Medical oncology future plan of the Spanish Society of Medical Oncology: challenges and future needs of the Spanish oncologists

A register of Medical Oncology Departments, including the number of medical oncologists in public and private hospitals in Spain in 2014 was prepared. Requests for information were sent to Directorates General for Human Resources of the Regions’ Health Departments, Human Resources Departments of the main private hospitals and Hospital Groups or their equivalents. Information was collected through an electronic survey. In private hospitals, information about professionals working simultaneously in private and public sectors was collected to avoid duplication of data.

Information was collected from 202 public and private centres. Complete information was obtained from 67% of medical oncologists registered in public centres and from 61% of oncologists registered in private centres. The data corresponding to these centres was extrapolated to the 100% of the Register of Medical Oncologists, in cases for which detailed information was not available.

The number of medical oncologists was converted to full time equivalent (FTE), considering part-time contracts, deducting 10% of the correspondent time for women, due to the higher probability of leaves or early departure from the labour market (using estimates from previous studies). [9].

With the aim of estimating the number of specialists who will make up the medical oncology workforce in our country with a time horizon to 2035, a predictive model was designed based on specialist replacement according to the entries (number of trained specialists) and exits (professionals who exit the healthcare delivery labour market for different reasons). The model applied made it possible to quantify the number of specialists in Medical Oncology with care delivery tasks, who will make up the Medical Oncology workforce within the next years, and who could be potentially available to meet healthcare delivery needs.

To estimate the number of entries into the labour market, the average of Resident Medical Intern (MIR)-resident doctor positions published in the Spanish Official Bulletin during the last 5 years was considered (112 positions per year), and this number was considered constant [11].

The following aspects were considered to estimate the number of exits from the labour market: (1) the percentage of trained specialists who work in sectors other than care delivery (research, management, pharmaceutical industry, etc.). This percentage was estimated at 4% based on previous studies [9]; (2) the percentage of interns’ re-circulation (Medical Oncologists who have finished their residency and apply for a new speciality, estimated at 10% based on previous studies [9]), (3) the percentage of interns trained in our country who work abroad after finishing their internships (estimated at 2% of the total of Medical Oncology interns [9]) and (4) the percentage of retirements. To estimate the number of retirements within the time frame of the study, the most probable age of retirement considered was 65 years old, although it was considered that 10% of professionals would continue working until the age of 67.

For the estimation of the number of specialists required to fulfil the present and future workloads, the model used was taken from the First White Book of Medical Oncology in Spain [12]. The data on the total activity performed by Medical Oncology Departments have been updated to 2013 through information generated by SEOM [13]. In the case of genetic counselling consultation activity, estimated based on data on activity in reference centres, as indicated in Table 1. The optimal time dedicated to each one of the main activities has been updated considering the increase in complexity of care delivery and based on the available literature on the subject [14, 15]. Specifically, regarding time dedication included in the First White Book of Medical Oncology in Spain, the time dedicated to the first visit has been increased from 45 to 60 min, and the second visit has been considered in a differential way from the rest of subsequent consultations, estimating optimal dedication at 90 min. We also considered new activities (not included in previous studies), which represent a growing proportion of total medical oncologist’s dedication time, such as tele-consultations (estimated dedication of 7.5 min/consultation) and the genetic counselling (90 min estimated for the first visit and 30 min for subsequent visits). The optimal dedication time of the medical oncologist for the first genetic counselling visit was estimated considering the consultation time and the requirement of later dedication for the computerization or analysis of genealogical tree, etc. The optimal times estimated by type of activity and the sources used for each case are shown in Table 1.

Considering the total activity carried out in Spain in 2013, the optimal dedication times, and the population requiring health services, we have estimated the number of working hours of a medical oncologist needed per 100,000 inhabitants to cover the present demand.

For the estimation of the optimal FTE to cover this demand, the total available time per FTE considered is 37.5 h per week, considering that dedication to healthcare delivery tasks represents, on average, 72% of the total time of the workday. The rest of the time would be distributed between training, research and management activities, depending on profiles.

The estimation of the needs of medical oncologists on the basis of optimal ratios of new cases/specialist was done using the incidence projections of the Globocan 2012 Study [4]. In all cases, the needs of specialists were estimated in terms of FTE.

For the estimation of new cases in Medical Oncology Departments, hematologic cancers were excluded, excepting 10% of the new cases of these types of cancer, considered to be attended at oncology offices.

In the opinion of the professionals surveyed, the aspects that may contribute significantly to improve the quality of care delivery are the development of a national quality assessment system and the development of functional units for specific cancer pathologies. In regard to the relative needs of cancer research and the introduction of innovations on the basis of their value in the area of oncology, it is important to note that 76% of the professionals surveyed request the development of appropriate-for-decision-making registers and databases, and 61% report the need for the development of specific indicators for assessing the quality of results and managing the incorporation of new evidence-based therapeutic approaches (Fig. 3).

In this sense, according to the data collected in this survey, 85.8% of oncologists do not have data demonstrating the impact in health outcomes derived from organizational changes and from the broadening of their service portfolios, and only 10.9% of professionals report having participated in studies on health outcomes. In addition, 67.1% feel that their department does not include an appropriate panel of indicators for the assessment of quality of care delivery.

The main concerns, challenges and needs of the speciality reported by the specialists surveyed have been grouped in 5 broad areas: (1) adapting Medical Oncology workforce to new needs; (2) developing specific care delivery plans adapted to new profiles and their specific needs; (3) ensuring the equity and access to quality healthcare delivery; (4) ensuring earlier diagnosis and (5) advancing towards a more accurate and comprehensive cancer care delivery. A total of 29 recommendations have been identified (Table 3).

SEOM decided to promote the elaboration of the Future Plan for Medical Oncology as a means of establishing the speciality’s strategic lines of development in the coming years and address future potential workforce shortages, with the participation and opinion of a large number of the Society’s members.

Both the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO) have approached this subject through similar studies aimed to identify differences between the actual needs of oncologists with regard to the increase of the Departments’ needs and to the previsions on the number of available professionals, in the basis of the expected workforce growth. According to a study published by ASCO in 2015, it was estimated that demand for medical oncology services would increase by 42% in the USA by 2025. Nevertheless, the expected growth of the oncology and haematology workforce is estimated at 28% for the same period, which means a foreseeable deficit of 1487 FTE oncology/haematology specialists in 2015 [16]. Different studies conducted in the last few years in Australia, Japan, Latin America, France and Belgium, also report an expected shortfall of specialists in the area of oncology within the next years [10]. According to this study published in 2014, the ratio of cancer cases per FTE in 2008 in European countries ranged from 113 in Hungry and 1067 in the United Kingdom, and these ratios are expected to decrease in the coming years in most of the countries. The study reported, however, as its main limitation, the lack of information on professionals in several countries, including Spain [10].

Studies from the University of Las Palmas de Gran Canaria (Spain) on the supply and demand for medical oncologists in Spain have been the main source of information on resource planning for different specialities [9]. Several scientific associations have promoted studies on the needs of different specialists [17, 18], for instance, the Spanish Association of Cardiology reports in its last study the existence of an imbalance of around 14% between the number of active cardiologists and the number needed [17].

Due to the lack of updated data, and in expectation of the results from the unified Register of Professionals, we decided to prepare our own register, with the aim of determining the current situation of Medical Oncology Departments related to the medical oncology workforce in Spain. It was also considered necessary to estimate the optimal ratios based on the increase and complexity of the current demand, and to compare the data obtained with published optimum ratios.

According to the data from published international standards, the optimal range of new cases/FTE is estimated to be between 150 and 180 [19]. In our study, the data from the Register of Medical Oncologists show a deficit of 211 FTE to achieve optimal ratios, estimated at 158 new cases/FTE, which means an imbalance of 18%. Our study also shows a lower average size of the Departments’ workforce, which is around 6.5 medical oncologists/Department compared to data from other countries such as USA where the average is 15 specialists/Department [16]. Our study also reports the concern regarding the dispersion and breakup of Departments experienced in recent years. This fact has been identified as an element that hinders the concentration of a sufficient number of cases to ensure equality in healthcare delivery quality.

The ageing of the population will foreseeably result in an increase in demand for oncology services. In 2012, 60% of the new cases of cancer in Spain corresponded to patients 65 years of age or older. This rate is expected to increase to 67% in 2035 [4]. Despite the expected decrease in the Spanish population within the next 10 years, the ageing trend will be maintained, and the number of people aged 65 or over is estimated at more than 12.5 million by 2025, an increase of 56% from 2012 [20]. Due to the difficulty of estimating activity figures corresponding specifically to the older population, we opted to use ratios in comparison with the general population, allowing that this aspect may be generating an underestimation of the demand in the coming years. Also, the incidence projections, used to estimate future needs, include the foreseeable ageing of the population in Spain in the year to come.

To attain the optimal number of 1881 FTE by 2035, the medical oncology workforce should present an annual average growth of 2.5%. According to a study in 12 European countries, the average workforce growth was 5.3% (balancing in a range between 1.8 and 8.7%) [10], so that the estimated growth rates for Spain would be within this range. The difference between the number of professionals trained in Medical Oncology and the expected retirements, would make it possible to cover this workforce growth, if the current number of internship positions remain constant, as it is estimated that 2480 medical oncologists would be available by 2035 (Fig. 2).

The main limitation identified in the study is the possible margin of error derived from the estimates of the register due to the lack of complete data from all regions, and the forecasts regarding the estimation of the number of future cancer cases. Although the estimated needs based on the forecast of the number of cases is considered a valid model, the estimation of prevalence projections may be a more precise model for estimating the actual workload.

In regard to the updating of workloads, the lack of information on the rate of consultations with patients included in clinical trials, or the time dedicated to home care, is also a limitation. Despite the estimated maintenance of 72% of time dedicated to care delivery, based on the need for increased involvement by medical oncologists in research, training and management, we recommend that this rate be revised downward to allow time to be allocated to these tasks.

In the coming years, there may be an increase in absences due to common illness, and the workforce needs may increase due to burn-out syndrome. These two factors would offset the expected reduction in maternity leave considered in the model. In this sense, a report prepared by ASCO in 2012 indicated that 44.7% of oncologists/haematologists in the US said that they suffered burn-out, especially in profiles with greater dedication to care activity. Close to 27% of oncologists said that they would like to reduce their work hours over the next 12 months, 34% would consider leaving their current job, and 28% planned to retire before the age of 65.

In a scenario of regulatory changes related to requirements for ordinary, partial, and early retirement, their different application at the regional healthcare services level and the diverse models for the hiring of medical professionals applied in recent years in Spain, an average retirement age of 65 was adopted. Even admitting that this estimate could cause a potential underestimation of the number of professionals in active service in the coming years, the possible impact of other factors, such as burn-out or possible budgetary limitations, which could lead to an increase in early retirement, must be taken into consideration.

The low participation in studies on health outcomes was one of the most remarkable conclusion of the survey (only 10.9% of those surveyed reported that they had participated in studies of this kind, despite the acknowledgement of their importance in the planning and incorporation of innovations to the National Health System). Although the available information is limited, the main programmes of comprehensive oncology applied in different countries acknowledge the need to generate evidence that proves its increased effectiveness in comparison with traditional models of cancer approaches. It is important to carry out a continuous assessment of key indicators related to control of symptoms, adherence to treatment protocols, quality of life, individual outcomes, prevention, rehabilitation, economic impact in services, and considerations regarding the impact on the health system as a whole [21].