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Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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7
Preparing the Workforce1

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 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, professional workforce.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

in psychosocial health needs and services could also be improved by a public–private 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 relevant to providing psychosocial health services; (3) further developing faculty skills to teach psychosocial health care using evidence-based teaching strategies; and (4) 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 diverse workforce comprises distinct, although at times overlapping, sectors, including (1) clinicians who are involved principally in the provision of biomedical health care services; (2) mental health and counseling professionals; 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 psychologists, 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 provide 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 Survivor: 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 providers 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).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Internal Medicine

Board certifieda (2006)

Member of American College of Physiciansb (2006)

186,868

120,000

Family Medicine

Board certifiedc (2006)

Member of American Academy of Family Physiciansd (2006)

66,421

94,000

Pediatrics

Board certifiede (2005)

Member of American Academy of Pediatricsf (2006)

84,826

60,000

Psychiatry

Board certifiedg (2005)

Member of American Psychiatric Associationh (2006)

43,850

35,000

Medical Oncology

Board certifieda (2006)

Member of American Society of Clinical Oncologyi (2006)

10,016

20,000

Pediatric Hematology-Oncology

Board certifiede (2006)

Member of American Society of Pediatric Hematology/Oncologyj (2006)

1,884

1,000

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 professional 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 individuals 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

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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

Registered nurses (RNs)

Licenseda (as of 2004)

2,909,357

RN with advance practice preparation and credentials in oncologya (2004)

2,573

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 (2006)

313

Advanced Oncology Certified Clinical Nurse Specialist (AOCNS)c (2006)

128

RN with advance practice preparation and credentials in psychiatry/mental healtha (2004)

19,693

Clinical nurse specialists in adult psychiatric and mental healthd (2007)

6,851

Clinical nurse specialist in child and adolescent mental healthd (2007)

988

Family psychiatric and mental health nurse practitionerd (2007)

635

Adult psychiatric and mental health nurse practitionerd (2007)

1,750

Social workers

Employed social workere (2004)

562,000

Social worker employed in mental health and substance abuse servicese (2004)

116,000

Social worker employed in medical and public healthe (2004)

110,000

Social worker employed in child, family, and school social servicese

272,000

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 (2006)

303

Certified by the Board of Oncology Social Work Certificationj (2007)

236

Psychologists

Licensedk (2004)

179,000

Member (worldwide) of American Psychological Association (APA)l (2006)

148,000

Member of APA Health Divisionm (2006)

532

Mental health counselors

Licensedn (2004)

96,000

Pastoral counselors

Certifiedo (2006)

3,000

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

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 communication, 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);

hPersonal 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, American 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,

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 development 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 psychosocial 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 inadequate 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 inadequate 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 psychosocial 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

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 psychosocial 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 undergraduate 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 Improving Medical Education: Enhancing the Behavioral and Social Science Content 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 impedes 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 Association 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 Committee on Medical Education (LCME), sponsored jointly by the Association of American Medical Colleges (AAMC) and the American Medical Association. 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 accreditation standards that address psychosocial health services. The stan-

3

Personal communication, M. Brownell Anderson, AAMC, November 9, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 subjects, 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 economic, 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 represented 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.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 assessment 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 result, 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 satisfaction 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 psychosocial, 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 2006 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).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

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 communication 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).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
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 focused 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 application 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 information exchange and teaming with patients, their families, and other health professionals

  5. Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population

  6. Systems-based practice, as manifested by actions that demonstrate an awareness 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.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

certification in internal medicine to complete 3 years of postgraduate training and an additional 2-year fellowship for subspecialization in medical oncology (ABIM, 2006b). ABIM incorporated the six ACGME competencies into its resident evaluation forms, and ACGME asked all residency review committees (RRCs) to make reference to them in their program requirements (Goroll et al., 2004). Program requirements for the medical oncology subspecialty further state that fellows “must have formal instruction, clinical experience, and must demonstrate competence in the prevention, evaluation and management of … rehabilitation and psychosocial aspects of clinical management of the cancer patient” (ACGME, 2005). However, very few questions on a typical certification examination in internal medicine or medical oncology directly address psychosocial health services. ABIM estimates that on average, five questions per examination may cover psychosocial or mental health content, but emphasizes that “drawing conclusions about examinee performance in these areas” would be impossible because “scores would be unreliable for such a small number of questions.”11


Family Medicine Residency Training Program The American Board of Family Medicine (ABFM) also requires candidates for certification in family medicine to complete 3 years of postgraduate training (ABFM, 2006b). Program requirements for family medicine state that residents must become trained in meeting the psychosocial health needs of patients. Specifically, residents must address the “total health care of the individual and family, taking into account social, behavioral, economic, cultural, and biologic dimensions” and become skilled in the “diagnosis and management of psychiatric disorders in children and adults, emotional aspects of non-psychiatric disorders, psychopharmacology … and counseling skills” (ACGME, 2006a:16,28).


Pediatric Residency Training Program and Pediatric Hematology-Oncology Fellowship The American Board of Pediatrics (ABP) similarly requires candidates for certification in pediatrics to complete 3 years of postgraduate training; an additional 3-year fellowship is required for subspecialization in pediatric hematology-oncology (ABP, 2006a). Program requirements in general pediatrics state, in part, that (ACGME, 2006b)

  • Residents should “be able to interview patients/families … with specific attention to behavioral, psychosocial, environmental, and family unit correlates of disease” (p. 11).

11

Personal communication, P. Poniatowski, ABIM, October 12, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
  • The comprehensive experience for all residents should include … acute psychiatric, behavioral, and psychosocial problems (p. 19).

  • Residents should demonstrate knowledge and skill in management of psychosocial problems that affect children with complex chronic disorders and their families (p. 23).

  • Residents should be able to serve as a member of a multidisciplinary team “since no one individual has all the needed expertise to attend to the medical, psychological, and social needs of patients” (p. 42).

Approximately 3 percent of questions on the general pediatrics certifying examination pertain to psychosocial issues and problems, such as family issues, chronic illness, and handicapping conditions (ABP, 2007). ABP emphasizes that there are many other aspects of psychosocial health services that subspecialty trainees need to learn that cannot be tested in a multiple-choice examination, but could be learned through clinical training during residency.12


Psychiatry Residency Training Program Because psychiatric services are by definition psychosocial health services, the written and oral examinations given by the American Board of Psychiatry and Neurology (ABPN) can reasonably be expected to address psychosocial health services.13 For these clinicians, a greater issue is the extent to which psychiatrists are knowledgeable about and qualified to address the effects of acute or chronic illness on mental health. Accordingly, program requirements in psychiatry state that clinical education should give residents experience in “the diagnosis and management of mental disorders in patients with multiple comorbid medical disorders” and “opportunities to apply psychosocial rehabilitation techniques and to evaluate and treat differing disorders in a chronically ill patient population” in a variety of clinical settings (ACGME, 2007b:15,16). However, such experiences may be inadequate to prepare psychiatrists to care for individuals with serious complex health conditions. As noted in Chapter 6, in 2003 ABMS approved a new subspecialty in psychosomatic medicine to address in particular the care of the “complex medically ill” (Lyketsos et al., 2001:5).

12

Personal communication, James Stockman, MD, ABP, October 9, 2006, and Jean Robillard, MD, ABP Sub-Board of Pediatric Hematology-Oncology, October 12, 2006.

13

Although this may not ensure that psychiatrists have competency in all aspects of psychosocial health services such as communication skills, assessment of social issues affecting the patient, competency working with an interdisciplinary team, or implementation of the psychosocial plan.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
Continuing Education and Ongoing Certification of Competency

U.S. jurisdictions (states, territories, and the District of Columbia) granting licenses to physicians require renewal of those licenses every 1, 2, or 3 years. Virtually all require completion and reporting of a specified number of hours of continuing medical education (CME) (12–50 hours per year) as part of license renewal. Some areas have also imposed content requirements (e.g., in geriatric medicine or palliative care) (AMA, 2006). Traditionally, CME has taken place through a lectures-at-a-conference format; however, this method has consistently been found ineffective as a means of changing clinical practice (Bero et al., 1998; Davis et al., 1999; Parochka and Paprockas, 2001). As a result, CME is being reconceptualized as “a more continuous process with more emphasis on self-assessment and continuous improvement and less on attending traditional lecture courses” (Goroll et al., 2004:908).

In addition, physicians with certification in a specialty are required to be recertified periodically. Similar to the changing conceptualization of CME, the specialty recertification process for physicians has evolved from periodic testing to a more continuous “maintenance of certification” (MOC) process (ABMS, 2006). Developed by ABMS and its Member Boards, the MOC process involves the assessment and improvement of practice performance by physicians in every specialty (Batmangelich and Adamowski, 2004; Miller, 2006). Each Member Board will be required to develop specific mechanisms for assessing evidence of diplomates’ competency in specific areas (Pugh, 2003), as shown through ABIM’s Practice Improvement Module (PIM), ABFM’s Maintenance of Certification Program for Family Physicians (MC-FP) (ABFM, 2006a), ABP’s Program for Maintenance of Certification in General Pediatrics (PMCP-G®) and in Pediatric Subspecialties (PMCP-S®) (ABP, 2006a), and ABPN’s MOC program (ABPN, 2006a). Within such programs, topics related to psychosocial health services could be incorporated in such mechanisms as self-assessment modules, used to evaluate knowledge, and performance-in-practice modules, used for peer review.

Registered Nurses

There are three major educational paths to becoming a registered nurse (RN): obtaining a 2-year associate’s degree in nursing from a community or junior college, a 3-year hospital-based diploma, or a 4-year baccalaureate degree in nursing from a college or university (IOM, 2004b). All state boards of nursing except those of North Dakota and New York accept these three educational paths as appropriate academic preparation for RN licensure (Kovner and Knickman, 2005).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
Associate and Baccalaureate Nursing Education

Two different organizations accredit nursing education programs. The National League for Nursing Accrediting Commission (NLNAC) accredits practical nursing, diploma, associate’s, baccalaureate, master’s, and doctoral programs and schools. The Commission on Collegiate Nursing Education (CCNE), an autonomous arm of the American Association of Colleges of Nursing (AACN), also accredits programs offering baccalaureate and master’s degrees in nursing.

NLNAC does not require nursing educational institutions to teach specific knowledge or skills to achieve accreditation. Rather, each institution is to identify the knowledge and skills to be acquired by students through its curriculum at each level of education it provides. NLNAC then verifies that the school is meeting the educational objectives it has set for itself. NLNAC does require, however, that each school’s curriculum meet specific standards; for example,

Curiculum developed by nursing faculty flows from the nursing education unit philosophy/mission through an organizing framework into a logical progression of course outcomes and learning objectives to achieve desired program objectives/outcomes.


Program design provides opportunity for students to achieve program objectives and acquire skills, values, and competencies necessary for nursing practice. (NLNAC, 2006:15)

Although not requiring that specific knowledge and skills be taught, NLNAC does require accredited schools to build their curricula around guidelines for nursing practice selected from among those established by a number of recognized nursing organizations. For example, NLNAC supports the Pew Health Professions Commission’s 21 Competencies for the Twenty-First Century as the basis for preparing practitioners to meet evolving health care needs,14 and recommends as guidance a set of core competencies, a number of which address psychosocial health services (see Box 7-4). With respect to all of the core competencies it identifies, NLNAC states: “It is essential that each nursing program interpret these skills and competencies in the content, context, function, and structure of their program” (NLNAC, 2006:84).

AACN identifies nurses as “practice[ing] from a holistic base and incorporate[ing] bio-psycho-social and spiritual aspects of health” (AACN,

14

NLNAC also recognizes other statements, including but not limited to the competencies published in Health Professions Education: A Bridge to Quality (IOM, 2003), the National Task Force on Quality Nurse Practitioner Education’s Criteria for Evaluation of Nurse Practitioner Programs (2002), and the National Association of Clinical Nurse Specialists’ 2004 Statement on Clinical Nurse Specialist Practice and Education.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

BOX 7-4

Selected NLNAC Core Competencies Addressing Psychosocial Health Services

Nurses should

  • care for community’s health and have broad understanding of determinants of health (i.e., environment, socioeconomic conditions, behavior, genetics)

  • incorporate the psychosocial-behavioral perspective into a full range of clinical practice competencies

  • emphasize primary and secondary preventive strategies (i.e., occupational health, wellness centers, self-care programs, and health education and health promotion programs)

  • involve patients and families in the decision-making processes

  • help individuals, families, and communities maintain and promote healthy behavior

  • provide counseling for patients in situations where ethical issues arise

SOURCE: NLNAC, 2006.

1998:5). Accordingly, topics related to psychosocial health services are to be woven in throughout the nursing curriculum.15 More specifically, baccalaureate curricula are required to incorporates knowledge and skills identified in The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 1998), which includes core competencies pertaining to psychosocial health services (examples are presented in Box 7-5).

CCNE’s accreditation standards require that baccalaureate curricula incorporate knowledge and skills identified in The Essentials of Baccalaureate Education for Professional Nursing Practice and (for master’s curricula) knowledge and skills identified in The Essentials of Master’s Education for Advanced Practice Nursing (CCNE, 2003).

Licensure

Graduates who have completed any of the above three educational paths must pass the National Council Licensure Examination for RNs (NCLEX-RN), administered by the National Council of State Boards of Nursing (NCSBN), to become licensed as an RN. Approximately 6–12 percent of questions on the NCLEX-RN are devoted to “psychosocial

15

Personal communication, Joan Stanley, AACN, November 9, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

BOX 7-5

Selected Core Competencies from The Essentials of Baccalaureate Education

Graduates must have the knowledge and skills to

  • adapt communication methods to patients with special needs, e.g., sensory or psychological disabilities

  • provide relevant and sensitive health education information and counseling to patients

  • perform a holistic assessment of the individual across the lifespan, including a health history that includes spiritual, social, cultural, and psychological assessment, as well as a comprehensive exam

  • assess physical, cognitive, and social functional ability of the individual in all developmental stages, with particular attention to changes due to aging

  • provide teaching, and emotional and physical support in preparation for therapeutic procedures

  • foster strategies for health promotion, risk reduction, and disease prevention across the life span

  • assess and manage physical and psychological symptoms related to disease and treatment

  • anticipate, plan for, and manage physical, psychological, social, and spiritual needs of the patient and family/caregiver

  • demonstrate sensitivity to personal and cultural influences on the individual’s reactions to the illness experience and end of life

  • coordinate and manage care to meet the special needs of vulnerable populations, including the frail elderly, in order to maximize independence and quality of life

  • coordinate the health care of individuals across the lifespan utilizing principles and knowledge of interdisciplinary models of care delivery and case management

  • understand how human behavior is affected by culture, race, religion, gender, lifestyle, and age

  • provide holistic care that addresses the needs of diverse populations across the lifespan

  • understand the effects of health and social policies on persons from diverse backgrounds

  • recognize the need for and implement risk-reduction strategies to address social and public health issues, including societal and domestic violence, family abuse, sexual abuse, and substance abuse

SOURCE: AACN, 1998.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

integrity” (which includes behavioral interventions, coping mechanisms, family dynamics, mental health concepts, psychopathology, religious and spiritual influences on health, and support systems). Another 13–19 percent relate to “management of care” (content includes continuity of care, referrals, and collaboration with interdisciplinary teams), and 6–12 percent to “health promotion and maintenance” (which includes self-care, lifestyle choices, principles of teaching and learning, health screening, health promotion programs, and disease prevention) (NCSBN, 2006a). However, recent revisions to the exam reduced the content on “psychosocial integrity” (Stuart, 2006), which suggests a decreased focus on psychosocial issues.

The scope of practice of RNs is defined by the state in which the nurse practices. Currently, 20 states participate in a Nurse Licensure Compact Agreement, whereby a nurse with a license in his/her state of residency is allowed to practice in another, subject to each state’s practice law and regulation (NCSBN, 2006b).16 All states require nurses to renewal their license periodically, which sometimes requires continuing education.

Specialty Certification and Continued Competency

Nurses can obtain specialty certification from various organizations to focus their practice in a certain field. For example, the American Nurses Credentialing Center (ANCC), a subsidiary of the American Nurses Association, certifies nursing specialties such as psychiatric nursing and mental health. The Oncology Nursing Certification Corporation (ONCC) also offers examinations in oncology nursing for care of both pediatric and adult patients, including exams for certification as an Oncology Certified Nurse (OCN), Certified Pediatric Oncology Nurse (CPON), Advanced Oncology Certified Nurse Practitioner (AOCNP), and Advanced Oncology Certified Clinical Nurse Specialist (AOCNS) (ONCC, 2006). Thirty-six percent of the content of the test for certification as an OCN addresses knowledge of “quality-of-life” issues, including (but not limited to) pain; fatigue; sleep disorders; coping (risk factors, prevention, and management); spiritual distress; financial concerns; emotional distress; social dysfunction; loss and grief; anxiety; altered body image; cultural issues; loss of personal control; depression; survivorship issues; sexuality (risk factors, prevention, and management); reproductive issues; supportive care; dying and death; local, state, and national resources; and rehabilitation. Eight percent of the content of the CPON certification examination addresses psychosocial issues, and an additional 8, 3, and 6 percent, respectively, addresses growth and development, health promotion, and end-of-life care. Fifteen

16

Colorado, Kentucky, and New Jersey have enacted but not yet implemented the compact agreement (National Council of State Boards of Nursing, 2006).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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percent of the AOCNP examination addresses “psychosocial management,” including risk factors for psychosocial disturbances (e.g., comorbidities, specific treatments, lack of social support); assessment techniques; sexuality; pharmacological interventions (e.g., anxiolytics, antidepressants); nonpharmacological interventions (e.g., relaxation techniques, hypnosis, biofeedback, art/music therapy); coping methods; family dynamics; and diversity (e.g., cultural, lifestyle, and religious factors). Sixteen percent of the AOCNS examination similarly addresses psychosocial management (ONCC, 2007a,b,c,d).

Evidence of continued competency is not yet uniformly required of licensed nurses. The most recent (2004–2006) data collected by NCSBN show that 13 states have no requirements for demonstration of “continued competence” for licensed nurses. The 31 states that do report using a variety of mechanisms for ensuring continued competency require peer review (4), continuing education (25), periodic refresher courses (5), minimal practice (11), assessment of continued competence (4), and other mechanisms (6). Twelve states require specific subject matter—such as AIDS, child abuse, domestic violence, end of life, law and rules, pain management, and pharmacology—to be addressed through continuing education (NCSBN, undated).

Social Workers

The practice of social work includes “helping people obtain tangible services; counseling and psychotherapy with individuals, families, and groups; helping communities or groups provide or improve social and health services … [and] requires knowledge of human development and behavior; of social and economic, and cultural institutions; and of the interaction of all these factors” (NASW, 2007b:1). Although social workers can practice with a bachelor’s, master’s, or doctoral degree, the master of social work (MSW) is the most common academic requirement for licensure. Obtaining an MSW degree usually requires 2 years of postundergraduate study and field placements/practica (Morris et al., 2004). Educational preparation for the different degrees varies in conceptualization and design, content, program objectives, and expected knowledge and skills (CSWE, 2004).

Baccalaureate and Master’s Degrees in Social Work

Baccalaureate programs in social work prepare graduates for generalist professional practice; master’s programs in social work prepare graduates for advanced professional practice in an area of concentration. The Council on Social Work Education (CSWE) accredits both degree programs in the United States (CSWE, 2004). Since social work is the primary profession

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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for the delivery of social services, its accreditation standards, like those for the discipline of psychiatry, can be assumed to be psychosocial in their orientation. Less certain is the extent to which these accreditation standards facilitate the preparation of social workers in the knowledge, skills, and abilities required to address psychosocial needs when dealing with individuals with complex medical conditions such as cancer. CSWE’s accreditation standards do not evidence substantial attention to psychosocial needs in the presence of illness. For example, a previous IOM report (IOM, 2006) documented that most schools of social work fail to provide students with basic knowledge of alcohol- and drug-use issues, and that a significant factor contributing to this situation is that accreditation standards do not mandate that curricula contain substance-use content (Straussner and Senreich, 2002).

Licensure

The Association of Social Work Boards (ASWB) develops and maintains four categories of social work licensure examinations—at the bachelor’s, master’s, advanced generalist, and clinical levels. Approximately 14 percent of questions on the bachelor’s-level exam are assigned to “human development and behavior in the environment,” with one of its six dimensions addressing “impact of crises and changes.” Eleven percent of the master’s-level examination addresses “assessment, diagnosis, and intervention planning,” of which “biopsychosocial history and collateral data” is one of five dimensions (ASWB, 2006a).

Specialization and Continuing Education

Additionally, many social workers specialize in a particular area of practice, and a variety of organizations issue voluntary credentials and specialty certifications for those individuals who have a bachelor of social work (BSW) degree or an MSW. For example, the National Association of Social Workers (NASW) issues many specialty certifications, including the Certified Social Worker in Health Care (C-SWHC). Social workers who hold the C-SWHC have a current NASW membership; an MSW degree from an institution accredited by CSWE; 2 years and 3,000 hours of paid, supervised, post-MSW health care social work experience; an evaluation from an approved supervisor and a reference from an MSW colleague; and an Academy of Certified Social Workers (ACSW) or Diplomate in Clinical Social Work (DCSW) credential and/or a current state MSW-level license or a passing score on an ASWB MSW-level exam. They also must agree to adhere to the NASW Code of Ethics and the NASW Standards for Continuing Professional Education, and are subject to the NASW adjudication process (NASW, 2007a).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

The Association of Oncology Social Work (AOSW) provides a definition for oncology social workers’ scope of practice, has established voluntary standards for practice, and serves as an educational resource. It defines oncology social work as providing “psychosocial services to patients, families, and significant others facing the impact of a potential or actual diagnosis of cancer,” such as “stress and symptom management, care planning, case management, system navigation, education and advocacy” (AOSW, 2001:1). Similarly, the Association of Pediatric Oncology Social Work (APOSW) is a membership organization for individuals engaged in clinical social work in the field of pediatric oncology. It promotes knowledge and skill competency in part though its continuing education programs. The Board of Oncology Social Work Certification additionally offers Oncology Social Work Certification (OSW-C) to individuals who have graduated from a CSWE accredited program; have 3 years of post-master’s degree work in oncology social work or a related field, such as palliative or end-of-life care; hold licensure in good standing and membership in AOSW or APOSW; have three professional statements of support; can show evidence of involvement in extramural service, education, or research activities; and have agreed to uphold AOSW Standards of Practice and NASW Code of Ethics. Certification renewal requires evidence of continued relevant work, licensure, and fulfillment of continuing education requirements.17 The American Cancer Society (ACS) awards students in MSW programs advanced training grants to provide psychosocial services to people with cancer and their families (ACS, 2006). Finally, nearly every jurisdiction requires continuing education courses for renewal of social work licenses, although these requirements vary from one jurisdiction to another, for example, in the number of hours or types of courses required (ASWB, 2006b).

Mental Health Providers

Psychosocial health services also are offered by licensed mental health providers, such as psychologists and counselors, who address psychological health as the primary purpose of their intervention. Because, as with psychiatrists, their services are by definition “psychological,” their education and training can reasonably be expected to address psychosocial health care. For these practitioners, as for psychiatrists and social workers, the issue is how well prepared they are to serve those with acute or chronic health problems (especially when these problems can be life-threatening) and how well they are prepared to carry out key psychosocial interventions, such as assessing social issues affecting the patient, coordinating care, and working with an interdisciplinary team.

17

Personal communication, Ginny Vaitones, Board of Oncology Social Work Certification, August 21, 2007.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
Psychologists

In 2004, the United States had 85,000 psychologists trained at the doctoral level, the standard educational path for practice as an independent clinical psychologist.18 To become a licensed clinical psychologist, graduates of doctoral programs also must complete supervised postdoctoral training (Olvey and Hogg, 2002).

Clinically oriented graduate programs are organized and accredited in three categories: clinical psychologist preparation, counseling, and school psychologist preparation. Psychologists can remain generalists or develop an area of expertise within these broad categories. Most relevant to the provision of psychosocial health services to medically ill patients and their families is the specialty of clinical health psychology, discussed in more detail below. Other relevant specialties include neuropsychology, rehabilitation psychology, and pediatric psychology. Just over 5,000 members of the American Psychological Association (APA) list a medically related interest area.19

Clinical health psychology has been a major area of growth, and part of the psychology discipline’s organized effort to broaden its scope from a mental health to a health profession. It was formally recognized by APA as a specialty in the professional practice of psychology in 1997. There are 68 doctoral programs across clinical, counseling, and school psychology with an emphasis in health or medically related areas (APA, 2006b). There are 201 predoctoral internships with a major rotation in health psychology and 381 with a minor rotation, plus an additional 51 postdoctoral fellowships that incorporate training on this topic (http://www.appic.org/directory/).


Accreditation Accreditation of educational programs for psychologists is managed by the APA’s Committee on Accreditation. The aim is to ensure that each program has “… clearly defined and appropriate objectives and maintains conditions under which their achievement can reasonably be expected. It encourages improvement through continuous self-study and review” (http://www.apa.org/ed/accreditation/). Accreditation is offered for doctoral programs, pre- and postdoctoral internships, and specialty post-doctoral internships. The latter are limited in number and include a focus on clinical child psychology (3), clinical health psychology (5), clinical neuropsychology (11), and rehabilitation psychology (1). (Doctoral accreditation encompasses master’s-level training, but accreditation is not

18

Individuals with a master’s degree in psychology also can practice under the direction of a doctoral-prepared psychologist, or independently as school psychologists or counselors (APA, 2003; Duffy et al., 2004).

19

Personal communication, Cynthia Belar, PhD, Executive Director for Education, American Psychological Association, October 18, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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available for terminal master’s programs.) The doctoral accreditation standards require that students be “exposed to the current body of knowledge in … biological aspects of behavior …” (APA, 2005:12). However, there is no additional detail regarding this standard. Pre- and postdoctoral standards contain no reference to this domain of knowledge.


Licensure The Examination for Professional Practice in Psychology (EPPP) was developed and is updated by the Association of State and Provincial Psychology Boards (ASPPB). This standardized exam is used by every jurisdiction in the United States and Canada except Puerto Rico and portions of Quebec. Many jurisdictions complement the EPPP with written and oral exams that assess clinical competence and knowledge of local mental health law. Licensing is generic for the practice of psychology and does not distinguish among clinical, counseling, and health psychologists. Only one state offers a license to practice in a specialty area of the discipline.

ASPPB conducts a practice analysis every 6–10 years, including a survey of practicing psychologists, in order to update the exam. From the ASPPB’s perspective, the objective of the national exam and the licensing process is to ensure a minimum level of competence and public safety. The objective is not to change or advance the field.20

Each EPPP comprises 225 multiple-choice questions (ASPPB, 2006), 11 percent of which focus on the content area “biological bases of behavior.” Issues related to the impact of disability constitute just 1 of 26 areas covered under the content area “social and multicultural bases of behavior” (12 percent of the exam). Numerous other content areas have some potential relevance: “cognitive-affective bases of behavior” (13 percent); “growth and lifespan development” (13 percent); “assessment and diagnosis” (14 percent); and “treatment, intervention, and prevention” (15 percent). While a significant portion of the exam focuses on the biological bases of behavior, experts in health psychology view this content as a necessary but largely insufficient knowledge base on the biopsychosocial interrelationships that must be understood in order to practice in a medically related specialty.


Certification The American Board of Professional Psychology (ABPP) certifies psychologists in 13 specialty areas, including clinical health psychology, clinical neuropsychology, and rehabilitation psychology. Board certification is not a requirement for practice in any jurisdiction or service organization, and it has not been pursued by the vast majority of psycholo-

20

Personal communication, Stephen DeMers, EdD, Executive Director, Associations of State and Provincial Psychology Boards, October 5, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

gists. Currently, there are only an estimated 3,000 board-certified psychologists in the United States.

Those seeking board certification in the area of clinical health psychology may specialize in any number of areas, including prevention, health promotion, public health, pain management, weight reduction, smoking cessation, and/or the psychological aspects of chronic illness. Board certification requires a degree from an APA-approved graduate program, plus licensure and two years of postdoctoral training or supervised experience in clinical health psychology. The elements of the certification process include review of qualifications, review of a work sample, an oral exam focused on the work sample and ethics, and endorsement by colleagues. Board-certified experts review the candidate and make a determination regarding certification. There are no competency sets or explicit standards used as criteria.

It has been difficult to interest health psychologists in applying for certification. Military psychologists constitute the one group that has promotion/salary incentives tied to certification. There are only an estimated 100 psychologists certified in this specialty.21


Graduate training Training in clinical health psychology during graduate study usually involves a number of additional required courses focused on this specialty, plus an advanced clinical placement working with medically ill individuals. This advanced placement follows basic training in core clinical skills. Graduate training in psychology at the doctoral level involves required and elective courses, complemented by supervised clinical experience. Other than limited didactic content on the biological bases of behavior, general students in these programs are usually not exposed to didactic or substantive experiential training related to chronic medical illnesses and the psychosocial aspects of care for persons with these illnesses.


Pre/postdoctoral internships A 1-year predoctoral internship is required for graduation from an APA-approved doctoral training program. Postdoctoral internships are optional, but are often the vehicle selected by recent graduates to obtain specialty training and the supervised experience necessary to apply for licensure.

To explore the nature of internship training related to cancer care, a request for information was circulated nationally by the Association of Psychology Postdoctoral and Internship Centers to its member programs. A total of 18 responses were received, most of which briefly summarized one program’s training activities. By and large, these internships appear to involve supervised clinical experience working with cancer patients and

21

Personal communication, Douglas Tynan, PhD, Chair, Board of Clinical Health Psychology, American Board of Professional Psychology, October 26, 2006.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

their families in hospital settings. Additional elements of the training may involve selected readings, while a few sites offer a related course. Though asked, respondents did not identify competency sets or model curricula related to this training.

A noteworthy exemplar is Children’s Hospital of Philadelphia, with its Psychology Training Programs in Pediatric Oncology (http://www.chop.edu/hc_professionals/psych_edu.shtml). Pre- and postdoctoral training is offered, as well as supervised experiences for graduate students. These programs provide opportunities for outpatient-, school-, and community-based work in addition to hospital-based training.


Competencies and curricula Core curricular components in graduate-level clinical health psychology were first specified through a national consensus conference in 1983 (Stone, 1983). These core components centered on the social, biological, and psychological bases of health and disease; health policy, systems, and organizations; health assessment, consultation, and intervention; health research methods; ethical, legal, and professional issues; and interdisciplinary collaboration (Belar, 1990). In 1997, Belar and colleagues developed a model for self-assessment of knowledge and skills by health psychologists that drew from the content areas identified in the original consensus conference (Belar et al., 2001). The Society for Pediatric Psychology also recently published a set of recommendations for training in the subspecialty of clinical child psychology (Spirito et al., 2003), which articulate a dozen suggested “domains of training.”


Conclusions The psychology profession has seen rapid growth, expanding the potential pool of mental health professionals who can respond to the psychosocial needs of cancer patients; clear growth has occurred as well in health-related specialties, including health psychology, neuropsychology, and rehabilitation psychology. However, accreditation standards for training in psychology are very general and have limited direct applicability to psychosocial aspects of serious, complex medical illness. While accreditation standards are often referenced in the health care workforce literature as potential levers of change in efforts to influence curricula (IOM, 2003), it is difficult to envision how the current standards in this profession, given their general nature, could be modified to effect substantive change in training programs on the issues addressed in this report. Moreover, board certification does not play a major role in the field of psychology and therefore is an unlikely vehicle for effecting change.

In comparison with accreditation standards, the content domains in the national licensing exam (EPPP) are relatively specific. While the biological bases of behavior are covered, it is possible to envision adding specificity in this area addressing the psychosocial aspects of illness and recovery. Doing

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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so might influence curricula design in graduate programs. However, it could conflict with the generalist nature of the exam and the aim of reflecting current rather than optimal practice.

A training focus on cancer appears to occur principally through supervised experience in cancer care settings. Any call for additional core or basic training should probably focus on the psychosocial aspects of chronic illnesses generally rather than cancer in particular. The knowledge and skill gained through basic training in medical illness and its psychosocial effects could then be applied during additional supervised clinical experience with unique populations of chronically ill individuals, such as persons with cancer. However, training activity in this profession, as in much of medicine, tends to be organized around hospital settings and funded through hospital-based activities. This situation serves as a barrier to the development and delivery of psychosocial services to medically ill patients in nonhospital community settings.

A striking finding is that there appear to be no detailed competency sets or model curricula related to cancer care in use within this profession; there is merely a brief list of “core curricular areas” from a seminal 1983 health psychology conference. The development, dissemination, and adoption of competency sets and model curricula are potential high-yield interventions for advancing training in the psychosocial aspects of illness. In addition to the absence of clear competencies and curricula, other apparent barriers to improved education and training in this area include the absence of funding for training and a lack of qualified faculty.

Counselors

Requirements to become a licensed counselor include completing a master’s degree in counseling, passing a state-recognized exam, adhering to ethical codes and standards, and completing continuing education (BLS, 2006a). Professional educational programs in counseling voluntarily undergo review by an accrediting body, such as the Commission on Rehabilitation Education (CORE), which accredits graduate programs in Rehabilitation Counselor Education (RCE) (CORE, 2006), or the Commission on the Accreditation of Counseling and Related Educational Programs (CACREP), which accredits a variety of master’s degree programs, including family, community, gerontological, and mental health counseling (CACREP, 2006). Licensed counselors may become certified by the Commission of Rehabilitation Counselor Certification, which grants the credential Certified Rehabilitation Counselor (CRC) (CCRC, 2006), or by the National Board for Certified Counselors (NBCC), which grants the general practice credential National Certified Counselor (NBCC, 2006).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
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Pastoral Counselors

A diagnosis of cancer or another serious illness can challenge a person’s spiritual as well as physical and psychological well-being. During illness and recovery, patients and their families may explore ways to address these difficulties by seeking pastoral counselors—ministers who integrate religious resources with insights from the behavioral sciences—to assist them with coping. The American Association of Pastoral Counselors (AAPC) accredits pastoral counselor training programs and credentials individuals in the discipline. To become a certified pastoral counselor, a candidate must possess a bachelor’s, master’s, or doctoral degree in divinity; become ordained or recognized by identified faith groups; maintain an active relationship to a local religious community; complete a supervised self-reflective pastoral experience; spend 3 years in ministry; and complete an AAPC-approved Training Program in Pastoral Counseling. Pastoral counselors are then able to work with a state license (AAPC, 2005).

EDUCATIONAL BARRIERS TO PSYCHOSOCIAL HEALTH CARE

The above discussion indicates that there is likely inconsistency in the extent to which the educational curricula studied by predominantly medically focused health care providers address psychosocial health care (and conversely the extent to which the curricula studied by predominantly psychosocial health care providers address the effects of illness on psychosocial functioning). Confounding the ability to understand and redress this inconsistency are the limited information systems available to collect data on how educational standards are translated into hours or methods of instruction, the content of such instruction, or the resulting skills of the workforce. Therefore, it is not possible to know with any certainty the characteristics of the education these health care providers receive on psychosocial issues, or the actual competency in assessing and addressing psychosocial needs they develop as a result of their education.

As discussed in Chapters 1 and 4, however, there is compelling evidence that the psychosocial needs of patients are not being adequately identified (Passik et al., 1998; McDonald et al., 1999; Fallowfield et al., 2001; Keller et al., 2004; President’s Cancer Panel, 2004; Maly et al., 2005; Merckaert et al., 2005; USA Today et al., 2006; IOM, 2007). Also as discussed previously, a range of interrelated factors—including how work in clinical practices is designed and how incentives from payers and oversight organizations operate—can impede the health care workforce’s identification of psychosocial needs and delivery of psychosocial services. Yet limitations of the content and methods of professional education and training play a role as well. In addition to a possible underemphasis on psychosocial issues in

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

health professions education, education that does not prepare clinicians to practice in today’s work environments, a lack of faculty or knowledge by faculty about what needs to be taught, and ineffective approaches to education can adversely affect the development of needed competencies.

Barriers to Education

Gap Between Health Professions Education and the Current Practice Environment

There are broad concerns about health professions education that go far beyond the lack of emphasis on biopsychosocial models of illness and recovery. Experts in education and health care delivery have concluded that clinical education has not kept pace with the shift in patient demographics and desires, changing expectations for the workforce within health systems, evolving practice requirements and staffing arrangements, the continuous flood of new information, the focus on quality improvement, and new technologies. Accordingly, they have called for the restructuring of health professions education to make it more relevant to twenty-first century health care (IOM, 2001, 2003). The IOM has recommended an intensive focus on five core competencies as the cornerstones of health professions education and improved workforce performance (IOM, 2003:4):

  • Patient-centered care—Identify, respect, and care about patient differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with, and educate patients; share decision making and management; and continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health.

  • Work in interdisciplinary teams—Cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable.

  • Employ evidence-based practice—Integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible.

  • Apply quality improvement—Identify errors and hazards in care; understand and implement basic safety design principles, such as standardization and simplification; continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs; and design and test interventions to change processes and systems of care, with the objective of improving quality.

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×
  • Utilize informatics—Communicate, manage knowledge, mitigate error, and support decision making using information technology.

The current weaknesses in health professions education in these five areas impede the delivery of psychosocial services to cancer patients in very concrete ways. Inattention to patient differences, values, preferences, and concerns contributes to psychosocial needs being undetected and unaddressed. Difficulties in communicating hamper collaboration with patients and families and undermine shared decision making about strategies for meeting psychosocial needs. The absence of skills related to interdisciplinary, team-based care creates a barrier to establishing the linkages with other professionals that are essential in connecting patients and families to available psychosocial resources. A tendency to rely on clinical tradition rather than evidence leaves the workforce unaware of emerging evidence on the effectiveness of psychosocial services and unfamiliar with new practice guidelines that are drawn from that evidence. A lack of familiarity with informatics creates an aversion to innovative, computer-assisted methods for the critical tasks of screening and assessment of psychosocial needs.

Inconsistent Use of Competencies to Guide Training

In response to growing concerns about the abilities of health professionals to keep up with the rapid pace of clinical developments and changes in health care systems, many health professions groups are undertaking initiatives to rethink the competencies their clinicians need to practice effectively. ACGME, for example, has launched a major, multiyear initiative to identify, better develop, and assess the competency of physicians in residency training (Swing, 2002). The Council identified six general competencies addressing patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (http://www.acgme.org/outcome/). ACGME required the committees that establish accreditation criteria for residencies in each specialty to incorporate these general competencies into their requirements. In a graduated fashion, residency programs are being required to define the specific knowledge, skills, and attitudes that make up each general competency; to redesign their programs to teach the competencies; and to formally assess the competency of their residents. There is emerging evidence that these requirements have had an impact on training programs. For example, Weissman and colleagues (2006) found that psychiatric residency programs provide didactic and supervised clinical experience in evidence-based psychotherapies much more frequently than do graduate-level psychology or social work programs. In the latter two

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

fields, accreditation standards are less prescriptive regarding the teaching of evidence-based practices.

This focus on competency identification is occurring broadly in other disciplines as well. Various mental health professions are developing competency models in such disciplines as marriage and family therapy, psychology, advanced practice psychiatric nursing, and psychiatric rehabilitation. Cross-disciplinary competencies are being developed for practice with specific populations, such as children and adults with severe mental illness. Other initiatives have focused on competencies for special treatment approaches, such as recovery-oriented care, peer support, and culturally competent care (Hoge et al., 2005a). The inadequate delivery of psychosocial health care in oncology suggests that there also may be benefits to specifying the competencies necessary for providing psychosocial services to medically ill patients in general, and to cancer patients in particular.

There are existing resources and some positive developments that could be used to advance the use of core competencies for the psychosocial care of cancer patients and their families. C-Change (http://www.c-changetogether.org), a coalition of federal and state government agencies, cancer centers, professional organizations, private businesses, nonprofit groups, and business leaders and individuals in the private sector whose missions relate to cancer research, control, and/or patient advocacy, has undertaken a major initiative to strengthen the core competencies of the cancer care workforce. The goal of this initiative is to develop and disseminate basic cancer care competencies to the general health care workforce—that not specializing in oncology. This focus on the nonspecialist workforce is deliberate, based on data showing an expanding need for oncology care that is not accompanied by as expansive a growth in the specialty oncology workforce. C-Change recognizes that the general health care workforce, as well as the specialty oncology workforce, needs to be competent in delivering cancer care (Smith and Lichtveld, 2007).

C-Change has already defined a set of core workforce competencies, many of which address the psychosocial services and interventions recommended in the committee’s model and standard for care (see Box 7-6). C-Change plans to work with pilot sites to implement the competencies in 2007. Based on the results of this pilot test and evaluation, in 2008 C-Change plans to pursue national dissemination of the core competencies through academic, health care, and professional organizations, as well as through comprehensive cancer control coalitions. The core competencies and to-be-developed curriculum resources will be able to be integrated into (1) basic health professions education curricula used at academic institutions, (2) continuing education programs and licensing requirements of health professional societies, and (3) worksite training programs offered by employers of health professionals (Smith and Lichtveld, 2007).

Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
×

The set of five competencies recommended by the IOM (2003) and the set of six general competencies required by ACGME (Swing, 2002) also can contribute to the development of core psychosocial competencies, as does a model for self-assessment of knowledge and skills by health psychologists described by Belar and colleagues (2001). Similarly, Division 54 of the APA recommended 12 areas of training in pediatric psychology, which could easily be translated into competency domains (Spirito et al., 2003). The Memorial-Sloan Kettering Cancer Center has identified specific competencies for its Fellowship in Psycho-Oncology and Psychosomatic Medicine within each of the six ACGME categories and is sharing these competencies with similar programs around the country.22 For example, a core competency for fellows in the “systems-based practice competency” involves the following: “Demonstrates a knowledge of community resources available to patients for continuing psychiatric care, care for family members, support and information and advocacy services for cancer patients/survivors, and hospice/palliative care resources” (Memorial-Sloan Kettering Cancer Center, 2007:4). As discussed earlier, the subspecialty of psychosomatic medicine also was recently approved as a subspecialty in psychiatry by ACGME, and the program requirements for this subspecialty indirectly identify essential competencies (http://www.acgme.org/acWebsite/RRC_400/400_prIndex.asp). The Academy of Psychosomatic Medicine has organized a committee that is charged with developing more specific competencies for this area of practice, which will serve as yet another resource.23

Finally, the model for providing psychosocial services to cancer survivors and their families detailed in Chapter 4 should inform efforts to specify the competencies relevant to providing psychosocial services for all members of the workforce. It provides clear direction regarding the types of core competencies that should be considered essential in future efforts to develop comprehensive competency sets and related curricula. These include knowledge and skills in the following:

  • Communication with patients and families

  • Screening

  • Needs assessment

  • Care planning and coordination

  • Illness self-management

  • Collaboration across disciplines/specialties and work in teams

22

Personal communication, Andrew J. Roth, MD, Attending Psychiatrist, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, March 21, 2007.

23

Personal communication, William S. Breitbart, MD, Chief, Psychiatry Service, Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, March 21, 2007.

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    BOX 7-6

    Selected C-Change Psychosocial Core Competencies

    DOMAIN I: CONTINUUM OF CARE. Within the context of the professional discipline and scope of practice, a health care professional should …


    Prevention and Behavioral Risks …

    Incorporate the shared decision-making process into cancer risk-reduction counseling.


    Treatment

    1. Access cancer treatment information specific to cancer location and type.

    2. Describe the available cancer treatment modalities….

    1. Describe options to manage disease and treatment-related symptoms.

    2. Manage disease and treatment-related symptoms.

    3. Refer for treatment of disease and treatment-related symptoms.

    4. Provide emotional support to patients.

    5. Refer for mental health services.

    Post Treatment

    1. Assess that resources for cancer services and insurance coverage are consistent with current recommendation.

    2. Assist patients and families in navigating the health care system following cancer treatment.

    3. Guide patients with cancer and their families toward support systems and groups.

    4. Provide ongoing health services that meet age and gender recommendations.

    5. Recognize the importance of survivorship in a long-term cancer care plan at the conclusion of active treatment.

    6. Manage continuing and late effects of cancer and cancer treatment.

    1. Refer survivors to rehabilitation services.

    2. Provide support for cancer survivors and their families and caregivers as they cope with daily living, including lifestyle, employment, school, sexual relationships, fertility issues, and personal intimacy.

    Pain Management

    1. Explain how cancer pain differs from other types of pain.

    2. Describe the methods used to diagnosis cancer pain throughout the progression of the disease.

    3. Differentiate between acute and chronic pain symptoms.

    • Linking of patients to psychosocial services

    • Outcome assessment

    • Informatics (to support screening, needs assessment, planning, care coordination, service provision, and outcome assessment)

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×
    1. Describe the characteristics used to assess cancer pain: frequency, intensity, and site.

    2. Perform a cancer pain assessment.

    3. Explain the different treatment options for cancer pain.

    4. Perform a pain-related history taken during a physical examination.

    5. Manage cancer-related pain and analgesic side effects.

    DOMAIN III: COLLABORATION AND COMMUNICATION.

    1. Participate Within an Interdisciplinary Cancer Care Team

      1. Define interdisciplinary care.

      2. Describe the contribution of each professional perspective in the development of cancer care plan.

      3. Consider the financial implications for recommended cancer care.

      4. Refer patients to an oncology social worker for financial guidance and resource navigation.

      5. Consider the resource challenges of the agency in implementing a treatment plan.

    1. Incorporate Psychosocial Communication Strategies in Conveying Cancer Information

      1. Refer patients to mental health, psychosocial, and support services.

      2. Recognize the signs and symptoms of cancer-related depression and anxiety.

      3. Explain the management of depression and anxiety in patients with cancer.

      4. Explain the useful copying [sic] mechanisms following a cancer diagnosis.

    1. Incorporate Cross-Cultural Communication Strategies in Conveying Cancer Information

      1. Identify cultural subgroups in a given patient population.

      2. Define culture-specific beliefs and practices.

      3. Communicate cancer care information that is sensitive to religious and spiritual beliefs and practices.

    1. Describe Common Ethical and Legal Issues in Cancer Care

      1. Adhere to HIPAA policies, procedures, and regulations.

      2. Access institutional and other ethics resources.

      3. Advocate for the use of advanced directives, including the right to refuse care.

      4. Justify the need for informed consent in cancer research.

    SOURCE: Smith and Lichtveld, 2007.

    Elaboration is required for each of these content areas, specifying behavioral descriptors for the underlying knowledge, skills, and attitudes required for (1) different sectors of the workforce (e.g., paraprofessional case manager versus medical oncologist), (2) different stages of development (e.g., completion of training versus independent practice), and (3) different

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    levels of competence (exceptional, acceptable, substandard). Such sophistication in competency identification and assessment is required to move the field beyond the common and limited practice of simply listing generic competencies with no specificity or behavioral anchors (Hoge et al., 2005b).

    Competency-based approaches offer a flexible foundation for staff development and assessment. Traditional approaches, in which qualifications or abilities are inferred from degrees, certification, licensure, discipline, or job description, lack specificity regarding skills and are of little utility when assessing skills that are shared by multiple segments of the workforce. Case management, for example, is a skill that can be performed by nondegreed paraprofessionals, such as navigators, or by highly trained professionals, such as master’s-prepared social workers or medical oncologists. Conceptualizing case management as a function or competency, defined by clear behavioral descriptors and several levels of expertise, would provide for greater utility and flexibility in providing training in and assessing workforce capacities.

    Faculty Needs

    Identified educational competencies are necessary but insufficient for the development of student/trainee knowledge and skills. Sufficient numbers of faculty who themselves possess the requisite attitudes, knowledge, and skills are required to teach the competencies. Faculty development programs are widely used to help train a critical mass of faculty in areas identified as deficient, such as education about substance use (Haack and Adger, 2002). Some professions, such as nursing, additionally suffer from an inadequate supply of faculty generally. Faculty development programs that attend to both numbers and expertise are needed to ensure the application of the competencies across health professions schools.

    Effective Teaching Practices

    Competency identification and curriculum development provide a foundation for training and education. However, they must be combined with effective teaching practices to achieve the desired learning outcomes (Stuart et al., 2004). A substantial evidence base exists in medicine regarding effective teaching and skill development approaches (Davis et al., 1999). The principal finding of research in this area is that didactic or noninteractive, single-session lectures and workshops constitute the most common training approaches in continuing education and much of preservice education, but have virtually no effect in changing the practice behaviors of trainees (Mazmanian and Davis, 2002; Bloom, 2005). Davis and colleagues (1999) argue that the evidence on this issue is so strong that continuing

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    education credit should probably not be offered for most continuing education events.

    Oxman and colleagues (1995) conclude there is no single magic bullet for achieving skill development and change in practice behaviors among learners. Combining multiple teaching strategies, each proven to have small effects on practice behavior, represents an evidenced-based approach to teaching. Such strategies include interactive or experiential methods; outreach visits, sometimes referred to as academic detailing; reminders; auditing of practice behaviors with the provision of feedback to the learner; the use of opinion leaders; and patient-mediated interventions (Soumerai, 1998; Borgiel et al., 1999; Davis et al., 1999; O’Brien et al., 2003). Examples of some of these strategies are presented below.


    Combined, multiple teaching strategies The Communication Skills Teaching and Research (Comskil) Lab at Memorial Sloan-Kettering Cancer Center is currently training fellows from nonpsychiatric medical specialties in communication skills. To date, 39 fellows have been trained around six core modules: (1) Breaking Bad News, (2) Shared Decision Making About Treatment Options, (3) Responding to Patient Anger, (4) Discussing Prognosis, (5) Discussing the Transition from Curative to Palliative Care, and (6) Shared Decision Making About “Do Not Recussitate” Orders.

    The Comskil training program was developed using best practices that have been established for communication skills training. Before attending a module, participants receive a booklet summarizing the literature and skill recommendations. Each 2½- to 3-hour training module consists of a didactic presentation, exemplary video clips demonstrating skills, and a small-group role play session in which learners have the opportunity to practice with a trained actor playing the role of a patient. Immediate video playback of this role play encourages review, experimentation, and reinforcement of new skills. Each session is cofacilitated by a medical/surgical and a psychosocial facilitator.

    Assessment and feedback are essential to the Comskil experience. Before attending their first Comskil training module, participants are video recorded in their outpatient consultations with two patients, with the patient’s permission. These recordings are analyzed using a coding system based on the Comskil curriculum to assess participants’ baseline. Participants receive feedback letters, based on this coding, that describe their current clinical communication strengths, as well as areas for improvement. Following training, participants are again video recorded in their consultations with two patients. The recordings are analyzed, and feedback letters are sent to participants describing their strengths, improvements, and areas in need of continued improvement.

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    Interactive, multicomponent education postlicensure The Individual Cancer 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 discussion and knowledge- and skill-building activities encompassing clinicians’ monitoring of their own attitudinal and emotional responses to cancer; psychosocial issues relevant to cancer patients, including stress management, coping, quality-of-life concerns, grief, and hope; and ongoing case consultation 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 making 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 participants 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 professionals 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, University 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 transmitting knowledge and using experiential educational strategies such as role

    24

    Personal communication, Patricia Doykos Duquette, PhD, Bristol-Myers Squibb Foundation, New York, December 14, 2006.

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    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 deliver the continuing education program. The majority of participants were nurses, complemented by social workers, nutritionists, clergy, and pharmacists. 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 psychosocial 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 optimally possess to provide the services;

    • the absence of well-developed curricula built around clearly defined competencies;

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×
    • inadequate numbers of faculty qualified to train and mentor students in psychosocial skills; and

    • insufficient specificity in accreditation and licensing standards regarding competencies in and curricula on psychosocial care.

    Moreover, the lack of information systems to track developments in education and training hampers the identification of effective educational approaches. 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 committee further makes the following recommendation.

    Recommendation: Workforce competencies.

    1. Educational accrediting organizations, licensing bodies, and professional 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.

    2. Congress and federal agencies should support and fund the establishment of a Workforce Development Collaborative on Psychosocial 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 educators 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 workforce 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 educational accreditation standards and professional licensing and certification exams by recommending revisions to the relevant oversight organizations.

    1. Organizations providing research funding should support assessment of the implementation in education, training, and clinical

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    practice of the workforce competencies necessary to provide psychosocial 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 psychosocial 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 membership and 2-year work plan for the proposed Workforce Development Collaborative.

    As a second step, DHHS should establish a full-time managerial position 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 representatives 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 allocation of federal funds to establish and support the operation of the Workforce 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 identified. 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

    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

    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.

    Finally, the committee notes that it is most common to call upon health professionals to incorporate necessary psychological and social content into their curricula, but that a similar need exists in the social service professions to incorporate content on biological stressors, including chronic illnesses, into their curricula.

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    Suggested Citation:"7 Preparing the Workforce." Institute of Medicine. 2008. Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/11993.
    ×

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    Cancer care today often provides state-of-the-science biomedical treatment, but fails to address the psychological and social (psychosocial) problems associated with the illness. This failure can compromise the effectiveness of health care and thereby adversely affect the health of cancer patients. Psychological and social problems created or exacerbated by cancer--including depression and other emotional problems; lack of information or skills needed to manage the illness; lack of transportation or other resources; and disruptions in work, school, and family life--cause additional suffering, weaken adherence to prescribed treatments, and threaten patients' return to health.

    Today, it is not possible to deliver high-quality cancer care without using existing approaches, tools, and resources to address patients' psychosocial health needs. All patients with cancer and their families should expect and receive cancer care that ensures the provision of appropriate psychosocial health services.

    Cancer Care for the Whole Patient recommends actions that oncology providers, health policy makers, educators, health insurers, health planners, researchers and research sponsors, and consumer advocates should undertake to ensure that this standard is met.

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