*Dept of Radiation Oncology, Westmead Hospital Westmead, NSW
**Research and Education, Royal Prince Alfred Hospital Sydney, NSW
*** Faculty of Radiation Oncology, Royal Australia and New Zealand College of Radiology Sydney, NSW
The focus of this session was on workforce issues relating to the three pivotal service-specific groups in radiation oncology: radiation therapists, medical physicists and radiation oncologists.
The most recent figures for current and projected staffing requirements come from the National Strategic Plan for Radiation Oncology, August 20011. The Tripartite Committee, comprising representatives from the Australian Institute of Radiography (AIR), the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) and the Royal Australian and New Zealand College of Radiologists, Faculty of Radiation Oncology, projected workforce requirements out to 20101.
This paper reviews the major points raised at the Summit and unapologetically gives emphasis to the immediate critical deficiencies amongst radiation therapists and medical physicists over the longer-term issue of radiation oncologist shortfalls.
The Australian radiation therapist workforce reached crisis point some time ago. In NSW alone, in November 2000, this major staffing shortfall resulted in an estimated 6.5 linear accelerators standing idle in a region serviced by a total of 34 machines, of which 29 are in the public sector.
In addition, growing numbers of radiation therapists leave our workforce each year. In November 2000, 88 of 859 full-time equivalent (10.2%) radiation therapist positions were vacant. Reasons for rising attrition rates are summarised below:
Of particular note, a quarter of radiation therapists leaving NSW centres did so to travel and work overseas, mainly in Canada and Britain, as Britain had undertaken a recruitment drive to redress its own staffing shortfalls. The opportunity to travel, higher remuneration packages and a fast-tracked visa acquisition process proved successful tactics in this campaign.
The issues of radiation therapist recruitment and retention and traditional staffing models need addressing. Potential solutions include the following:
1. Financial considerations
Improvement in pay is undeniably important in order to recruit and keep staff in the workplace. In the public health sector in some Australian states, the award wage structure is highly restrictive. The government employer has exploited its monopoly position to keep wages below market conditions. This is unsustainable in the face of international competition. Although negotiations between governments and the industrial bodies representing radiation therapists are continuing, it is unlikely that substantial changes in remuneration will be achieved until there is freedom from such an out-dated system.
2. Optimising recruitment
As a potential career choice, radiation therapy has a weak profile. Targeting career advisers and school leavers to increase awareness of this profession has begun in NSW schools. Increasing university training positions so that intake exceeds expected losses is vital but difficult, due to the competing agendas and funding restrictions on university faculties. An increase in training positions at Newcastle University will not begin to redress the problem until at least 2005. It was suggested at the Summit that a project officer employed by the AIR could develop and coordinate these activities as well as streamline the assimilation of overseas radiation therapists recruited to the Australian workforce.
3. Reducing attrition of students and trained staff
The University of Sydney has committed to lessening attrition from undergraduate courses. The scheme has been developed whereby students with radiation therapy on their selection list will be referred to participating departments to allow students to experience this first hand and to improve the profile of the profession. However, this places an extra burden on already stretched departments and is only helpful if high moral is demonstrated in the centre (often not the case).
Changes to traditional workforce structure are required to make conditions more attractive. Most radiation therapists would value having more career path options. This might include specialisation in a chosen area of interest, provision for further training and education, and research opportunities. Academic radiation therapist positions are already being created, aiming to foster research activities for radiation therapists within the scope of their service responsibilities.
Improving flexibility of work practices, including increasing numbers of part-time and job-share arrangements, will be mandatory to best utilise the skills of the 70% majority female workforce, in particular. Updating or retraining courses will facilitate radiation therapists returning to the workforce after intervals away for family or other reasons.
4. Management of junior graduates
Radiation therapists in their first year after qualifying occupy Professional Development Year (PDY) positions. In some Australian states these are part of the total radiation therapist allocation. This means that if centres are fully staffed, they have no capacity to take on (and further train) junior staff. It also means that services desperate for radiation therapists may employ several PDYs who may be required to take on duties beyond their level of experience. Creating supernumerary PDY positions “protected” from the general radiation therapist pool is more costly in the short term but is an economical investment for future workforce strength and stability.
The medical physicist workforce in Australia and New Zealand also experiences severe shortfalls often overlooked, due to the small numbers in the profession and the fact that this problem is hidden from the patient and public arena. In late 2001, there were 130 established radiation oncology medical physicist positions in Australia. It has been calculated that to meet the benchmark level of service, 211 medical physicists were required: a deficit of 81 positions. It is common for newer technologies such as electronic portal imaging and multi-leaf collimators to be installed but under-used, due to the medical physics staff being unable to extend their services from “routine” patient treatment.
Currently, general physics graduates are employed as medical physicists and forced to take on duties for which they have little training. Approximately one-third of employed physicists are still in training but counted in the full-time establishment.
The salary scales of medical physicists in the USA and Europe are two to five times higher than in Australia, resulting in many senior medical physicists seeking employment overseas. There are no radiation oncology medical physicists in training to take up positions as they arise2.
Key areas that need to be addressed include the following:
Potential solutions to the medical physicist problem include:
1. Funded medical physicist registrar positions in hospitals
The federal government is financially supporting a feasibility study addressing strategies to implement the ACPSEM training, education and accreditation (TEA) program, with the ultimate goal of formalising medical physicist basic training. Funded trainee registrar positions are required to realise this objective.
2. Radiation oncology medical physicist tertiary education
In an attempt to maintain high standards of knowledge and skills the ACPSEM has conducted an accreditation program on a professionally voluntary and cost recovery basis. Courses for dedicated post-graduate study need to be more feasible for tertiary institutions to conduct (for example grant/scholarship schemes or increasing course numbers by taking overseas students).
3. Expansion of workforce to achieve maximum utilisation of equipment
Medical physicist workforce requirements are closely linked to equipment utilisation. Consequently, investment into any radiation oncology technology needs to be linked to the appropriate medical physicist staffing, ensuring full and safe utilisation of that equipment.
4. Review of remuneration in keeping with international levels
Increases in salary reflecting the level of responsibility held by medical physicists is an important factor in stemming the attrition of medical physicists overseas or to other, better paid technical professions with the inherent costs associated with such staffing losses.
At present, full-time Australian radiation oncologists on average see in excess of 300 new patients per year compared with an evidence-based benchmark of 190 new patients per year3. Although debate continues surrounding the ideal number of patients treated annually by radiation oncologists and the optimal patient referral ratios for radiation therapy, it is obvious within the profession that more radiation oncologist positions (and therefore training registrar positions) will need to be created to ensure timely service expansion. Treatments are becoming increasingly complex, and this requires more time to be spent with each patient. Appropriate forward planning and maintaining government commitment to projected medical staff requirements is an ongoing task of the profession, in cooperation with AMWAC, employers and other planning groups.
It is vital that the long-standing radiation oncology workforce deficiencies – especially in the radiation therapist and medical physics groups – be addressed urgently if ongoing deterioration of service and/or serious radiation accidents are to be prevented, in a service already stretched to breaking point. Sadly, decisions relating to radiation oncology services (like other health-related issues) continue to be made reactively, often purely on political grounds. Until conditions are improved for our workforce on a long term and stable basis, Australia is going to continue to struggle to offer the first-class service that it is otherwise more than adequately equipped to deliver. The world-wide shortage of staff and the opening of the global market means that all countries that wish to have adequate radiation oncology services must plan their workforces, otherwise constant poaching of staff will drive wages beyond sustainable limits.
1. The Royal Australian and New Zealand College of Radiologists, The Australasian College of Physical Scientists and Engineers in Medicine, Australian Institute of Radiography. National Radiation Oncology Strategic Plan. The Royal Australian and New Zealand College of Radiologists, Sydney, 2001.
2. L Oliver, J Drew, R Fitchew. “Requirements for radiation oncology physics in Australia and New Zealand.” Australian Phys and Eng Sciences Med, 24, 1 (2001): 1-18.
3. Agnew Peckham and Associates. Canadian Association of Radiation Oncologists Manpower study report. September 2000.