Chapter 28: Physician Extenders and a View of the Coming Physician Shortage

Chapter 28: Physician Extenders and a View of the Coming Physician Shortage

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Dr. Hortobagyi explains that he worked with Dr. Robert Benjamin to encourage the Texas Legislature to pass laws enabling the use of physician extenders, then notes that this profession will play an increasingly important role as oncology moves forward. He then moves to a related subject: the shortage of physicians in chronic illnesses. Dr. Hortobagyi explains that he became a ‘pseudo-expert’ in the area when he was president of the American Society of Clinical Oncology and conducted a study which projected that, by 2020, there available physicians would only be able to cover 2/3 of the hours required by patients for treatment. He then lists the causes of this projected shortage and what is going to be result. He observes that Medicare patients are already seeing the effects, as they are having difficulty locating doctors. He also notes that, in the aftermath of the study, little has been done to ease the shortage. “How we deal with that will define us as a society,” he says, and notes the other diseases that will experience the same shortfall as cancer.

Identifier

HortobagyiGN_05_20130315_C28

Publication Date

3-15-2013

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Overview The Researcher The Administrator Beyond the Institution MD Anderson and Government Cultural/Social Influences Understanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient Care Contributions Activities Outside Institution Career and Accomplishments

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Gabriel Hortobagyi, MD:

Tacey Ann Rosolowski, PhD:

Then also in that process, we developed physician extenders. I may have talked about that earlier, but Dr. [Robert S.] Benjamin and I helped the Texas Legislature to pass a bill that would structure the roles and utilization of the services of physician assistants and nurse practitioners. Then eventually those two groups of highly skilled people became very important in this institution, and today we have hundreds of them employed in a variety of roles throughout the institution, and as we go into the future of medicine in general—and oncology in particular—they will play an increasingly important role—in part because they can focus in a narrow area and develop extraordinary high quality skills and in part because we expect to have a fairly serious problem with physician shortage in the county, especially in those specialties that deal with chronic illnesses like cancer, diabetes, arthritis—a variety of these conditions that in the past had no real treatment or few effective treatments. Today they have increasingly effective treatments and many options for treatment.

Tacey Ann Rosolowski, PhD:

What’s the source of that shortage? What’s created it?

Gabriel Hortobagyi, MD:

Well, it’s a complicated problem, and it’s a multifactorial problem. But I became sort of a pseudo-expert in that because when I was president of ASCO we commissioned a study—a workforce study—for oncology which was done. It came up with projections that by 2020 we would have a shortage of something like a third of the physician hours that would be needed to serve the population. Part of the reason is the continued growth of the US population, and that growth rate is higher than the growth rate of physicians. The increase in the life expectancy of the population, and of course, cancer in general is—the frequency with which people develop cancer is in direct proportion with age. So the older you get the higher your chance of developing cancer. So if you die at age thirty, your chances of developing cancer are rather low. If you live to age eighty-five then—if you are a man, you have a one-in-two chance of developing cancer. If you are a woman, you have a one-in-three chance of developing cancer, so the incidence is huge. And of course, we projected that the life expectancy of the average American citizen will continue to increase.

Tacey Ann Rosolowski, PhD:

Then there were all the successes of other specialties. As cardiovascular causes of death started to drop—and they have dropped by, I believe, half over the past half a century; but of course you have to die of something—and then cancer has become a much more prominent cause of death. It was also related to the successes of cancer research. It used to be—just to give you an example, when I started working with breast cancer we had about four or five drugs that were worth something. Once you used those up—at least in metastatic breast cancer—you had nothing else to offer. You just used symptom control, and that was all you could contribute. So the number of visits per patient was much more limited, and the survival of patients with cancer was much more limited. Now we have improved the survival of most cancers—of patients with most cancers so people live longer. We have dozens of active drugs for most of the cancers. There is much more to do for oncologists. In addition, we are treating with drugs the bulk of patients with primary breast cancer who in the past were only treated with surgery, for instance. So instead of me seeing only patients with metastatic breast cancer—who arguably represent maybe twenty-five percent of all breast cancer patients—and seeing them for six, eight visits throughout their lifespan, now I see virtually all patients with breast cancer—with primary and metastatic. Those with primary I might see forty, sixty times over their lifespan, and if they develop metastatic disease, then many more. A single patient has occupied or is now occupying a much greater fraction of the oncologist’s time than it used to.

Tacey Ann Rosolowski, PhD:

And then there are the regulatory issues. We are much less efficient now than we used to be forty years ago. We see fewer patients per unit of time than at that time because we spend a lot more time documenting and justifying our existence, filling out forms, making phone calls, dotting i’s and crossing t’s, and doing a lot of stuff that doesn’t add much value to what we do. But that’s what’s happening today.

Tacey Ann Rosolowski, PhD:

We are only seven years away from that 2020 landmark. What do you feel in the intervening years since that report came out that we are indeed on track to that one-third hours of shortfall, and what’s the effect going to be?

Gabriel Hortobagyi, MD:

Clearly we are on track for that. You probably won’t notice it now, but a good segment of the population is already noticing it. If you are on Medicare and you have cancer, you have far fewer options. If you are looking for a physician, it might take you a year to a year and a half to find a physician who will treat you. Now that’s in part because Medicare doesn’t reimburse very well so physicians pick and choose but also because there are so many other patients that can fill the average physician’s appointment template that they don’t feel the need to bring in those on Medicare and Medicaid and whatnot. That represents maybe thirty-five percent or maybe forty percent of the population, and as the population continues to age it will compound the problem. And also we notice it less because there are many more physician extenders now doing what physicians used to do.

Tacey Ann Rosolowski, PhD:

But since we undertook that workforce study, there has been very little change in the number of training positions for oncology or for postgraduate training in medicine. It takes—from the moment you make the decision, suppose that today the powers that be decided they are going to increase training positions for oncology by thirty percent. Well, the earliest you could make a difference would be about eight years from now because it would take that long to get people through a pipeline. None of that has happened. I think that is going to be a serious issue. How we deal with that will, I think, define us as a society. But of course, one way to define that or to solve the problem is to say, “Well, we’re just going to have to ration care. That way it will be cheaper.” And then if insurance companies, Medicare, and Medicaid disallow about half of the stuff we do as physicians, we will have more time on our hands. I don’t think it’s the right way to do it. It’s something similar to the sequester, but it is one option. Some insurance companies are already doing something like that, so it’s going to be a complicated future in terms of that. And it’s not unique to oncology. Rheumatology, for instance, is in a very similar situation. When I went to medical school, there was very little you could do for lupus or for scleroderma or for a variety—for rheumatoid arthritis, osteoarthritis—and today there are multiple treatments for all of those conditions. The lifespan of patients with those conditions—and most importantly the quality of life of those patients—has improved enormously. But they also take up a much greater fraction of the rheumatologist’s time than they used to, so they are also going to face a shortage.

Tacey Ann Rosolowski, PhD:

Diabetes—you know, when we started—when I started in medical school, we had two different types of insulin, and we had maybe one or two oral anti-diabetic agents. We didn’t have very good ways to keep blood sugar under control, and we were not that sophisticated about the long-term effects of diabetes, so we didn’t do as many things. Well, today management of diabetes is a science in and of itself. It keeps endocrinologists and internists occupied almost fulltime. It is a much more complex and a much more demanding branch of medicine than it used to be. As we learn more about each of the diseases we treat as physicians, I think that is going to be reflected in our efficiency and what we are able to do. And how we react as a society to that, I think, will be important.

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Chapter 28: Physician Extenders and a View of the Coming Physician Shortage

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