In the model going forward, the oncologist is going to be more of a supervisor overseeing care delivered by other people. The oncologist will deal with the more stressful, more acute, or more serious cases.
—Michael A. Goldstein, MD
A study commissioned by ASCO in 2006 predicted a significant shortage of medical and gynecologic oncologists in the United States by 2020. As a result, the organization created the Workforce Implementation Group to develop recommendations to stem the projected workforce shortfall and ensure ongoing care for the rising number of cancer survivors. The study, published the following year in the Journal of Oncology Practice,1 forecasted a looming perfect storm of events that included an aging and growing population, increasing numbers of cancer survivors, and an aging and retiring oncology workforce, which together would result in a shortage of between 2,550 and 4,080 oncologists by the next decade—approximately one-quarter to one-third of the supply of oncologists in 2005.
Workforce Shortage Projections
Today, new indicators are showing that while demand for health-care services may be increasing, the way it is delivered is changing, possibly altering the future shortfall projections of oncologists. “When we published our first study, we were trying to get a snapshot of what was going on in the oncology world. This established a baseline from which we set up a database that now allows us to be aware of changes in real time, and thus, to be more proactive,” said Michael A. Goldstein, MD, Co-chair of ASCO’s Workforce Advisory Group and Workforce in Oncology Task Force, and an oncologist at Beth Israel Deaconess Medical Center in Boston. “Since that time, there has been a shift in where and how clinical care is delivered. A lot of small practices have amalgamated or been bought out by hospitals, and some have actually closed. So the distribution of oncologists has changed, and we don’t yet know whether those changes will bring increased or diminished efficiency and capacity.”
The financial recession, which began in late 2007 and still lingers today, is also having an effect on the oncology workforce, possibly rendering the earlier projections obsolete. “At the time the study was published, the economic decline hadn’t yet started. A lot of physicians who were going to retire have not retired, and some have even come back into the workforce for financial reasons, so the supply projections are probably inaccurate,” said Michael P. Kosty, MD, a member of the Workforce Advisory Group and Director of the Scripps Green Cancer Center in La Jolla, California.
Advances in treatment, such as oral cancer medications, which patients administer themselves, and the increasing use of nonphysician practitioners in oncology practices, are also easing demand on oncologists’ time. “In both formal and informal canvassing of oncologists around the country, we found that very few practices are in a situation where they are overrun with patients and the waiting times are exorbitant. I think there is a feeling that there still will be a shortage of oncology specialists, but the magnitude might be different from even the most optimistic projection in the 2007 paper,” said Dr. Kosty.
Although the economic downturn may be keeping physicians in the workforce longer than they had planned, the lull in a projected workforce shortage may be short-lived. “At the time of the study, we did not contemplate a scenario where the economy was in such bad condition, so it is plausible that physicians are staying in practice longer than they have in the past due to the economic situation,” said Clese Erikson, Director of the Center for Workforce Studies at the Association of American Medical Colleges (AAMC). “But presumably the economy is going to recover, and we may have a lot of pent up demand to retire,” she added.
The AAMC conducted ASCO’s 2006 Survey of Practicing Oncologists, which collected data from practicing oncologists, oncology fellows, and oncology fellowship program directors. The questions on the survey explored issues ranging from current practice activities, work hours, and patient visit rates to the use of nurse practitioners and physician assistants.
How Medical Care Is Delivered
To get an updated picture of what the future supply and demand for oncologists may be over the next decade, ASCO is launching a new survey and expects to have some results in about 18 months. ASCO has also established an oncology database to track the number of practicing oncologists in real time. Currently, ASCO puts that number at approximately 14,000.
Even if the predicted workforce shortages in the coming years come true, better coordination in how oncology care is delivered through initiatives such as team-based medical homes and Choosing Wisely (see sidebar)—which calls for the reduction of unnecessary procedures and tests—may help mitigate the problem.
“We are seeing dramatic changes in the personnel involved in delivering health care,” said Dr. Goldstein. “The study we did about the use of nonphysician providers in oncology practices showed that [nonphysician practitioners] are widely employed.2 They increase efficiency and are very well accepted by both physicians and patients, so in the model going forward, the oncologist is going to be more of a supervisor overseeing care delivered by other people. The oncologist will deal with the more stressful, more acute, or more serious cases.”
Adding to the uncertainty over the future supply and demand of oncology services in the United States is the impact of the Patient Protection and Affordable Care Act, which will expand health-care coverage to 32 million previously uninsured Americans by 2014. (A decision by the U.S. Supreme Court on the constitutionality of the law is anticipated this month.)
Although the greatest workforce shortfall is expected to come in the number of primary care physicians—the AAMC is predicting a shortage of 27,200 primary care physicians in 2014; rising to 45,400 by 2020—the impact may trickle down to other medical specialties, including oncology.
“If you look at the specialties people go into after their internal medical residencies, cardiology is number 1 and hematology/oncology and gastroenterology are numbers 2 and 3, depending on the year. ASCO and those of us in medical oncology are doing what we can to make oncology an attractive career choice,” said Dr. Kosty. “But one of the consequences of that is unless more people go into internal medicine and then subspecialize, we’re going to be creating a potential shortage in other medical specialties.”
The Workforce Advisory Group realized early on that it would need a multifaceted approach to solve a potential future deficit in the number of practicing oncologists and help physicians remain active longer. Thus, the group is examining how strategies such as job sharing and part-time employment might be appealing to oncologists as they move through different stages in their careers and look to balance work and private life.
“More women are going into oncology, and one of the consequences of that is they take time off to have children and raise families. In general, both men and women going into medicine today have a different outlook on life and are less willing to sacrifice everything for their career. We have to become more creative in [accommodating different lifestyle needs],” said Dr. Kosty.
The Workforce Advisory Group is also engaging in joint initiatives with nonphysician oncology professionals and general practice physicians to study the workforce shortage problem and come up with solutions.
“We now have close relationships with the American Academy of Physician Assistants and the Oncology Nursing Society and interact with oncology nurse practitioners, so we have a much more team-oriented approach. We’re also validating the demand projection to see if it’s still on the same curve as originally predicted. I think it’s much more of an organic and ongoing process than just taking a snapshot in time with a survey,” said Dr. Goldstein. ■
Disclosure: Drs. Goldstein and Kosty and Ms. Erikson reported no potential conflicts of interest.
1. Erikson C, Salsberg E, Forte G, et al: Future supply and demand for oncologists: Challenges to assuring access to oncology services J Oncol Pract 3:79-86, 2007.
2. Towle E, Hanley A: Examining the role of nonphysician practitioners in oncology practice. Oncology Metrics, 2011.