We’re Running Out of Doctors for Stem Cell Transplantation and Cellular Therapy. What can WE do...
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Transcript of We’re Running Out of Doctors for Stem Cell Transplantation and Cellular Therapy. What can WE do...
We’re Running Out of Doctors for Stem Cell Transplantation
and Cellular Therapy. What can WE do about it?
Richard Champlin, M.D.
Borrowed heavily from James L. Gajewski, M.D.
How did we get into this mess?
Trainees- it’s not like when the giants walked the wards Generation X,Y,Z values, Social Pressure, Lifestyle, Debt
Government- weak Federal guidance, primarily left to states, universities and medical schools Emphasis in primary care, IMGs- have helped us
Pharmaceutical Industry- major source of medical education and training support Support SCT fellowship training programs
****Us-- Academic Medicine Marginalize training for SCT, even in Heme/Onc programs SCT needs to compete effectively for trainees
Big Problem
Physician shortage Oncologist shortage Particular shortage of SCT physicians Intense competition within medicine for
new physicians Trainees- go where the money is -seek
best career opportunities
Major Physician Shortage Predicted
The Council on Graduate Medical Education supply of US practicing physicians to rise to
971,800 physicians by 2020. demand will grow much faster.
The expected shortage of physicians ~90,000 by 2020.
The US Has a Relatively Low
Supply of Physicians Compared to Other Developed Countries
130193
201210
222223
244264
304318
326326329
342351
368383386
405448
0 50 100 150 200 250 300 350 400 450 500
KoreaJapan
United KingdomCanadaIreland
New zealandAustralia
United StatesSwedenPortugalGermany
SpainFrance
DenmarkSwitzerland
Slovak RepublicAustria
BelgiumItaly
Greece
Source: The Supply of Physician Services in OECD Countries. OECD, Steven Simoens & Jeremy Hurst. Health Working Papers. 2006
Physicians Per 100,000 (2000)
Per Capita MD Enrollment has Fallen Since 1980 With a 30% Increase, the Rate will Still be Below 1980
5.65.4
5.25
5.8 5.85.6
6.8
6.46.2
5.8 5.8
6.1
6.56.4
7.3
4
4.5
5
5.5
6
6.5
7
7.5
1980 1985 1990 1995 2000 2005 2010 2015 2020
No Change in Allopathic Matriculants
15% Increase in Allopathic Matriculantsbased on 2003 Enrollment
30% Increase in Allopathic Matriculantsbased on 2003 Enrollment
Source: AAMC Data Book; US Census Bureau.
Prepared by Center for Workforce Studies, AAMC, Feb 2006.First Year Enrollment per 100,000
Factors Driving Physician Demand
Growth of U.S. population. An increase of 50 million people (18%) is expected between 2000 and 2020.
Aging of the population. The number of Americans over 65 will increase from 35 million in 2000 to 54 million in 2020.
Changing physician utilization rates. Those over 45 will use more services.
Physician Workforce Planning in the United States
States and private institutions responsible for undergraduate medical education Era of shrinking government budgets No substantial growth in medical school slots 25 years Tough sell when major goal is to reduce national cost of medical
care
Medicare and Medicaid GME funding Faces Major Budget Cuts
No national planning system: Training grants, recommendations Medical Schools positions determined by States,
institutions.
Age of BMT Physicians
All BMT Adult Pediatric 70 to 78 1.6% 1.8% - 65 to 69 3.1 3.5 - 60 to 64 10.2 11.7 2.4 55 to 59 13.6 14.8 6.5 50 to 54 21.2 21.5 18.7 45 to 49 18.6 20.0 12.2 40 to 44 17.1 15.1 28.5 34 to 39 14.6 11.6 31.7 100.0% 100.0% 100.0%
Source: ASBMT Membership Records
Average Time Allocation of SCT Physicians
Clinical Practice 49.1% Clinical Research 23.3 Lab Research 14.7 Administration 10.8 Other 2.1
100.0%
Source: ASBMT Membership Records
We are not alone: other specialty groups reporting physician shortages
Allergy/Immunology Cardiology Critical Care Dermatology Emergency Medicine Endocrinology Family Practice Gastroenterology
Geriatric Medicine Infectious Disease Internal medicine Oncology Psychiatry/Child and
Adolescent Psychiatry
Pediatric Subspecialties Radiology General Surgery
New physicians choice of 150 specialties, many choices within Heme/Onc-Need to effectively compete
Good Help is Hard to Find: Shortage of Clinical Support Staff
Hospitals across the country are struggling to find qualified staff
Average ages are climbing: Nurses 49 years Pharmacists 48 years Med-techs >45 years Physician Assistants 41years
Training Required for SCT Physicians
College (4 years) Medical School (4 years) Internal Medicine/Pediatrics (3 years) Heme/Onc Fellowship (3 years)
if no major experience, Stem Cell Transplant Fellowship (1 year)
Attracting New Physicians to SCT-CT
Specialty, Subspecialty Selection SCT used to be the cutting edge of with rapid advances in medicine- now
lots of competition
Massive student indebtedness; need career which can repay loans
Lifestyle issues; fewer seeking research/academic careers; value free time
(new residency rules instill concept of “shift work”)– Fewer select research career; increasing reliance on foreign trained physicians
Internal medicine training- emphasis on primary care, outpatient medicine;
decrease emphasis on specialty care
More financial support in other areas
Heme/Onc fellows attracted to solid tumors– Exciting new science, new therapeutic targeted therapy opportunities
– NIH view- Too many transplant grants
– Residency, Oncology Training- too much time on SCT
– Most common forms of cancer
0
2,000
4,000
6,000
8,000
10,000
12,000
1988 1992 1996 2000 2004
Growth of SCT; Transplants reported to CIBMTR
Use of SCT-Cell Therapy is increasing-
Unique Effective Treatment Modality
Increasing Reduced intensity strategies in older patients Success of alternative donors for allos Novel GVHD control strategies Novel Cell Therapy approaches
Decreasing Alternative effective treatments
– CML– ? Myeloma
Stem Cell Transplant Cell Therapy – Use is Increasing
Allogeneic Matched siblings (~20%) Unrelated donors (~30%) Alternative donors (~50%)
– Cord Blood– Haplos– 7 of 8 MUDs
Autologous Cell therapy
Stem cells Cellular Immune Therapy
0
200
400
600
800
1,000
1,200
1,400
1,600
1,800
2,000
2006 2008 2010 2012 2014 2016 2018 2020
Projected Demand for Physicians Providing SCT Patient Care Services
Adult
Pediatric
2020 BMT Physician Supply Problem
Estimated Demand and Supply
Adult Pediatric Total
BMT Physician Requirements in 2020
1,991 235 2,226
Current Supply (959)
86%
(156)
14%
(1,115)
100%Projected Retirements
232 15 247
New BMT Physicians Needed
1,264 94 1,358
Things That Can Help practice of SCTCT
Increased use of NPs, PAs, Pharm.D.s and other clinicians
Increased use of hospitalists Not easy to apply to HSCT
Training Fight to keep SCT in core training
experience of Internal Medicine and Pediatrics Residents Hematology- 17% Board is SCT Oncology- losing interest in hematology, SCT
Need to make SCT experience relevant to training at each level
SCT Training Programs
Except for large transplant centers, most H/O training programs have little exposure to SCT. An additional year of SCT training is needed to become competent as a SCT physician
The U.S has ~246 transplant centers 82 transplant centers (33%) have BMT fellowship
programs Program sizes vary from 1 slot to 10 slots Need for funding
Generally not supported by funding institution Count on philanthropy, pharmaceutical company support
Strategies to Increase the Supply of SCT Physicians
Support increases in physicians, internal medicine, Hematology/Oncology and SCT training Support increases in U.S. medical school enrollment
and graduations (new funding sources required) Support GME increases for Internal Medicine,
Pediatrics and Hem-Onc. GME proposed to be cut FY2009 from federal budget.
Recommend changes to Internal Medicine and Pediatric curriculums to support training related to oncology and stem cell transplant
Support development of SCT training programs Welcome talented IMGs (not eligible for federal training
grants)
Strategies to Increase the Supply of BMT Physicians
Increase the number of BMT training programs and training slots*
Increase recruitment of International Medical Graduates into SCT
Retain active physicians longer Develop more efficient care delivery systems for
SCT More transplants per physician
Strategies to Increase Supply of SCT Physicians
Make SCT sexy again! Reach out to trainees
– Get them while they’re young and impressionable
Raise interest in cutting edge research– Stem Cells– Cellular Immune Therapy– Cure Cancer
For our Pharmaceutical Partners** Support SCT training and fellowship research grants**