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When I witness someone ask the question, “Who is looking for a new associate?” at meetings of practicing medical oncologists, invariably more than 50% of the hands are raised. In this issue of the Journal of Oncology Practice, a thought-provoking contribution to this topic is published as an ASCO Special Article on “The Future Supply and Demand for Oncologists.”1
As background, in August 2003, ASCO's Board of Directors formed a task force to assess the current oncologist workforce (medical oncologists, hematologists/oncologists, pediatric hematologists/oncologists, and gynecologic oncologists) and to project future demand and supply. Dr Michael Goldstein served as chair of the task force, which included oncology program directors, health services researchers, community and academic oncologists, and workforce specialists. In December 2004, ASCO contracted with the Association of American Medical Colleges' Center for Workforce Studies to conduct the study under the guidance of the task force. The ASCO Workforce in Oncology Task Force presented the findings of its study to the Board at its November 2006 meeting.
ASCO's previous oncology workforce study, conducted in the early 1990s, employed a survey methodology to investigate the practice patterns and desires of ASCO members, who were estimated to represent 95% of the medical oncology practitioners in the United States.2 This first-pass determination was done during a time when the expense of oncology care was starting to become an issue, in an era of more rudimentary cancer treatments, and on a background of proposals to reduce oncology-training slots by 40%. The then-estimated 3,600 full-time-equivalent oncologists were adequate, based on comparisons with staff model health maintenance organizations' (HMOs) use of oncologists per 100,000 population. Though this estimate of the workforce size was almost certainly wrong, the earlier study's two main conclusions are largely true: oncologists desired delivering less primary care, and the workforce was right-sized. Fifteen years on, most oncologists are as busy as they want to be, and they spend their professional time delivering specialty oncology care.
The current study used many data sources (both existing and new data from four surveys) to provide a more reliable estimate of the current oncology workforce—the American Medical Association Masterfile of physicians—and a more robust estimate of the potential patient population and oncology practice patterns.
The results indicate that we will be facing a shortage of 2,550 to 4,080 oncologists by 2020—which could translate to 9.4 to 15 million fewer oncologist visits. The study used a combination of Medicare visit data and National Cancer Institute incidence and prevalence projections to determine the demand for services and capacity of the workforce to deliver those services. The authors performed sensitivity analyses, testing the effects of increasing oncology training slots, electronic medical record use, and midlevel provider use on visit capacity and workforce supply. Projections were also made on the effects of delaying retirement of current oncologists and potential for decreased work hours and thus productivity in younger oncologists. The model's sensitivity to increases in the number of new cancer patients seen by an oncologist, to varying the intensity of oncologist interaction with each patient, and to truncation of oncologist interaction with each patient by use of hospice or primary care providers to manage various stages of the illness was tested.
Making predictions, especially about the future, is difficult, as was observed by both the theoretical physicist Niels Bohr and the applied physicist Yogi Berra. The wildest swings in the predictive model for visit demand (Table 4) occur when the proportion of new cancer cases seen by an oncologist is varied.1 Many other specialists manage early-stage colon, skin, and prostate cancers. Medical oncologists add little value to management of these early-stage tumors, but radical changes in the management of these conditions (effective adjuvant systemic therapy for early-stage, high-risk prostate and colon cancers for instance) could radically alter the demand forecast. On the contrary, simplification in the management of hormone receptor–positive early-stage breast cancer could lead to more management of this now-common condition by surgeons or other nononcologists. It is difficult to predict the changes in practice patterns that biomedical or information technology will bring 15 years from now.
Market forces should be allowed to continue to guide adjustments of oncology care. The reason medical oncologists see less early-stage prostate and skin cancer is that we currently add little value to the care of these patients. As oncologists become relatively rarer and our time more dear, we will figure out ways to become more productive diagnosticians, innovators, and problem solvers. We will spend less professional time performing extensive documentation and other non–value-added tasks, and more time developing and leading our teams. We should develop and refine guideline-based care so that we can delegate more routine tasks to midlevel providers, experienced oncology nurses, and others who specialize in managing various aspects of the cancer care continuum. Information technology should be developed to allow us to spend more productive time with our patients. Those new associates who are identified and hired should add value to patient care and only do work for which a trained medical oncologist is required.