Delivering High-Quality Cancer Care Charting a New Course for a System in Crisis (2013) / Chapter Skim
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4 The Workforce Caring for Patients with Cancer
4 The Workforce Caring for Patients with Cancer
Pages 153-206
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From page 153... ...
. The cancer care team includes those with specialized training in oncology, such as oncologists and oncology nurses, other specialists and primary care clinicians, as well as family caregivers and direct care workers.
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The next section focuses on strategies for ensuring the quantity and quality of the clinicians on cancer care teams, including the recruitment and retention of clinicians, the importance of team-based cancer care, training the workforce, and telemedicine. The chapter concludes with a discussion of the role of family caregivers and direct care workers in providing cancer care.
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Each section describes the general role of the profession in cancer care and the projected workforce supply and demand. Many other professionals are also involved in cancer care teams, such as laboratory personnel, public health workers, and cancer registrars.
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. These general trends in the physician workforce have a substantial impact on the physicians and specialists who provide care for cancer patients, such as oncologists, primary care physicians, and geriatricians.
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This section focuses on medical oncologists because they are the primary physicians involved in cancer care, and their workforce has been studied extensively by the American Society of Clinical Oncology (ASCO)
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. It may be possible to offset the need for additional primary care physicians by diverting some patients to nonphysician professionals, such as advanced practice registered nurses and physician assistants (discussed below in the sections on advanced practice registered nurses and physician assistants)
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They often provide continuous treatment for their patients' concurrent illnesses and conditions, which may need to be adjusted or monitored differently during cancer treatment, as well as survivorship care and cancer surveillance after their acute cancer treatment is complete. Primary care clinicians can also play a role during active treatment in establishing advance directives and coordinating with family caregivers and direct care workers (IOM, 2011b; Klabunde et al., 2009)
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, who must complete a 4-year bachelor's degree program, a 2-year associate degree program, or a 3-year diploma program and pass a national licensure examination; and (3) advanced practice registered nurses (APRNs)
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forecasted the RN job shortage in all 50 states between 2009 and 2030 and assigned letter grades based on the projected RN job shortage ratio. The number of states receiving a grade of "D" or "F" for their RN job shortage ratio is projected to increase from 5 in 2009 to 30 by 2030.
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(See Box 4-1 for a description of the role of primary care clinicians in cancer care.) The inclusion of APRNs on care teams has been shown to improve the quality of care that health care delivery organizations provide to patients, especially when they are involved in patients' transitions between care settings (Naylor and Keating, 2008; Naylor et al., 1994, 1999, 2004, 2005, 2009, 2011)
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, and they are playing an increasingly important role on collaborative cancer care teams (Coniglio, 2013; Coniglio et al., 2011)
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. Cancer care teams are exploring new models of integrating palliative care and hospice care into their practices.
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They can also help patients to communicate more effectively with the other members of the cancer care team and help them to decide on an appropriate care plan. In addition, psychologists can play an important role in helping the families of cancer patients cope with their own stress, as well as work through sexual and relationship challenges (APA, 2013a; Clay, 2010)
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Although accrediting groups often require hospitals to meet their patients' spiritual needs, the role of chaplains on the cancer care team is often less prominent and less recognized than it should be. In one study, close to 90 percent of cancer patients receiving palliative radiation therapy reported that their spiritual needs were an important component of their psychological
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From page 167... ...
. Patients whose spiritual needs are not supported by the cancer care team are more likely to receive hospice care for less than 1 week, more likely to die in an intensive care unit, and generally have higher end-of-life care costs (Balboni et al., 2010)
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This portion of the chapter reviews the main strategies for ensuring that the workforce caring for patients with cancer has sufficient numbers of professionals to meet the demand for cancer care; that the team of professionals providing care is functional and well-coordinated; and that the workforce is prepared with the knowledge, skills, and experiences necessary to provide high-quality cancer care. Recruitment and Retention of Professionals Who Provide Cancer Care A key aspect of ensuring that there are sufficient numbers of professionals to care for patients with cancer is attracting individuals into oncology careers and retaining individuals once they choose a career in oncology.
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From page 169... ...
. Surveys of medical oncologists confirm that professionals providing care to cancer patients experience significant career burnout, defined as emotional exhaustion and the lack of motivation to continue working in a given field (Allegra et al., 2005; Grunfeld et al., 2005; Kash et al., 2000; Ramirez et al., 1995, 1996; Shanafelt et al., 2005; Whippen and Canellos, 1991)
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. Factors that influence the retention of health care workers include salary, benefits,
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. A white paper published by the IOM recently identified a core set of principles common to high-functioning health care teams (see Box 4-2)
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. The committee identified as a goal that all of the members of the cancer care team coordinate with each other and with primary/geriatrics and specialist care teams to implement patients' care plans and deliver comprehensive, efficient, and patient-centered care (Recommendation 3)
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. Establishing effective care teams requires time and effort, and there are few incentives for health care clinicians to make this investment.
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Survivorship Care Another model of team-based care in oncology is treating patients who no lon ger require active cancer treatment (e.g., chemotherapy, radiation) in settings out side of an oncologist's office.
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At Memorial-Sloan Kettering Cancer Center, nurse practitioners administer examinations and preventive care, evaluate and manage long-term or late effects of cancer and its treatment, provide cancer screening, and coordinate with each patient's primary care team through disease-specific survivorship clinics (MSKCC, 2012)
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FIGURE 4-2 An illustration of a coordinated cancer care team. Figure 4-2 R02518 bitmapped uneditable
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. As the delivery of cancer care becomes more team based, academic institutions and professional societies should develop interprofessional education programs to train the workforce in team-based cancer care and promote coordination with primary/geriatrics and specialist care teams.
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. Fortunately, the Health Resources and Services Administration's Coordinating Center for Interprofessional Education and Collaborative Practice is currently providing financial support for efforts to develop successful interprofessional educational programs (HRSA, 2013)
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The goal is to integrate interprofessional educational content into existing core health sciences curriculum, expand student access to opportunities to become involved in collaborative practice, and build facilities that encourage formal and informal interprofessional interactions. SOURCES: RUMC, 2012; UMN, 2013; University of Colorado, 2013a,b; UW, 2012, 2013.
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• Working in interprofessional care teams and coordinating with other care teams (see discussion above in the section on team based cancer care) • Demonstrating knowledge about established and evolving clini cal and health services research (see Chapter 5)
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The relevant professional organizations representing primary care clinicians and other medical specialists who work in oncology should define the cancer core competencies for these workforces. In order to ensure that members of the cancer care team have core competencies in other relevant fields, professional organizations representing nononcology clinicians should reciprocate by sharing tools and information about their specialties with the cancer care community.
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. Caregivers Caregivers, including family caregivers and direct care workers, are critical members of the cancer care team.
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. Both family caregivers and direct care workers are particularly important in cancer care because of the debilitating effect of the disease; the side effects associated with many of the common cancer treatments; the complexity of the medical decisions; and the ongoing need for medical treatment, home care, and surveillance.
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. Caregivers are more likely to report a positive experience if they receive psychological support, the care team validates the care they are providing, and health care professionals assist in solving any problems that arise with the care recipient (Haley, 2003; Kim et al., 2007)
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. Integration with the Cancer Care Team Caregivers may provide assistance at any point in the continuum of cancer care, starting with diagnosis, treatment, palliative care, survivorship, through the end-of-life phases of cancer care.
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Family caregivers and direct care workers often have different informational needs and ways of communicating (e.g., technological sophistication) compared to the patient, and there are sometimes conflicting values and preferences between patients and family caregivers (IOM, 2011c)
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Recommendation 3: An Adequately Staffed, Trained, and Coordi nated Workforce Goal: Members of the cancer care team should coordinate with each other and with primary/geriatrics and specialist care teams to implement patients' care plans and deliver comprehensive, ef ficient, and patient-centered care.
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To accomplish this: • rofessional organizations that represent clinicians who care P for patients with cancer should define cancer core competencies for their memberships. • ancer care delivery organizations should require that the C members of the cancer care team have the necessary compe tencies to deliver high-quality cancer care, as demonstrated through training, certification, or credentials.
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Medical school seniors match to primary care residencies. https://www.aamc.org/newsroom/newsreleases/2011/180410/110317.html (accessed September 7, 2012)
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http://allhealth.org/publications/ Physician_Workforce_Shortage_110.pdf (accessed September 6, 2012)
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http://www.nursingworld. org/EspeciallyForYou/What-is-Nursing (accessed September 7, 2012)
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2013f. Occupational outlook handbook, 2012-13 edition, social workers.
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2012. A competency-based approach to expanding the cancer care workforce part III: Improving cancer pain and palliative care compe tency.
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2013. Coordinating Center for Interprofessional Education and Collaborative Practice.
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http://www.iom.edu/ Activities/Workforce/GMEGovFinance.aspx (accessed September 7, 2012)
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2013. American Society of Clinical Oncology statement: Achieving high quality cancer survivorship care.
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2007. Direct care workers' recommen dations for training and continuing education.
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http://www.penncancer.org/ patients/centers-programs-services/livestrong-cancer-survivorship-center (accessed September 20, 2012)
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2013. Generalist plus specialist palliative care -- creating a more sustainable model.
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2011. Preventive care in prostate cancer patients: Following diagnosis and for five-year survivors.
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2010. Framework for action on interprofessional education & collaborative practice.
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Annex 4-1 Professionals involved in cancer care 202 Health Care Professional Role in Cancer Care Overview of Available Information Physicians Physicians (general) • Principal clinicians of medical care • Current shortage of ~8% • Shortage will increase to >20% by 2025 if no new residency slots are added Oncology Physicians Geriatric Oncologists • Diagnose and treat cancer in older adults • No information available Hematologists • Diagnose and treat blood disorders, including • American Society of Hematology has +14,000 members cancer Medical Oncologists • Diagnose and treat cancer • Shortage of 2,500-4,080 oncologists by 2020 predicted • More than 14,000 medical oncologists and 8,000 hematologists in 2012 Radiation Oncologists • Treat cancer with radiation therapy • The American Society for Radiation Oncology has ~10,000 members Surgical Oncologists • Specialize in the surgical management of cancer • The number of general surgical subspecialties, including surgical oncology, grew 20% between 2004 and 2008 Medical and Surgical Specialists Gastroenterologists • Diagnose and treat cancers in the digestive • 15,000 in 2012 system Gynecologists • Diagnose, treat, and manage patients with • 49% of counties in the United States lack an ob-gyn gynecological cancers (e.g., ovarian, cervical)
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• 45% of all urologists are 55 years or older Primary Care Clinicians Geriatricians • Specialize in the care for older adults • 9,000+ in 2012 Primary Care Physicians • Provide comprehensive and continuous care for • More than 200,000 primary care physicians in 2007 patients regardless of diagnosis, organ system, • Only 2% of internal medicine residents planned to go or problem origin into primary care in 2009 Nurses and Physician Assistants Nurses (general) • Focused on caring for and dealing with • 3 million registered nurses individual responses to health problems • Shortage of 1 million registered nurses predicted by 2020 • 6.9% nursing school faculty vacancy rate in 2010 • 30% drop-out rate for first-year nurses 203 continued
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2008-2018 Laboratory personnel • Collect samples and perform tests to analyze • 60% of the health care workforce body fluids, tissue, and other substances • By 2015, an additional 81,000 clinical laboratory technologists are needed to replace retiring personnel; 68,000 to fill newly created positions • Aging 78% faster than the general U.S. labor market Occupational Therapists • Help patients develop, recover, and improve • ~100,000 in 2010 skills necessary for everyday living that are • 33% increase between 2010 and 2020 impaired due to cancer or cancer treatment
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Patient Navigators • Help patients navigate through the various • No information available components of the health care system, • Education and training varies widely including physicians' offices, clinics, hospitals, outpatient centers, insurance and payment systems, and patient-support organizations Pharmacists • Provide chemotherapy, medications for • 25% of pharmacists are approaching retirement age palliative care, and patient education on drug • 75% of pharmacy directors and middle managers side effects and interactions anticipate retiring from their positions within the next decade • 6.4% vacancy rate in 2007 Physical Therapists • Promote mobility, functional ability, quality of • ~200,000 in 2010 life, and movement potential • 39% increase projected between 2010 and 2020 Public Health Workers • Screening, prevention, and early detection of • 250,000 more workers are needed by 2020 cancer • 50,000 fewer workers in 2000 than in 1980 • Surveillance of cancer incidence, prevalence, • 23% of the current workforce was eligible to retire in and mortality 2012 • Schools of public health would have to train three times the current number of graduates to replenish the workforce Social Workers • Provide patient navigation, psychosocial • 650,500 social workers; 1,000 in oncology screening and assessment, and support for • 13% of licensed social workers specialize in health care cancer-related depression and anxiety • 29% of licensed social workers are over 55 years • 85% of all health care social workers are likely to practice in metropolitan areas; 2% are likely to practice in rural areas NOTE: The information presented for each professional varies, depending on what information is available about that workforce. SOURCES: AACN, 2010; AAMC, 2007, 2008; AAPA, 2012a; ABIM, 2012; ACCP, 2012; ACG, 2012; ACOG, 2011; ACR, 2012; ACS/HPRI, 2010; AGA, 2012; AOSW, 2013; ASCP, 2004; ASH, 2011; ASHP, 2007, 2008; ASTRO, 2012a; BLS, 2013b,f; Blum et al., 2006; Buerhaus et al., 2009; CWS, 2006; Hauer, 2008; Hillborne, 2008; HRSA, 2010, 2012; HWS, 2007; IOM, 2011a; KHN, 2011; Lupu, 2010; McDonald and Sutton, 2009; NASW, 2006; NCRA, 2006; Passiment, 2006; PricewaterhouseCoopers, 2007; Routson, 2010; Sargen et al., 2011; Sheldon, 2010; UT, 2007; White, 2005.
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