cancer care team, and an overview of available information about the workforce. In general, data suggest that the growth in the absolute number of older adults is likely to result in a greater total volume of patients with cancer and a greater need for services than our current workforce can pro- vide. As noted in previous IOM reports, however, it can be challenging to accurately translate data on illness prevalence into estimates of workforce supply and demand (IOM, 2005, 2008b, 2012c). Data on health care pro- fessions are not routinely or systematically collected across the multiple disciplines involved in cancer care, giving an incomplete picture of the current workforce. Several provisions of the ACA may improve available information on the workforce, including the National Center for Health Workforce Analysis and National Health Care Workforce Commission, but it is unclear whether funding will continue for these activities (see Annex 2-1). In addition, many factors can lead to forecasting errors, such as changes in utilization patterns of medical technologies, changes in the organization of care, and changes in patient demands. Physicians Several recent studies estimate that the physician workforce lacks the capacity to meet the future demand for health care services. The Associa- tion of American Medical Colleges (AAMC) estimated that the United States will have a shortage of 90,000 physicians in the next 10 years due to the aging and growing population (AAMC, 2011b). Sargen and colleagues (2011) projected further into the future, calculating a current physician shortage of around 8 percent, which could rise to more than 20 percent by 2025 if the rate of medical residents being trained does not increase. The escalating amount of time physicians are devoting to documentation, compliance, and other indirect patient care services could further increase

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156 DELIVERING HIGH-QUALITY CANCER CARE demand for physician services by an additional 10 to 15 percent during the same time period. A major driver of the physician shortage is the aging workforce. Cur- rently, 40 percent of practicing physicians are older than 55 and roughly one-third of physicians are expected to retire over the next 10 years (AAMC, 2011b, 2013). These physicians are being replaced by a younger generation of physicians who more often prefer to work part time or in specialties that have less demanding on-call responsibilities (Hauer et al., 2008). A study by Staiger and colleagues found that the mean hours worked by physicians decreased by more than 7 percent between 1996 and 2008, with the largest decrease in hours worked among physicians younger than 45 years (Staiger et al., 2010). The distribution of physicians across urban and rural areas may also contribute to the physician shortage. For example, only 11 percent of the 300,000 primary care physicians practicing in the United States are located in rural areas (UnitedHealth, 2011). Specialists are also more concentrated in urban areas than in rural areas. Thus, patients in rural areas have less access to medical services, including oncology, and often have to drive long distances to receive health care services. The medical education system is unlikely to keep pace with the rising demand for physician services. Although medical school enrollment has increased by 30 percent over the previous 5 years (AHR, 2012b), the fed- eral government has not substantially increased the number of residency slots that it supports to train newly graduated medical students. This is problematic because Medicare is the largest payer of Graduate Medical Education (GME) (Health Affairs, 2012). The Balanced Budget Act of 1997 froze the number of resident slots and fellowships funded by Medicare without regard to whether the number of physicians generated would meet future demands for health care services (AAMC, 2011b). Recent pro- posals to reduce the federal debt have included further cuts to Medicare’s GME support. An ongoing IOM consensus study is examining this issue in more detail and will be proposing solutions to GME’s governance and financing (IOM, 2012b). These general trends in the physician workforce have a substantial impact on the physicians and specialists who provide care for cancer patients, such as oncologists, primary care physicians, and geriatricians. These clinicians are the focus of the remainder of this section. Physicians Providing Cancer Care There are numerous types of physicians who provide cancer care, including surgical oncologists who operate, radiation oncologists who treat with radiation, and medical oncologists who provide systemic treat-

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THE WORKFORCE CARING FOR PATIENTS WITH CANCER 157 ments. There are also a limited number of geriatric oncologists who pri- marily conduct academic research on caring for older adults with cancer (Bennett et al., 2010). Additionally, many cancer patients are treated by other types of physicians, such as urologists for prostate cancer, pulmon- ologists for early-stage lung cancer, dermatologists for early-stage mela- noma, and gastroenterologists for early-stage colon cancer. This section focuses on medical oncologists because they are the primary physicians involved in cancer care, and their workforce has been studied extensively by the American Society of Clinical Oncology (ASCO). Less information is available about other physician workforces who provide cancer care. The American Society for Radiation Oncology, however, is currently con- ducting a survey of the radiation oncology workforce in order to assess the profession’s supply, education, and employment situation (ASTRO, 2012b). In order to become board certified in medical oncology, physicians must complete a 3-year residency program in internal medicine followed by an oncology fellowship (at least 2 clinical years of training, often with additional time for research). Few medical oncology fellowship programs currently have plans to increase the number of training slots, which limits the size of the workforce (AAMC, 2007; Erikson et al., 2007). Training new medical oncologists is expensive and there is little financial support avail- able from the government to expand these programs. In addition, merely increasing the size of existing oncology fellow- ship programs would not solve the workforce problem. The size of the oncology workforce is constrained by the pipeline of residents. Medical oncologists must first complete a residency in internal medicine, but the number of students undergoing training in internal medicine has in- creased only marginally in recent years. There is also a growing number of subspecialties available to internal medicine interns (Salsberg et al., 2008), and medical oncology fellowship programs must compete against interventional subspecialties, such as cardiology and pulmonology, for this limited supply of internal medicine residents. Moreover, many medi- cal students are opting for specialties that do not require a residency in internal medicine, such as dermatology, orthopedic surgery, or radiology, as well as radiation oncology and surgical oncology. A study commissioned by ASCO predicts that the demand for medi- cal oncologists will increase dramatically between now and 2020 due to a 48 percent increase in cancer incidence and an 81 percent increase in people living with or surviving cancer (AAMC, 2007; Erikson et al., 2007). During this same time period, the supply of oncologists is predicted to increase only 14 percent. The study found that more than half of currently practicing medical oncologists are age 50 or older and will reach retire- ment age by 2020. Medical oncologists younger than 45 are also working

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158 DELIVERING HIGH-QUALITY CANCER CARE fewer hours on average than those ages 45 to 64, exacerbating the problem of an aging workforce. Based on these trends, the study concluded that there will be a shortage of 2,500 to 4,080 medical oncologists by 2020. It is likely that the other professionals involved in providing cancer care will also face similar imbalances between the workforce supply and demand. Primary Care Physicians Primary care physicians are generalists who provide comprehensive and continuous care to patients regardless of the diagnosis, the organ sys- tem involved, or the origin of the medical problem (biological, behavioral, or social) (AAFP, 2012). Box 4-1 describes the diverse roles that primary care clinicians play in caring for patients with cancer. In 2007, there were more than 200,000 general internal medicine and family medicine physicians in the United States, the principal primary care medical specialties (AAMC, 2008). This number has been increasing steadily over the past several years because more medical students have been matching into primary care residencies (AAMC, 2011a). However, a number of factors may limit the long-term supply of primary care physicians. In a survey of fourth-year medical students, only 2 percent of the respondents planned a career in internal medicine without specialization (Hauer et al., 2008). The respondents identified a number of concerns about careers in general internal medicine, including inadequate admin- istrative and technical support to deal with the paperwork demands, the complexity of caring for older adults and chronically ill patients, and preferences for work schedules that provide fewer demands on time and more opportunities for personal satisfaction outside of work. A major deterrent to becoming a primary care physician is also the more than $135,000 median annual income gap between primary care physicians and subspecialists, a difference of $3.5 million in expected income over a life- time (RGC, 2010). These factors have likely contributed to approximately 20 percent of primary care physicians departing from general internal medicine within a decade of becoming certified to practice, with many leaving to work in another medical field (Lipner et al., 2006). It may be possible to offset the need for additional primary care phy- sicians by diverting some patients to nonphysician professionals, such as advanced practice registered nurses and physician assistants (discussed below in the sections on advanced practice registered nurses and physi- cian assistants), and using patient-clinician electronic communication (see discussion in Chapter 6) (Green et al., 2012; Kuo et al., 2013).

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THE WORKFORCE CARING FOR PATIENTS WITH CANCER 159 BOX 4-1 The Roles of Primary Care Clinicians in Caring for Patients with Cancer Primary care clinicians fulfill a diverse set of roles in cancer care. They are often the first clinicians that patients see when they have signs or symptoms of cancer and are the most likely to screen their patients for cancer. Thus, they are usually the ones diagnosing cancer and providing patients with referrals to oncolo- gists or other specialists for treatment. During active cancer treatment, primary care clinicians provide patients with ongoing health promotion, disease prevention, health maintenance, counseling, education, and diagnosis and treatment of other acute and chronic illnesses. This is especially important in older adults with cancer who tend to require treatment for other chronic conditions, such as high-blood pressure and diabetes (Unroe and Cohen, 2012). It is important for the cancer care team to effectively coordinate with a patient’s primary care clinicians during the acute cancer treatment phase. Primary care cli- nicians often have known their patients longer than the cancer care team and are more likely to be familiar with their patients’ needs, values, and preferences. It is also important that primary care clinicians be informed about their patients’ cancer treatments. They often provide continuous treatment for their patients’ concurrent illnesses and conditions, which may need to be adjusted or monitored differently during cancer treatment, as well as survivorship care and cancer surveillance after their acute cancer treatment is complete. Primary care clinicians can also play a role during active treatment in establishing advance directives and coordinating with family caregivers and direct care workers (IOM, 2011b; Klabunde et al., 2009). Cohen (2009) has described the ideal relationship between the primary care team and the cancer team as “shared care,” where both care teams are involved in a patient’s care during the entire continuum of the disease, but have a bigger or smaller role at a given time depending on the needs of the patient and the disease status. In a survey by Del Giudice and colleagues, primary care clinicians reported that they are interested in being involved in their patients’ cancer care, especially if they have a long-term relationship with the particular patient, but often feel they lack the preparation and knowledge to do so effectively (Del Giudice et al., 2009). A more recent survey by Potosky and colleagues (2011) found that primary care clinicians differ significantly from oncologists in their knowledge, attitudes, and practices related to follow-up care for breast and colon cancer. Cancer care plans which summarize a patient’s needs, treatment information, and follow-up care, are tools to aid primary care clinicians in coordinating with the cancer care team and providing complementary health care services to their patients (see discussion on care plans in Chapter 3) (IOM, 2005, 2011b).

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160 DELIVERING HIGH-QUALITY CANCER CARE Geriatricians Geriatricians are primary care physicians trained to meet the unique health care needs of older adults. Currently, the number of geriatricians does not adequately meet the health care needs of the older adult popu- lation, and the situation is growing worse (IOM, 2008b). There are over 9,000 certified geriatricians (ABIM, 2012). In 2011, there was 1 geriatrician for every 2,620 Americans 75 years or older. By 2030 that ratio is expected to drop to 1 geriatrician for every 3,798 Americans 75 years or older. Many geriatric fellowship slots are not being filled due to lack of interest. For academic year 2009-2010, only 56 percent (273 out of 489) of allopathic ge- riatric training slots were filled and only 2 out of 46 osteopathic geriatric medicine fellowship slots were filled (AGS, 2012). The recent IOM report Retooling for an Aging America: Building the Health Care Workforce (2008b) made a series of recommendations intended to improve and grow the geriatric workforce by enhancing geriatric com- petence, increasing recruitment and retention of geriatric specialists, and redesigning models of care to meet the rising needs of older adults. The committee believes that these recommendations are important to improv- ing the quality of cancer care in this country and efforts should be made to implement them. Nurses The American Nurses Association defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (ANA, 2012). Nursing is a multilevel profession, and includes (1) licensed practical nurses who are trained through 12- to 18-month programs in vocational/technical schools or community colleges; (2) registered nurses (RNs), who must complete a 4-year bachelor’s degree program, a 2-year associate degree program, or a 3-year diploma program and pass a national licensure examination; and (3) advanced practice registered nurses (APRNs), who have master’s or doctorate’s degrees in nursing and work with more independence. There are currently more than 3 million nurses in the United States and they make up the largest segment of the health care workforce (IOM, 2011a). A number of analyses suggest that the existing nursing workforce is insufficient to meet the rising demand for services. The Bureau of Labor Statistics has predicted that nursing will be one of the fastest-growing pro- fessions in the United States and that the country will need over 1 million new nurses by 2020 to fill new jobs and replace vacancies resulting from

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THE WORKFORCE CARING FOR PATIENTS WITH CANCER 161 retiring nurses (BLS, 2012a). Juraschek and colleagues (2012) forecasted the RN job shortage in all 50 states between 2009 and 2030 and assigned letter grades based on the projected RN job shortage ratio. The number of states receiving a grade of “D” or “F” for their RN job shortage ratio is projected to increase from 5 in 2009 to 30 by 2030. This translates into a deficit of almost 1 million RNs by 2030. Buerhaus and colleagues published several studies showing that peo- ple who have turned to nursing in response to the recent economic down- turn have eliminated the current nursing shortage (Buerhaus et al., 2009; Staiger et al., 2012). Older nurses are delaying retirement or returning to the workforce and part-time nurses are becoming full-time employees in response to their own and their spouses’ employment insecurity. In addi- tion, the number of RNs has grown faster than predicted (Auerbach et al., 2011). Between 2002 and 2009, the number of full-time RNs between the ages of 23 and 26 increased by 62 percent. Nonetheless, Buerhaus and col- leagues cautioned that these trends may not continue and that a number of factors suggest there will be nursing shortages in the future (Buerhaus et al., 2009; Staiger et al., 2012). The workforce is rapidly aging, with an increasing number of baby boomers nearing retirement. There has also been a decline in RN earn- ings relative to other career options. Nurses express more dissatisfaction with their jobs than do people in other professions, and the changing demographics in the United States have led to an older and less healthy population, which discourages younger generations from entering nurs- ing (AHR, 2012a). In a survey of the current RN workforce conducted by AMN Healthcare, almost one-third of the nurses reported planning to make career changes in the next 1 to 3 years (AMN Healthcare, 2012). Only 56 percent of respondents said that if they were starting out today they would choose nursing as their career. The shortage of nursing faculty is compounding the shortage of nurses. A recent IOM study recommended that the nursing workforce in- crease the number of nurses with a baccalaureate degree from 50 percent to 80 percent of the workforce and double the number of nurses with a doctorate by 2020 (IOM, 2011a). However, nursing schools lack the capac- ity to train this workforce. A 2007 survey by the American Association of Colleges of Nursing (AACN) found that 85 percent of nursing schools have faculty vacancies or need more faculty members but lack the budget to pay their salaries (AACN, 2012b). In 2011, more than 75,000 qualified nursing applicants were not accepted into a nursing program due primar- ily to a shortage of faculty and resource constraints (AACN, 2012a). One of the major factors contributing to the faculty shortage is the requirement for faculty to hold Ph.D.s (Berlin and Sechrist, 2002). In 2007, enrollment in nursing Ph.D. programs was up less than 1 percent

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162 DELIVERING HIGH-QUALITY CANCER CARE from previous years despite the demand for nurses with this qualification (AACN, 2008). A major deterrent to nurses becoming faculty is the fact that advanced practice registered nurses earn significantly higher salaries if they work in clinical positions than if they work in academic positions. The aging workforce is also a factor. Nursing faculty tend to retire earlier than other medical professions, with an average retirement age of 62.5 years (Berlin and Sechrist, 2002). The average age of doctorate-level fac- ulty in nursing is currently 60.5 years for professors (AACN, 2011). This nursing shortage means that there is likely to be an insufficient number of nurses knowledgeable in oncology and able to meet the needs of the growing number of patients with cancer and cancer survivors. Gen- eral nursing programs cover a limited amount of information about oncol- ogy, and the number of nursing schools with a specialty in oncology has been drastically reduced in recent years (Ferrell et al., 2003; IOM, 2005). Out of the more than 1 million registered nurses with a certification in a clinical specialty, only 1.2 percent are certified in oncology (HRSA, 2010). Advanced Practice Registered Nurses APRNs are nurses who have completed graduate-level education and have national certification and licensure from a state board. Nurses meeting this requirement include certified registered nurse anesthetists, certified nurse-midwives, clinical nurse specialists, certified nurse practi- tioners, and individuals who hold a doctorate of nursing practice (DNP). APRNs are credentialed to practice in a specific patient population (e.g., family/individual across lifespan, adult-gerontology, neonatal, pediat- rics, women’s health/gender, or psychiatric–mental health), and their credentials allow them to work independently or in collaboration with a physician (NCBSN, 2010, 2012). In most states, APRNs can diagnose disease, order tests, refer pa- tients to specialists, and prescribe medication without physician oversight (Christian et al., 2007). As a result, they often serve as patients’ primary care clinicians and develop long-term relationships with their patients. (See Box 4-1 for a description of the role of primary care clinicians in cancer care.) The inclusion of APRNs on care teams has been shown to improve the quality of care that health care delivery organizations pro- vide to patients, especially when they are involved in patients’ transitions between care settings (Naylor and Keating, 2008; Naylor et al., 1994, 1999, 2004, 2005, 2009, 2011). APRNs wishing to become certified in oncology can go through one of the Oncology Nursing Certification Corporation’s three advanced on- cology nursing certification programs: (1) Advanced Oncology Certified Nurse Practitioner, (2) Advanced Oncology Certified Clinical Nurse Spe-

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THE WORKFORCE CARING FOR PATIENTS WITH CANCER 163 cialist, or (3) Advanced Oncology Certified Nurse (ONCC, 2012). In 2008, there were approximately 250,000 APRNs and 2.6 percent were certified in oncology (HRSA, 2010). The DNP was launched in 2008, and as of April 2013, there were 217 DNP programs with 97 additional programs in the planning stages (AACN, 2013). DNPs play an important role in collabora- tive cancer care teams, specifically because of their training as agents of system change and their focus on quality as clinical leaders (Bajorin and Hanley, 2011). Physician Assistants Physician assistants (PAs) are medically trained and licensed profes- sionals who practice medicine as part of a care team. They perform duties under the supervision of a physician, including providing physical exami- nations, diagnosing and treating illnesses, ordering and interpreting lab tests, providing patient education, and establishing and managing care plans. They have prescription privileges in all 50 states and the District of Columbia (AAPA, 2012b). The American Academy of Physician Assistants projected that the number of PAs will increase from 75,000 in 2008 to between 137,000 and 173,000 certified in 2020 (AAPA, 2012a). They are the second-fastest-grow- ing profession behind nurses. PAs receive a generalist education and then must pass a national certification examination, which includes content on the diagnosis and treatment of all of the major cancers for each organ system. There is also one postgraduate PA residency program in oncology (Coniglio et al., 2011). However, the majority of PAs who work in oncol- ogy receive on-the-job training though mentorship with their cancer care team (Ross et al., 2010), and they are playing an increasingly important role on collaborative cancer care teams (Coniglio, 2013; Coniglio et al., 2011). Palliative and Hospice Care Clinicians Palliative care and hospice care are essential components of high- quality cancer care (see discussion in Chapter 3). Palliative care is spe- cialized medical care that provides patients with pain and symptom management, counseling on goals of treatment, coordination of care ser- vices, support when ending anti-cancer therapy, and end-of-life care. It can be provided at any point along the continuum of cancer care, often in conjunction with anti-cancer therapy. Hospice care is a form of palliative care and is focused on maintaining the quality of life for patients with advanced cancers. In order to provide these services, the cancer care team should include clinicians with training in palliative and hospice medicine.

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Annex 4-1 Professionals involved in cancer care 202 Health Care Professional Role in Cancer Care Overview of Available Information Physicians Physicians (general) • Principal clinicians of medical care • Current shortage of ~8% • Shortage will increase to >20% by 2025 if no new residency slots are added Oncology Physicians Geriatric Oncologists • Diagnose and treat cancer in older adults • No information available Hematologists • Diagnose and treat blood disorders, including • American Society of Hematology has +14,000 members cancer Medical Oncologists • Diagnose and treat cancer • Shortage of 2,500-4,080 oncologists by 2020 predicted • More than 14,000 medical oncologists and 8,000 hematologists in 2012 Radiation Oncologists • Treat cancer with radiation therapy • The American Society for Radiation Oncology has ~10,000 members Surgical Oncologists • Specialize in the surgical management of cancer • The number of general surgical subspecialties, including surgical oncology, grew 20% between 2004 and 2008 Medical and Surgical Specialists Gastroenterologists • Diagnose and treat cancers in the digestive • 15,000 in 2012 system Gynecologists • Diagnose, treat, and manage patients with • 49% of counties in the United States lack an ob-gyn gynecological cancers (e.g., ovarian, cervical) physician • 18% shortage by 2030 and 25% shortage by 2050 • 15,000+ will likely retire in next 10 years

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Hospice and Palliative • Palliative care physicians prevent and relieve • 4,400 hospice and palliative care physicians Care Physicians the suffering of patients throughout the • Majority work part time in the palliative care field. continum of cancer care Current shortage of 2,787 to 7,510 full-time employees, • Experts in hospice care relieve the symptoms which equals 6,000-18,000 individual physicians of terminally ill patients and provide emotional support Pulmonologists • Diagnose and treat patients with cancers in the • ~15,000 certified in pulmonary disease in 2012 respiratory track • American College of Chest Physicians has 18,500 members Radiologists • Use imaging and radiation technologies to • The American College of Radiology has +35,000 diagnose and treat cancer members, including radiation oncologists Surgeons • Remove diseased tissue from the body • The workforce decreased by 16.3% between 1996 and 2006, and is projected to increase by only 3% between 2005 and 2020 • One-third of critical access hospitals lack a surgeon living in the county Urologists • Diagnose, treat, and manage patients with • Ranks last among all specialties in “production rate” of urological cancers (e.g., prostate, kidney, new physicians bladder) • 45% of all urologists are 55 years or older Primary Care Clinicians Geriatricians • Specialize in the care for older adults • 9,000+ in 2012 Primary Care Physicians • Provide comprehensive and continuous care for • More than 200,000 primary care physicians in 2007 patients regardless of diagnosis, organ system, • Only 2% of internal medicine residents planned to go or problem origin into primary care in 2009 Nurses and Physician Assistants Nurses (general) • Focused on caring for and dealing with • 3 million registered nurses individual responses to health problems • Shortage of 1 million registered nurses predicted by 2020 • 6.9% nursing school faculty vacancy rate in 2010 • 30% drop-out rate for first-year nurses 203 continued

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Health Care Professional Role in Cancer Care Overview of Available Information 204 Advanced Practice • Have master’s degrees, doctorates of nursing • 250,000 APRNs in 2008; 2.6% were certified in Registered Nurses practice, or Ph.D.s in nursing and work with oncology (APRNs) a high level of independence in the care of patients Oncology Nurses • Provide care to individuals with cancer • The Oncology Nursing Society has more than 35,000 members • 2.6% of advanced practice nurses are trained in oncology Physician Assistants • Provide care under the supervision of a • Fastest-growing profession behind nursing physician • Projected to increase from 75,000 professionals in 2008 • Prescription privileges across the entire United to between 137,000-173,000 in 2020 States Other Health Professionals Cancer Registrars • Collect and analyze data for national and • 72,800 registrars in 2006 regional cancer priority research • 800 new registrars will be needed by 2020 Direct care workers • Provide long-term care and personal assistance • 3.2 million people (i.e., personal and home • Help clients bathe, dress, and other daily tasks • Predicted to account for 40% of new health care jobs in care aides) 2008-2018 Laboratory personnel • Collect samples and perform tests to analyze • 60% of the health care workforce body fluids, tissue, and other substances • By 2015, an additional 81,000 clinical laboratory technologists are needed to replace retiring personnel; 68,000 to fill newly created positions • Aging 78% faster than the general U.S. labor market Occupational Therapists • Help patients develop, recover, and improve • ~100,000 in 2010 skills necessary for everyday living that are • 33% increase between 2010 and 2020 impaired due to cancer or cancer treatment

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Patient Navigators • Help patients navigate through the various • No information available components of the health care system, • Education and training varies widely including physicians’ offices, clinics, hospitals, outpatient centers, insurance and payment systems, and patient-support organizations Pharmacists • Provide chemotherapy, medications for • 25% of pharmacists are approaching retirement age palliative care, and patient education on drug • 75% of pharmacy directors and middle managers side effects and interactions anticipate retiring from their positions within the next decade • 6.4% vacancy rate in 2007 Physical Therapists • Promote mobility, functional ability, quality of • ~200,000 in 2010 life, and movement potential • 39% increase projected between 2010 and 2020 Public Health Workers • Screening, prevention, and early detection of • 250,000 more workers are needed by 2020 cancer • 50,000 fewer workers in 2000 than in 1980 • Surveillance of cancer incidence, prevalence, • 23% of the current workforce was eligible to retire in and mortality 2012 • Schools of public health would have to train three times the current number of graduates to replenish the workforce Social Workers • Provide patient navigation, psychosocial • 650,500 social workers; 1,000 in oncology screening and assessment, and support for • 13% of licensed social workers specialize in health care cancer-related depression and anxiety • 29% of licensed social workers are over 55 years • 85% of all health care social workers are likely to practice in metropolitan areas; 2% are likely to practice in rural areas NOTE: The information presented for each professional varies, depending on what information is available about that workforce. SOURCES: AACN, 2010; AAMC, 2007, 2008; AAPA, 2012a; ABIM, 2012; ACCP, 2012; ACG, 2012; ACOG, 2011; ACR, 2012; ACS/HPRI, 2010; AGA, 2012; AOSW, 2013; ASCP, 2004; ASH, 2011; ASHP, 2007, 2008; ASTRO, 2012a; BLS, 2013b,f; Blum et al., 2006; Buerhaus et al., 2009; CWS, 2006; Hauer, 2008; Hillborne, 2008; HRSA, 2010, 2012; HWS, 2007; IOM, 2011a; KHN, 2011; Lupu, 2010; McDonald and Sutton, 2009; NASW, 2006; NCRA, 2006; Passiment, 2006; PricewaterhouseCoopers, 2007; Routson, 2010; Sargen et al., 2011; Sheldon, 2010; UT, 2007; White, 2005. 205

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