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**