COMMENTARY
Impending Challenges in the Hematopoietic Stem Cell Transplantation Physician Workforce James L. Gajewski,1 C. Frederick LeMaistre,2 Samuel M. Silver,3 Michael C. Lill,4 George B. Selby,5 Mary M. Horowitz,6 J. Douglas Rizzo,7 Helen E. Heslop,8 Claudio Anasetti,9 Richard T. Maziarz1 With increasing use of high dose chemotherapy with autologous and allogeneic transplants the need for the transplant physician workforce requires reassessment. The types of transplants and patients are also shifting toward transplants being done in patients with more comorbidities and more commonly these types of patients require more work effort per patient from the transplant physician. Additionally, HSCT survivors often require ongoing care at the transplant center due to the inability of the primary care workforce or the hematology/oncology workforce to absorb caring for post complex post transplant patients. The adult transplant workforce has had very few physicians join under age 40. Nearly 50% of adult transplant physicians are over age 50 whereas only 28% of pediatric transplant physicians are over age 50. By 2020, it is projected that we will need 1,264 new adult transplant physicians and 94 pediatric transplant physicians. Training time for a physician is approximately 15 years. The capping of both medical school slots and residency slots since the early ‘80s is now having a very big impact on supply, but other factors are also affecting supplies such as generational differences, lifestyle expectations, and the change of the medical workforce from being mostly men. Workforce shortages are being reported for many specialities. Workforce problems are also present for nurses, pharmacists and medical technologists. So increasing use of general internists and mid-level providers may not exist as a solution. Transplant physicians must be actively engaged in the medical education process to show young medical students and residents who are not committed to another sub specialty career the excitement and challenges of a career in bone marrow transplantation, so that our field will have providers for the future. Biol Blood Marrow Transplant 15: 1493-1501 (2009) Ó 2009 American Society for Blood and Marrow Transplantation
KEY WORDS: Physician workforce, HSCT, Clinical activity
INTRODUCTION Since the first report of allogeneic marrow transplantation in humans more than 50 years ago, the applications have evolved from developmental therapies in a select group of desperate patients to standard therapies for patients with a wide variety of indications [1]. The Center for International Blood and Marrow
From the 1Center for Hematologic Malignancies, Oregon Health & Science University, Portland, Oregon; 2Texas Transplant Institute, San Antonio, Texas; 3Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; 4 Blood and Marrow Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California; 5Department of Medicine/ Hematology-Oncology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; 6Divison of Neoplastic Disease and Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin Clinical Cancer Center, Milwaukee, Wisconsin; 7Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; 8Center for Cell and Gene Therapy, Baylor College of
Transplant Research (CIBMTR) reports that 50,000 allogeneic and autologous transplantations are performed annually worldwide [2]. According to the CIBMTR registry, more than 18,600 allogeneic and autologous transplantations were performed in the United States in 2006, with evidence of continual annual growth [1].
Medicine, The Methodist Hospital and Texas Children’s Hospital, Houston, Texas; and 9Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida. Financial disclosure: See Acknowledgments on page 1500. Correspondence and reprint requests: James L. Gajewski, MD, FACP, Oregon Health & Science University, Center for Hematologic Malignancies, Mail Code L-586, 3181 SW Sam Jackson Park Road, Portland, OR 97239 (e-mail:
[email protected]). Received August 16, 2009; accepted August 17, 2009 Ó 2009 American Society for Blood and Marrow Transplantation 1083-8791/09/1512-0001$36.00/0 doi:10.1016/j.bbmt.2009.08.022
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Historically, the application of hematopoietic stem cell transplantation (HSCT) has been limited by patient selection, the toxicity of the procedure, the availability of donors, and the significant expense of building and staffing facilities to deliver these complex therapies. As these limitations have been at least partially overcome, the number of patients treated with HSCT has continually increased [1]. It now appears that a lagging physician workforce—specifically a lack of specialty-trained hematologists and medical oncologists with a focused interest in cellular therapy—may represent a new barrier to the expansion of HSCT and other cellular therapies [3,4].
COMPLEXITY IN STUDYING PHYSICIAN WORKFORCE NEEDS BASED ON TRANSPLANTATION USAGE Initially, HSCT was limited to younger patients suffering from a limited number of hematologic, immune, and genetic diseases, often in relatively advanced stages. Transplantation therapies were further restricted by the need to collect hematopoietic stem cells from the marrow of either matched histocompatible family members or the patients themselves. The use of high-dose chemotherapy and autologous stem cell transplantation was significantly enhanced by the use of hematopoietic progenitors harvested from the peripheral blood, commonly referred to as peripheral blood stem cells (PBSCs). The ability to collect large numbers of PBSCs facilitated more rapid engraftment and, in conjunction with other advances in supportive care, decreased treatment-related morbidity and mortality [5]. These improvements catalyzed the evolution of autologous HSCT as a standard of care and its integration into planned treatment algorithms for several diseases. In addition, for patients with some diseases (eg, multiple myeloma), HSCT has been used to improve disease control or progression-free survival, rather than exclusively as a curative treatment modality, further expanding its applicability to new patient populations [6]. Autologous HSCT also is considered a standard treatment for elderly patients, who are at the greatest risk for developing malignancies [7]. These expanded applications for autologous HSCT, coupled with improvements in survival from cardiac disease as a result of improved treatment and prevention and the changing age demographics in the United States, Europe, and Japan, are likely to significantly increase the need for autologous HSCT over the next decade. Conversely, the development of novel therapeutics may result in a decrease in utilization of HSCT in specific disease states that currently represent common indications for autologous transplantation (eg, multiple myeloma).
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Expanded applications have not been limited to autologous HSCT; in fact, expansion of HSCT applications may be even more accentuated with allogeneic HSCT. For example, improvements in supportive care and other innovations that reduce toxicity have expanded the number of patients eligible for allogeneic HSCT [1,7]. Clinical research studies have addressed and will continue to address other major obstacles to allogeneic HSCT. Well-designed research trials have demonstrated the ability to use less-intense, upfront conditioning regimens that give older and more infirm recipients the opportunity to receive a donor immune system with the goal of eradicating their cancer [8]. The identification of strong graft-versus-cancer effects in various malignancies has expanded the number of diseases that potentially can be treated with allogeneic HSCT. Advances in the prevention and treatment of graft-versus-host disease (GVHD), as well as the identification and expansion of treatments for opportunistic infections, have increased the number of patients considered for transplantation [9]. In addition, the ability to reproducibly and rapidly perform molecular DNA sequencing for human leukocyte antigen (HLA) typing has allowed the selection of donors for unrelated transplants with a diminished risk of advanced GVHD [10]. This technology, coupled with the rapid expansion of the National Marrow Donor Program (NMDP) to 11 million volunteer donors, has made unrelated donor transplants an option for far greater numbers of patients. Furthermore, recent advances in the use of umbilical cord transplantation coupled with the expansion of umbilical cord banks have extended allogeneic transplantation to those lacking unrelated donors [11]. As a result, patients with comorbid conditions who previously would have been denied transplantation are now eligible for HSCT. Patients in their seventh and even eighth decade are now being treated with allogeneic HSCT [7], and some investigators no longer consider age a barrier to treatment. Today, a more accurate assessment of clinical comorbidities appears to have a greater influence than age on HSCT outcomes [12]. The cumulative effect of recent advances in HSCT has significantly increased the number of patients being referred to and cared for in transplantation centers. Most of this growth has been in allogeneic HSCT, primarily for patients receiving unrelated cord blood and adult donor hematopoietic stem cells [13]. This expanded patient load is requiring many centers to provide more pretransplantation malignancy care, transplantation procedures, and sophisticated posttransplantation management. The greatest increase in patient volume is occurring in older patients and in those receiving allogeneic transplantations from alternative donors—the most complicated patients. This means that when evaluating physician workforce needs, the expanded patient
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load cannot be viewed simply as an incremental growth in patient volume. In addition to increased medical needs, psychological, social, and caregiver needs also may further increase workload demands on the specialty practitioner. Finally, the success of HSCT has established a need for long-term care programs to manage transplantation survivors with chronic diseases, including not only chronic GVHD, but also acquired secondary hepatic, pulmonary, cardiac, and renal disorders, as well as preexisting comorbidities. Along with facing problems associated with the active care of patients during transplantation, HSCT physicians also bear some responsibility for long-term survivors. Many of these survivors cannot be easily reintegrated into a primary care physician’s practice or a medical oncologist’s practice. With the increasing numbers of transplantations and survivorship percentages has come a significant growth in patient volume. The estimated number of HSCTs performed annually in the United States has increased from 15,000 in 1999 to 18,600 in 2006. Similar trends are seen worldwide [14]. Approximately 40% of those undergoing HSCT become long-term survivors, suggesting that a substantial and increasing number of survivors are requiring care for survivorship issues following HSCT on an annual basis. For many patients with GVHD or whose immunodeficiency state exacerbates general medical management, the HSCT physician becomes their primary care physician, and the transplantation clinic becomes their medical home (D. Rizzo and M. Horowitz, personal communication, June 2009). Although registry information from the CIBMTR and surveys from the European Group for Blood and Marrow Transplantation provide some insight into transplantation therapy utilization, forecasting future needs remains complex [15]. While it is likely that advances in HSCT will lead to improved outcomes and an even wider use of transplantation therapies, it also is likely that advances in identification of cancerspecific molecular pathways and subsequent pharmaceutical innovations may replace HSCT for some diseases. The use of tyrosine kinase inhibitors in the treatment of chronic myelogenous leukemia is a notable example [16]. The impact of access (or lack thereof) to care on the number of patients offered HSCT has historically been difficult to assess. Data from the European Group for Blood and Marrow Transplantation suggest that transplantation rates are higher in countries with greater gross national income or health care expenditures per capita [17]. If uninsured Americans (11% of children and 15% of nonelderly adults) had full access to health care, then HSCT rates may increase [18-20]. Economic systems influence transplantation access differently. In countries with high tariffs (or restrictions?) on imported novel drugs, access to new drugs
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is limited to wealthier families; allogeneic transplantation remains the preferred treatment option for patients with chronic myelogenous leukemia [21]. With a reduction in treatment-related toxicities, HSCT has become an option for various diseases, particularly in pediatric patients, not previously considered for this type of treatment. Clearly, assessing health care needs for the future is problematic and fraught with inaccuracy if done with straight-line predictions based on population growth and demographic shifts. A recent CIBMTR publication suggests that the lifetime probability of undergoing HSCT is much higher than previously thought [22]. The CIBMTR considered several scenarios using the following assumptions: (1) no change in current indications for autologous and allogeneic HSCT, (2) universal donor availability, and (3) broadened use of HSCT in hematologic malignancies. The estimated lifetime probability of undergoing HSCT ranged from 0.23% to 0.98% depending on the scenario under consideration, and was deemed to be greater with increasing donor availability and HSCT applicability. These transplantation rates suggest that 17,000-32,000 HSCTs will be performed annually in the United States. But these predictions did not account for the predicted expansion of the US population by more than 50 million between 2000 and 2020 [1], nor did they fully account for the expansion of the elderly population. The population over age 85 years is one of the fastest-growing demographic groups in the United States [23,24]. Information from the NMDP demonstrates the current unmet need for unrelated HSCTs. The NMDP predicts that the number of transplantations that they facilitate will increase from the current level of 4,000 to 10,000 within the next 6 years [1], validating the concerns regarding increased workforce pressures on transplantation facilities going forward [25]. The number of transplantations facilitated by the NMDP has tripled over the last decade and is growing by 12.5% annually (D. Confer, personal communication, June 2009). Whether or not this growth rate is sustainable given current workforce and facility space is unclear. According to the NMDP, as with other HSCT patients, the greatest growth in unrelated donor HSCT is for patients age 60 years and older with preexisting comorbidities [26]. The eligibility of these patients has contributed to an increase in both allogeneic and autologous transplantations for diseases that Table 1. Survival of Unrelated HSCT Recipients at US Transplantation Centers [27] Report Year 2003 2006 2007
Period
One-Year Survival Rate, %
1996-2001 2000-2004 2001-2005
42.2 48.8 51.5
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Table 2. Age of BMT Physicians Age Range, Years 70-78 65-69 60-64 55-59 50-54 45-49 40-44 34-39 All ages
Table 3. Estimated Supply and Demand of BMT Physicians
All BMT Physicians, %
Adult BMT Physicians, %
Pediatric BMT Physicians, %
1.6 3.1 10.2 13.6 21.2 18.6 17.1 14.6 100
1.8 3.5 11.7 14.8 21.5 20.0 15.1 11.6 100
0 0 2.4 6.5 18.7 12.2 28.5 31.7 100
Data derived, with permission (R. Krawisz, personal communication, June 2009), from the ASBMT membership records.
occur more commonly in older adults, such as myelodysplastic syndromes, acute myelogenous leukemia, and non-Hodgkin lymphoma [26]. Despite these challenges, 1-year survival rates for unrelated allogeneic HSCT recipients have increased to . 50% over the last 10 years [26]. These successes create challenges for the long-term care of these complex patients. Table 1 shows that NMDP transplantation outcomes have improved by nearly 10 percentage points in just 4 years [27].
HSCT PHYSICIAN WORKFORCE PROJECTIONS No formal attempts have been made to establish projections for the number of physicians needed to perform the predicted increase in the number of HSCTs. Moreover, a detailed description of the physician workforce performing transplantations is lacking. Consequently, the American Society of Blood and Marrow Transplantation (ASBMT) agreed to investigate this potential problem. The ASBMT is a national professional association that promotes advancement of the field of blood and marrow transplantation, of which its constituent members are active both in clinical practice and research. In attempting to analyze physician workforce requirements, given the lack of a database truly identifying transplantation specialists, the ASBMT began with the assumption that 90% of physicians performing HSCTs in the United States are ASBMT members. Table 2 presents the age distribution of BMT physician members of the ASBMT (R. Krawisz, personal communication, June 2009). The difference in age distribution between pediatric and adult transplantation physicians is striking, with a much higher percentage of pediatric transplantation physicians in younger age groups. One possible explanation for this discrepancy is that pediatric hematology/oncology practices are almost exclusively academic practices, whereas adult hematology/oncology practices are primarily private practices. Graduates of
Adult BMT Pediatric BMT All BMT Physicians, n Physicians, n Physicians, n BMT physician requirements in 2020 Current supply Projected retirements New BMT physicians needed
1991
235
2226
959 232 1264
156 15 94
1115 247 1358
Data derived, with permission (R. Krawisz, personal communication, June 2009), from the ASBMT membership records.
adult hematology/oncology fellowship programs are lured by the higher compensation offered by private practice compared with academic practice settings. A similar effect is noted in enrollment to clinical trials. Enrollment of pediatric patients with hematology/oncology diseases into clinical trials is higher than enrollment of adult patients with hematology/oncology diseases, in part because patients treated in academic settings are more likely to be enrolled in clinical trials. Most pediatric patients with hematology/oncology illnesses are treated in academic centers [28]. The fact that nearly 50% of adult transplantation physicians are over age 50 has raised concerns about succession planning in this specialty (Table 2). In contrast, 72% of pediatric hematology/oncology physicians are under age 50, with most in the early stages of their career. The results of an ASBMT membership survey also provide insight into how physicians spend their time. BMT physicians spend approximately 50% of their time in clinical practice, 23% in clinical research, and 15% in laboratory research, with the balance devoted to administrative or teaching duties. (R. Krawisz, personal communication, June 2009) Based on data from the ASBMT’s membership roles, it is estimated that 959 adult and 156 pediatric physicians, or a total of 1115 physicians, perform HSCTs (Table 3) (R. Krawisz, personal communication, June 2009). To estimate physician workforce needs for the year 2020, the following assumptions were made: (1) Population-based growth projections were adjusted for age, (2) the current transplantation usage rates were not adjusted, and (3) projections to predict greater numbers of unrelated donors or new therapeutic uses of transplantation were not done. With these assumptions, an estimated 2226 transplantation physicians (1991 adult physicians and 235 pediatric physicians) will be needed in the year 2020. This calculation assumes that these physicians will have similar clinical commitments and that the increase in midlevel practitioners providing care will be proportional. Furthermore, it can be assumed that almost 22% of the transplantation physician workforce will have retired at age 65. With projected growth and retirement rates, these data suggest the need for 1358 new physicians performing HSCTs just to meet the current demand.
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Supply of Physicians Compared to Other Developed Countries 448
Greece Italy Belgium Austria Slovak Republic Switzerland Denmark France Spain Germany Portugal Sweden United States Australia New zealand Ireland Canada United Kingdom Japan Korea
405 386 383 368 351 342 329 326 326 318 304 264 244 223 222 210 201 193 130 0
50
100
150
200
Source: The Supply of Physician Services in OECD Countries. OECD, Steven Simoens & Jeremy Hurst. Health Working Papers. 2006
250
300
350
400
450
500
Physicians Per 100,000 (2000)
Figure 1. Supply of physicians in the United States and other developed countries [29]. Data prepared by Association of American Medical Colleges Center for Workforce Studies (E. Salsberg, personal communication, May 2009).
DISCUSSION The ASBMT’s workforce projection is based on several assumptions and is subject to limitations. If the estimated number of US-based subspecialty physicians needed to manage HSCT patients is real, then the paucity of physicians available to fill this need is of concern. At the very least, the government, the health care community, and the patients served need a better understanding of the HSCT physician workforce. In some respects, the issues facing the HSCT physician workforce reflect the larger physician workforce issues in the United States. Both the Council on Graduate Medical Education and the American Association of Medical Colleges project a physician shortfall of 85,000-96,000 by 2020. Currently, the US ranks 13th in physicians per 100,000 people among developed countries (264 physicians/100,000 people) [29] (Figure 1). Physician demand is driven both by the growth of the US population and by demographic shifts within that population [30]. As stated previously, the US population is expected to increase by more than 50 million between 2000 and 2020. As a result of the ‘‘baby boomer’’ population surge, the ‘‘over-65’’ population segment is expected to grow from 35 million in 2000 to 54 million in 2020; similar population surges are anticipated in other countries [23]. Given that patients over age 65 use more health care services and often require multispecialty care, the physician workforce must expand at a more than proportional rate to meet the demands on health care.
Despite these demands, per capita enrollment in medical schools has remained flat since 1980. The American Association of Medical Colleges noted that a 30% increase in medical school enrollment by the year 2015 is needed to keep up with current population growth [30]. Even if this goal is achieved, the enrollment rate will be below that documented in 1980. Barriers to increased medical school enrollment exist include a lack of available financial support and/or scholarships, limited classroom/laboratory space, and limited ambulatory and other hospital-based clinical training sites [30]. US medical schools are funded
Table 4. Recent Reports of Physician Shortages by Specialty Specialty
Year Reported
Allergy and immunology Anesthesia Cardiology Child psychiatry Critical care workforce Dermatology Emergency medicine Endocrinology Family medicine General surgery Geriatric medicine Medical genetics Neurosurgery Oncology Pediatric subspecialty Psychiatry Public health Rheumatology
2000 2003 2004 2006 2006 2004 2006 2003 2006 2008 2007 2004 2005 2007 2008 2003 2007 2007
Data from the Association of American Medical Colleges Center for Workforce Studies (E. Salsberg, personal communication, May 2009).
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primarily through state budgets. In the current economic climate, expanding the number or capacity of existing medical schools will be difficult given the tremendous pressure to reduce state spending and reduce or maintain expenditures on resource-intensive projects. Thus, whether a 30% increase in US medical school capacity is realistically achievable by 2015 is unclear. A true expansion of the physician workforce can occur only with a coordinated and equal expansion of graduate medical education slots required for completion of residency training. Reconsideration of the current caps on graduate medical education slots in the US is needed. Funding for graduate medical education has been in jeopardy for years [30]. If funding for medical schools is reduced significantly, then the essential mission of teaching hospitals will be severely compromised, because passing on teaching costs as a direct patient care expense is neither feasible nor realistic. Funding for graduate-level medical education comes primarily from the federal government and is placed within the Medicare budget [30]. This budgeting anomaly associated with an embattled entitlement program creates pressure to eliminate Medicare funding as a cost-saving measure; interestingly, some of the dollars targeted for elimination include those used to pay graduate-level medical school faculty. Other factors are contributing to the physician shortage as well. Many medical students graduate from medical school with significant debt, often as much as $100,000-$200,000 [31]. Several years of low-income compensation during residency and fellowship training follow. These financial realities are contributing to the increasing difficulty in recruiting talented college graduates into the medical field. Furthermore, attrition from the medical field before retirement age has been increasing, attributed in part to the increased workload requirements [32,33] and decreased reimbursement for services provided relative to other professions in our society [31]. As a consequence, the primary care fields and many medical specialties are experiencing shortages (Table 4) [4; E. Salsberg, personal communication, May 2009]. For decades, one solution has been to recruit foreign-trained physicians to meet these shortages [30]. But recent changes in immigration policies are making it more difficult for foreign medical school graduates to enter the United States for both residency training and new positions [34]. In addition, worldwide economic development is increasing local health care needs. Today, Asian and European countries are more likely to retain their medical school graduates [34]. With recognition that many of the younger members of the ASBMT are international medical graduates, the pool of US-trained physicians specializing in HSCT needed to replace those who retire and to accommodate growing demands may be even smaller than projected.
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Midlevel practitioners, while helpful, also are facing demographic challenges as they attempt to maintain their current workforce levels. The average age of nurses in the US is almost 50 years [35]. Many more opportunities are available for nurses beyond direct patient care; for example, nurse practitioners are drawn from this workforce pool. In addition, most nurse practitioner training programs focus on outpatient care rather than on inpatient acute care. Physician assistants often seek training 10 years after completing an initial undergraduate degree, and because the clinical training program is only 2 years long, find it difficult to transition into supporting complex medical patients without extensive on-the-job training. Pharmacy and medical technology workforces are aging as rapidly as the physician and nursing workforces, which may further affect physician workload demands. Other difficult-to-measure factors have unintended influences on the ability to maintain an adequate pool of specialty-trained physicians to meet the needs of patients requiring HSCT. Resident training programs in internal medicine and pediatrics are focusing increasingly on ambulatory care, with an emphasis on single-organ system problem management [36,37]. Inpatient training for internal medicine house officers is being increasingly provided under the tutelage of a general internal medicine hospitalist rather than from the supply of internal medicine subspecialists. Using subspecialists as the teaching attending has the additional benefit of integrating complex specialty medicine with ongoing active general medicine problems requiring acute hospitalization. Hospitalist-led inpatient teaching often focuses attention solely on the patient care issue requiring acute hospitalization, leaving the management of other ongoing medical problems to individual specialty consultants in the outpatient setting, with possible readmission under a separate specialty service. Both of these trends influence the ability to train a cadre of internal medicine graduates comfortable in managing patients with multiorgan dysfunction or failure in complex inpatient and outpatient milieus. This change in focus increasingly results in leaving the hospital management of cancer patients to the hematology and medical oncology subspecialists, whose training of fellows also has become increasingly focused on ambulatory medicine. Cancer care must now be delivered in conjunction with treatment of other comorbid diseases, which may either complicate cancer care or eliminate certain options from consideration. Primary care physicians have not been adequately trained to decipher optimal cancer treatments in the context of a patient’s overall health paradigm. HSCT training requires physicians to have good basic internal medicine or pediatric skills, in addition to a thorough understanding of transplantation and the disease processes that it is used to treat.
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In addition, we are facing major changes in the demographics of the US physician pool. Currently, US medical school enrollment is almost 50% women [38]. The increase in female physicians has produced dramatic changes in practice patterns. Many women choose to share professional duties with childbearing and rearing [39]. As the current aging physician workforce approaches retirement, a one-to-one replacement of the clinical physician full-time equivalents (FTEs) may not be possible. The implementation of electronic medical records and ordering, in response to the Institute of Medicine’s position statement on the need to decrease the number and impact of patient care medical errors, has led to even greater demands on physician time. These responsibilities add to the non–face-to-face time burden of physicians managing patients with multiple laboratory abnormalities and multiple medications. These systems may be helpful for patients with a single problem, but often lead to information overload with complex patients. HSCT physicians need to prioritize face-to-face time with patients given the immediate life-threatening aspects of the disease requiring transplantation and potential treatment-related morbidity of the transplantation procedure. The natural response to all of these demands for specialized medical care, recognizing the lack of an available physician pool, has been to create a new workforce. Specifically, the critical importance of the ‘‘mid-level providers’’ for our field has emerged, utilizing advanced-level nurse practitioners, physician assistants, and clinical pharmacists [40]. In addition, more clinical management is being diverted to generalists, such as hospitalists. HSCT care providers are usually good hospitalists. Most HSCT physicians prefer to be the hospitalist. Should this continue? Different programs given staffing options may need to consider alternatives. All of these workforce groups have growing supply problems; thus, this may prove to not be the ultimate remedy. In addition, the issue of compensation for the co-management of complex patients by hospitalists and BMT physicians has not been well addressed by the current payment system. Another difficult-to-assess effect on the HSCT physician workforce is the economics of reimbursement. Primary care practices have outpatient clinics that can focus on only one problem per visit. This makes it hard for these practices to reabsorb transplantation survivors, who have multiple medical and often socioeconomic and psychological issues to be addressed in the outpatient treatment milieu. In addition, this workforce faces shortages and age distortions mimicking those of HSCT physicians [3,40]. Private practice hematologists and medical oncologists also remain in short supply [3]. Most of their compensation is accrued from the active treatment of new cancer patients in ambulatory care facilities. The lack of financial incen-
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tive, short supply, and older age demographics suggests that private practice hematologists and medical oncologists are also not a viable option to provide care for the increasing number of HSCT survivors. HSCT survivor care is more complicated, given the intertwining transplantation-related toxicities and comorbid diseases present preceding and following transplantation. Developing the necessary clinical acumen in HSCT takes time. The years required to develop expertise in clinical HSCT adds to the already increased demands for both internal medicine training and hematology/oncology training. The total training period can now be as long as 10-12 years after undergraduate training. Increasing the workforce supply by the year 2020 requires changes in medical school and postgraduate training now. Additional surveys are needed to better understand the problems with the BMT workforce. New Current Procedural Terminology codes have been created to help bill for services for which transplantation physicians could not bill previously. Billing for this requires increased documentation to capture the work effort, to ensure that HSCT providers receive an appropriate salary for their work. But because this billing documentation is timeconsuming, physicians often do not bill for these new services. Recent data raise the possibility that compared with peripheral blood progenitor cell harvest, traditional bone marrow harvest improves survival in patients undergoing allogeneic HSCT because of a decreased risk of grade II-IV acute and chronic GVHD [41]. If this is confirmed by more studies, this raises the concern of possibly an inadequate number of doctors with time to go to the operating room. The increased clinical demands on the BMT workforce can be anticipated to have a negative impact on the performance of quality clinical and basic science research. In addition, with the increasing stress on the BMT workforce to meet ongoing patient needs, less time and energy will be available for teaching and effective involvement in medical education roles. This can become a vicious cycle, because contact with HSCT physicians in teaching roles might otherwise inspire medical students and residents to consider cell therapy as a career subspecialty. Failure to make time for teaching medical students and residents before they enter fellowships can only further exacerbate the BMT workforce problems. As HSCT physicians, we support an increase in US medical school enrollment and graduations. The ASBMT must work to expand support for graduate medical education funding, regardless of whether or not the Medicare budget is the proper source of that funding. We need to support an across-the-board increase in funding for graduate-level internal medicine, pediatric, and hematology/oncology medical education. Our members must increase involvement with their medical schools and internal medicine and
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pediatric colleagues to ensure that adequate training for managing inpatients with complex multiorgan dysfunction is provided and that the field of HSCT is presented in a positive fashion. The society and medical institutions need to reward efforts to encourage HSCT physicians’ involvement in medical education. We also need to assess ways to better fund training for HSCT careers and develop programs that retain active physicians beyond the traditional retirement age of 65 years. This will require more creative care delivery systems for the long-term HSCT survivors. Like so many specialties, HSCT physicians are on the cusp of problems facing the health care system as a whole. The fact that the HSCT field is a paradigm for the problems facing the medical community at large reflects the complexity of our patients and the large amount of health care resources that they consume. With primary care and other workforces taking care of larger groups of patients, the HSCT community cannot rely on outside or governmental help to alleviate the impending lack of providers. The HSCT community and the facilities providing this care must address this workforce shortage to ensure that our patients continue to have access to care. Only through a concerted, prolonged effort can we ensure an adequate supply of physicians specializing in HSCT to care for the many new patients and survivors requiring our services.
ACKNOWLEDGMENTS Financial disclosure: The authors thank the ASBMT staff, especially Robert Krawisz, and Michael Boo of the National Marrow Donor Program staff for assistance with the data, and Syntaxx Communications, Inc for editorial assistance.
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