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An estimated tally of medical oncologists -- roughly 1.8 full-time equivalent medical oncologists per 100,000 U.S. adults -- may be adequate for right now, said Wade, "but I think that the work force is probably inadequate to meet the growing need over the next 10 years." He said the situation could be exacerbated if experienced oncologists, tired of health care delivery system hassles, decide to retire early.
Population Changing
Speaking at the recent ACCC's 24th annual meeting in Crystal City, Va., Wade said, "The population is changing and the number of people age 65 and over is growing. We know that cancer is a disease of folks who get older." Because of these trends, said Wade, president of Cancer Care Specialists of Central Illinois and director of medical oncology at Decatur Illinois Memorial Hospital Cancer Care Institute, oncologists need to "think outside the box" about how to provide care to a large population in increasing need. One way, he noted, is to rely more heavily on oncology nurses, oncology nurse practitioners, and oncology physician assistants.
Mushrooming Demand
A study comparing the American Society of Clinical Oncology's figure above to the numbers published by health maintenance organizations suggests that "we have a reasonable supply [of oncologists] at this time," said Wade. But, he noted, as the country faces the year 2000, the projected need for specialists in the United States is 3.6 oncologists/hematologists per 100,000 U.S. adults -- about twice as many as there are now. The study was published by the Graduate Medical Education Advisory Committee.
Wade added that "our technology is not going to remain static; we will have more to offer, so I predict that the 3.6 per 100,000 will be a low figure." He also questioned whether training approximately 180 new medical oncologists per year -- as is now done -- will produce enough new oncologists to meet the growing demand.
Skilled registered nurses could help solve a projected crisis in the oncology work force, according to Kathi H. Mooney, Ph.D., professor of oncology nursing at the University of Utah and immediate past president of the Oncology Nursing Society. Mooney noted that the ONS has about 25,000 members; of these, the majority, 52% practice in hospitals, while 34% are in ambulatory and office settings, and 7% are in home care or hospice work.
The ONS has taken an active, visible role in cancer patient-care issues. It sponsored a national Cancer Fatigue Awareness Day April 2 to educate health care professionals about cancer treatment-related fatigue so they, in turn, can educate patients and the public.
Today, there are pressures on the nursing profession and on oncology nurses specifically, said Mooney. She said there are about 2.1 million registered nurses working in the field, and that the projected need will be for 2.6 million by 2020.
"By 2015, 115,000 jobs for full-time RNs will be unfilled nationwide," said Mooney. "The Bureau of Labor Statistics predicts that registered nurses will be one of the fastest growing occupations through 2006."
Growing Shortage
In addition to a growing shortage of nurses, however, Mooney said there is a "de-skilling" -- a lack of emphasis on specialized skills -- of oncology nurses caused by the cost pressures of managed care. This is happening, she said, as hospitals focus more on medical/surgical care and less on oncology, downsize hospital nursing staffs, and close their specialty inpatient units. "Oncology nurses have been laid off and reassigned, and there has been a decrease in the number of oncology clinical nurse specialists in inpatient settings," said Mooney.
She noted that chemotherapy is now frequently given in the outpatient setting. In order for oncology nurses to keep contributing fully to the oncology work force, Mooney said there must be enough of them and they must find new ways to use their skills -- such as in pain management and patient counseling.
Role of Nurse Practitioners
Because of their relative autonomy in the nursing profession, skilled oncology nurse practitioners also could help ease a crisis in the oncology work force, said Mooney. Data from nurse practitioners in the ONS (who make up about 3% of the society) show that 69% have hospital admitting privileges, 64% perform procedures, 52% administer chemotherapy, 50% can write prescriptions (a privelege governed by state law), 77% provide symptom management, and 37% provide cancer screening and detection.
Nurse practitioners have come a long way from the 1960s when nursing educators were not supportive of their role, said Kathleen Murphy-Ende, Ph.D., an oncology nurse practitioner with Physicians Plus/Meriter in Verona, Wis. "They called us junior doctors," said Murphy-Ende. "They said, 'Why do you want to do that?' "
Today, there are 50,000 nurse practitioners, according to the American Academy of Nurse Practitioners. Murphy-Ende said the role of oncology nurse practitioners is now well recognized and most are certified in family, adult, geriatric, or acute care, she noted. Murphy-Ende said nurse practitioners practice with a physician collaborator, and most earn higher salaries than staff nurses -- about $45,000 to $60,000 a year.
Physician assistants who specialize in oncology are another way to meet a crisis in the oncology work force, suggested Roxane K. Biggerstaff, a physician assistant with Hematology & Oncology Consultants in Omaha, Neb. More PAs are opting to practice in the specialties, said Biggerstaff, whose duties include taking histories and performing the initial physical examinations on the majority of new patients.
Wages, Hours Better
Generally the wages are better and the hours are better, she said of specialization. Physician assistants make nearly $64,000 a year, according to a survey from the American Academy of Physician Assistants. Of the approximately 31,000 physician assistants in clinical practice this year, the majority (52.6%) report that they are in one of the primary care fields, according to the survey, said Biggerstaff. This figure may change if more PAs decide to specialize.
The utilization of PAs in hematology/oncology is becoming more popular, especially in light of the diminishing number of medical oncology specialists, according to Biggerstaff. She said that many of the PAs in oncology can be found in the bone marrow transplant units. For example, the University of Nebraska Medical Center bone marrow transplant team includes five physician assistants.
Wade noted that the work productivity of non-physician providers in oncology will need to be measured, just as it is measured for physicians. Measurement of productivity for all types of health professionals, he said, is part of the environment of quality control and accountability ushered in by managed care.
-- Peggy Eastman
Non-Physician Providers May Ease Oncology Work Force Crisis
The cancer treatment needs of the aging baby boom generation may create a crisis in the oncology work force, according to James L. Wade III, M.D., president of the Association of Community Cancer Centers. And oncologists may not be the force to solve the dilemma.
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