Wednesday, March 14, 2007
Shortage of Oncologists!? What about Shortage of Palliativists!
The US media has been hot on the article out of the Journal of Oncology Practice by Erikson yesterday about the forecasted shortage of oncologists. The study was well done and should be replicated by many disciplines, including hospice and palliative medicine, but since I don't have the time to write that article I will do a hastily written, poorly designed, non-blinded, utterly biased, uncontrolled case report of my opinion.
First looking at the JOP study (available free, so you don't have to rely on NBC news or USA Today to get your facts.), they looked at the following numbers*:
Existing Oncologists: 10,000
Annual Graduation of Fellows: 500 from 250 programs
2005 Capacity of Oncology Visits: 42 million
2020 Expected Demand of Oncology Visits: 65 million
2020 Expected Capacity of Oncology Visits: 47 million
They attribute much of the rapidly increasing demand to increased survivorship and increased incidence of cancer in a graying baby boomer population.
Well, in the hospice & palliative medicine world we already have a shortage of MD-patient interaction, but lets look closer at the numbers:
My hospice has this many doctors that do clinical visits with patients: 4
We see (optimistically and approximately) 20% of patients admitted to our hospice.
Hospices see roughly 30% of all patients who die (2.2mil non-traumatic) in the US.
So if all hospices had a single board certified physicians (they don't)
And that MD made home visits (very rare) or rounded at an inpatient hospice (kinda rare):
only 132,000 people (6%) who die each year
see a physician specialist
who could ease their suffering before they die!
Sinclair Formula for Estimating MD-Patient Interaction at the End of Life
2.2mil * 30% * 20% = 132,000
So we don't need to forecast a shortage, we already have one. Also with over 4,000 hospices nationwide, and with only 2,000+ board certified HPM docs, you have a pretty good chance your doctor running your hospice is not board certified.
Limitations of this crummy study include that I did not say a thing about hospital based Palliative Medicine, and a lot of people die in hospitals. Well, hopefully those docs are referring those patients to hospice so I did not want to double dip, and if they are seen by a HPM doc in the hospital and never make it to hospice that does not really bump that number up to high.
So why do I bring this up. Because I just got back from the AAHPM-led Fellowship Director's conference and it was very inspiring to be with such a great group of people who are going to teach all the future specialists in our field. I would encourage any of you who read Pallimed, and are not affiliated with any HPM Fellowship Training Program, to find your local one and ask them what you can do to help, time wise or money wise. Trust me they can use the support from and individual or your organization.
Post-script:
Also, I have nothing against oncologists. I am not trying to say their cause is frivolous, it is just that we already have a shortage and no one is making a big deal out of it. Besides some of my best friends are oncologists! Also, I am not advocating that everyone needs to see me or someone like me before they die, but we (HPM docs) should at least be available.
And if you decide to do this study in a decent way, feel free to give me some original idea credit!
*all numbers are rough for ease of understanding, look at the original article for exact numbers
6 Responses to “Shortage of Oncologists!? What about Shortage of Palliativists!”
March 15, 2007
Christian, nice review. In October last year I did a presentation titled " What End of Life Care(EOL) Can Learn From Beginning of Life Care (BOL)". ( Article to be published in two months). So, similar in context to your review, I explored the Obstetrician during birthing and the Hospice Doctor during the dying process. Interesting stats from 2003, US NVSR #'s with 4,089,950 live births and 33,633 Boarded Obstetricians (18% Family Medicine) compared to 2,448,288 deaths and much less than 2000 Boarded H/P doctors. Also interesting in 2003, 83% of women began prenatal care in the first trimester(that is first three months of pregnancy for those of us who forgot)compared to less than 27% ( Medicare Patients)of men and women beginning hospice care usually within six months till death. The lack of doctor- specialist workforce in H/P care is compelling.One important issue outside of (or in collaboration with) the Palliative Sub-specialist development is the need to "change the face" of the traditional hospice medical director away from "director"and more towards "hospice physician" and good ole-fashioned bedside care.Many of us are working very hard on this both from competency and skill-set development to workforce efficiency and fair reimbursement. Just some thoughts. Thanks! Todd Cote
March 16, 2007
To be a little contrarian... (& I know you were engaging in a bit of rhetorical gamesmanship!)
While I agree there is a shortage of palliative docs and an even more acute shortage of 'good' terminal medical care that doesn't mean that palliative docs/specialists need to see every dying patient in order to ensure appropriate, timely, and compassionate terminal care. Most physicians who care for dying patients (internists & IM subspecialists, family docs, pediatricians, a lot of surgeons, etc.) *should* have good basic palliative care skills which is all that most people need as they're dying--it's often not hugely complicated (although when it is complicated it's really complicated!). I think we, as a profession, should be offering ourselves as specialists for 1) more complicated cases and 2) special environments (hospice medical directorship etc.) and then promoting a general improvement/uptake of palliative skills in the profession at large. Wishful thinking all around (that's a huge *should* up above), but what else can we do but try, and god knows people are trying.... But placing ourselves as the sole arbiters of a good death is a recipe for failure on many grounds.
March 16, 2007
Oh and is it Palliativists or Palliatists?
I'm still sticking with 'palliative care doc.'
March 16, 2007
Drew... one problem with the printed word in blogs like this is the de-personalization of the "true meaning". So , if you knew me " rhetorical gamesmanship" is not in my vocabulary!I don't have any time for that. I applaud those that think outside the box. I was commending Christian for thinking outside the box. I do agree with everything you said.I would never imply a doc at every death. We docs depend so much on all the other hospice/palliative disciplines. Thanks so much to them! Peace.
March 16, 2007
Todd thanks for the comments. I guess the other thing about the written word & Blogger comments is that unless I say who the comment is for my friendly but cryptic accusations of 'rhetorical gamesmanship' miss their mark: they were directed towards Christian's original post!
March 17, 2007
Ha ha! Yes Drew you were right, I was trying to make a point that would allow people to see some holes in my argument. I actually had a paragraph talking about just your point, but I took it out for brevity, since my post was getting long.
And what this surely does not address is the array of health care professionals required to care for dying patients. As much as we may have a MD shortage, our supply of quality RN/LPN/CNA/SW/Chaplains should be
closely looked at as well, for I fear we may not have enough of them!
Todd,
I look forward to your study coming out. I think your analogy between the BOL and EOL is particularly apt, and it has been one I have been calling on lately when talking with patients and families.
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