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 ? l Trainees- it’s not like when the giants walked the wards n Generation X,Y,Z values, Social Pressure, Lifestyle, Debt l Government- weak Federal guidance, primarily left to states, universities and medical schools n Emphasis in primary care, n IMGs- have helped us l Pharmaceutical Industry- major source of medical education and training support n Support SCT fellowship training programs l ****Us-- Academic Medicine n Marginalize training for SCT, even in Heme/Onc programs n SCT needs to compete effectively for trainees

Big Problem l Physician shortage l Oncologist shortage l Particular shortage of SCT physicians l Intense competition within medicine for new physicians l Trainees- go where the money is -seek best career opportunities

Major Physician Shortage Predicted l The Council on Graduate Medical Education n supply of US practicing physicians to rise to 971,800 physicians by n demand will grow much faster. l The expected shortage of physicians ~90,000 by 2020.

The US Has a Relatively Low Supply of Physicians Compared to Other Developed Countries Source: The Supply of Physician Services in OECD Countries. OECD, Steven Simoens & Jeremy Hurst. Health Working Papers Physicians Per 100,000 (2000)

Per Capita MD Enrollment has Fallen Since 1980 With a 30% Increase, the Rate will Still be Below 1980 Source: AAMC Data Book; US Census Bureau. Prepared by Center for Workforce Studies, AAMC, Feb First Year Enrollment per 100,000

Factors Driving Physician Demand l Growth of U.S. population. An increase of 50 million people (18%) is expected between 2000 and l Aging of the population. The number of Americans over 65 will increase from 35 million in 2000 to 54 million in l Changing physician utilization rates. Those over 45 will use more services.

Physician Workforce Planning in the United States l States and private institutions responsible for undergraduate medical education n Era of shrinking government budgets n No substantial growth in medical school slots 25 years n Tough sell when major goal is to reduce national cost of medical care l Medicare and Medicaid GME funding n Faces Major Budget Cuts l No national planning system: n Training grants, recommendations n Medical Schools positions determined by States, institutions.

Age of BMT Physicians All BMT Adult Pediatric l 70 to % 1.8% - l 65 to l 60 to l 55 to l 50 to l 45 to l 40 to l 34 to % 100.0% 100.0% Source: ASBMT Membership Records

Average Time Allocation of SCT Physicians l Clinical Practice49.1% l Clinical Research23.3 l Lab Research14.7 l Administration10.8 l Other % Source: ASBMT Membership Records

We are not alone: other specialty groups reporting physician shortages l Allergy/Immunology l Cardiology l Critical Care l Dermatology l Emergency Medicine l Endocrinology l Family Practice l Gastroenterology l Geriatric Medicine l Infectious Disease l Internal medicine l Oncology l Psychiatry/Child and Adolescent Psychiatry l Pediatric Subspecialties l Radiology l 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 l Hospitals across the country are struggling to find qualified staff l Average ages are climbing: n Nurses 49 years n Pharmacists 48 years n Med-techs >45 years n Physician Assistants 41years

Training Required for SCT Physicians l College (4 years) l Medical School (4 years) l Internal Medicine/Pediatrics (3 years) l Heme/Onc Fellowship (3 years) n if no major experience, Stem Cell Transplant Fellowship (1 year)

Attracting New Physicians to SCT-CT l Specialty, Subspecialty Selection n SCT used to be the cutting edge of with rapid advances in medicine- now lots of competition n Massive student indebtedness; need career which can repay loans n 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 n Internal medicine training- emphasis on primary care, outpatient medicine; decrease emphasis on specialty care n More financial support in other areas n 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

Growth of SCT; Transplants reported to CIBMTR

Use of SCT-Cell Therapy is increasing- Unique Effective Treatment Modality l Increasing n Reduced intensity strategies in older patients n Success of alternative donors for allos n Novel GVHD control strategies n Novel Cell Therapy approaches l Decreasing n Alternative effective treatments –CML –? Myeloma

Stem Cell Transplant Cell Therapy – Use is Increasing l Allogeneic n Matched siblings (~20%) n Unrelated donors (~30%) n Alternative donors (~50%) –Cord Blood –Haplos –7 of 8 MUDs l Autologous l Cell therapy n Stem cells n Cellular Immune Therapy

Projected Demand for Physicians Providing SCT Patient Care Services Adult Pediatric

2020 BMT Physician Supply Problem Estimated Demand and Supply AdultPediatricTotal BMT Physician Requirements in , ,226 Current Supply (959) 86% (156) 14% (1,115) 100% Projected Retirements New BMT Physicians Needed 1,264941,358

Things That Can Help practice of SCTCT l Increased use of NPs, PAs, Pharm.D.s and other clinicians l Increased use of hospitalists n Not easy to apply to HSCT

Training l Fight to keep SCT in core training experience of Internal Medicine and Pediatrics n Residents n Hematology- 17% Board is SCT n Oncology- losing interest in hematology, SCT l Need to make SCT experience relevant to training at each level

SCT Training Programs l 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 l The U.S has ~246 transplant centers l 82 transplant centers (33%) have BMT fellowship programs l Program sizes vary from 1 slot to 10 slots l Need for funding n Generally not supported by funding institution n Count on philanthropy, pharmaceutical company support

Strategies to Increase the Supply of SCT Physicians l Support increases in physicians, internal medicine, Hematology/Oncology and SCT training n Support increases in U.S. medical school enrollment and graduations (new funding sources required) n Support GME increases for Internal Medicine, Pediatrics and Hem-Onc. GME proposed to be cut FY2009 from federal budget. n Recommend changes to Internal Medicine and Pediatric curriculums to support training related to oncology and stem cell transplant n Support development of SCT training programs n Welcome talented IMGs (not eligible for federal training grants)

Strategies to Increase the Supply of BMT Physicians l Increase the number of BMT training programs and training slots* l Increase recruitment of International Medical Graduates into SCT l Retain active physicians longer l Develop more efficient care delivery systems for SCT n More transplants per physician

Strategies to Increase Supply of SCT Physicians l Make SCT sexy again! n Reach out to trainees –Get them while they’re young and impressionable n Raise interest in cutting edge research –Stem Cells –Cellular Immune Therapy –Cure Cancer n For our Pharmaceutical Partners** Support SCT training and fellowship research grants**