We’re training enough oncologists, so why aren’t enough positions being filled?
Australian oncologists are burnt out and the system is close to breaking point, experts warn, as improved cancer survival puts more pressure on a stretched workforce.
Australia faces greater oncology workforce challenges than the US, said Associate Professor James Lynam,chair of the Medical Oncology Group of Australia (MOGA), following the release of a study showing that 68% of the US population lived in counties where more than a quarter of oncologists were nearing retirement age.
The analysis of the US medical oncologist and haematologist workforce found that 11% of adults aged 55 years and over lived in the 55% of counties without oncologists.
“Counties with high cancer mortality rates were twice as likely to not have oncologists practicing in or around them compared with counties with lower mortality rates,” the researchers said in JCO Oncology Practice.
“Similar trends were observed by county rurality, uninsurance prevalence and smoking status.
“Some of the most vulnerable populations are likely to experience the most challenges accessing care.”
Professor Lynam said the US study highlighted the significant issues regarding the lack of long-term planning of the medical oncology workforce and the resulting health outcome disparities.
But he said Australia’s oncology workforce was around five times smaller per capita than in the US.
“There’s not enough positions being generated to meet the increasing workforce demands or workload demands in cancer care,” Professor Lynam told The Medical Republic.
“Let’s be honest, the US still has a tonne more medical oncologists than we do. They’ve still got a much larger workforce per capita than we do.
“The challenge is that the real workload is not happening at the point of diagnosis, but the survivorship and long-term survivors of cancer. That’s where things are expanding dramatically.”
The need for medical oncology services is far outstripping the supply, Professor Lynam said.
“For every one new person coming into the system, there’s three or four people at the end of the system who are living longer because of the treatments that they’re had that still require that ongoing care and/or monitoring.
“Do we focus our care on the people who are newly diagnosed? Or do we continue to offer that brilliant care to people who are still in the system and requiring that?”
Professor Lynam said patients in rural areas and Aboriginal populations had “significantly worse cancer outcomes” than those in urban areas, and access to oncologists contributed to that disparity.
Rural and remote patients are travelling “extraordinary” distances of hundreds of kilometres to receive care or take part in clinical trials, he said.
“I can guarantee that unless we expand the medical oncology workforce to meet the emerging requirements of the cancer population, we will start getting much worse outcomes.”
Australia has some of the best cancer outcomes in the world, Professor Lynam said.
“When compared to other OECD-equivalent countries, we do amazingly well.
“And MOGA and the medical oncologists want to continue to offer world-leading cancer care.
“The problem is, we’re struggling to fit in the patients that we already have, much less than new ones coming.”
While we’re doing well in training new oncologists, there simply aren’t enough positions out there, he said.
“Just because people are registering with AHPRA doesn’t mean they’re in an appropriate position.
“We’ve got 40 new oncologists registering with AHPRA every year. I can guarantee that that is not translating into 40 new senior staff specialists or senior clinician positions each year.
“There’s a massive mismatch with the number of people that we’re training with the available positions, though we know that the workload justifies it.
“We’ve got oncologists out there. We just don’t have the positions to put them in, because the health services are struggling to be able to fund those positions.”
Another major challenge was the fractionation of full-time positions, Professor Lynam said.
There are around 840 registered oncologists in Australia, but not all of those are full-time equivalent, he said.
“The number of actual full-time equivalent that are seeing cancer patients is dramatically less. There are a lot working part time.
“Not only do we not have enough positions, but positions that are being advertised are increasingly being fractionated, especially in metro.
“They’re taking up a 1.0 position and breaking it up into fractions, because you can get more work out of a fractional worker than a full-time worker. They always end up having more time to work that little bit extra outside of their paid hours.”
As with most things, it comes down to funding, Professor Lynam said.
“We’re in a fiscally constrained situation where there’s not enough money to go around, and people are having to say, ‘what are our priorities?’
“The problem is the system is at close to breaking point.
“Increasingly, the clinicians are burnt out, there’s no end in sight and there’s very few new positions being put on to enable us to meet the increase in workload.
“The government will talk about new models of care, that we have to think of ways of doing things smarter. The problem is that’s not going to solve the problem.
“We just need more publicly funded positions to meet the increasing workload that we’re faced with or that workload is going to be moved on to other people.”
That means, for instance, that once patients have completed chemotherapy, their post-chemotherapy follow-up would be handed over to GPs, Professor Lynam said.
“All we will do is the chemotherapy, and then all the subsequent care and survivorship will have to be someone else’s problem.
“Are we going to have to offload work onto primary care? Or are we going to be able to fund our services enough to continue the care that we’re giving?
“People are staying alive longer with more advanced disease, they’re getting more complicated and they’re requiring more time.”
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What’s more, finding data on how many patients each oncology unit sees each day isn’t that simple, Professor Lynam said.
One MJA article on the oncology workforce suggested that the appropriate workload for a medical oncologist was 140 to 180 new patients a year.
But that paper used Canadian modelling from 2008, when someone diagnosed with metastatic disease had an average life expectancy of less than 12 months, Professor Lynam said.
“The average life expectancy with someone with metastatic disease, regardless of the metastatic disease, is dramatically different compared to 2008 and the number of tumour types that we treat now was dramatically different in 2008,” he said.
That means we don’t have a good barometer to assess what is appropriate for oncology units, he said.
“We also don’t have any good oversight on how busy some units are and how some units aren’t.
“There’s no data collated around whether one unit is working twice as hard as another unit.
“The health systems are on so many different electronic systems that it’s almost impossible to get a global picture.”
The good news, though, is that Australia’s oncologists are, on the whole, younger than those in the US, Professor Lynam said.
“One of the concerns the US has is that they’ve got an aging population of oncologists who are all reaching retirement,” Professor Lynam said.
“We don’t have as much of an issue with that. We still have more young oncologists than we have old oncologists, so I don’t see that we’re going to have this early retirement issue.
“We’ve got excellent foundations on which to build on, and we don’t have that precipice that other specialties have, where there will be a bunch of people retiring soon and no one to fill their shoes.”
