- Email: [email protected]
Advancing Our Practice Through the Advanced Practice Radiation Therapist Model: Catching Up With Canada
International Journal of
Radiation Oncology biology
physics
www.redjournal.org
COMMENTARY
Advancing Our Practice Through the Advanced Practice Radiation Therapist Model: Catching Up With Canada Neha Vapiwala, MD,* Meredith Giuliani, MBBS, MEd, FRCPC,y and Nicole Harnett, MEd, MRT(T)y *Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, and y Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada Received Nov 14, 2016, and in revised form Feb 17, 2017. Accepted for publication Feb 27, 2017.
Contemporary radiation oncology (RO) practice is facing numerous competing pressures in this era of high-quality, high-value, high-volume care. An aging population and modern medicine’s conversion of many cancers into chronic conditions are expected to result in increased cancer incidence and prevalence, respectively (1-3). Complex, interdisciplinary patient management and survivorship needs are compounded by rapid and ongoing expansion of available treatments and technology in an environment of increasing budgetary considerations. Add intensive documentation requirements (4) amid the renewed emphasis on patient safety and care quality, and today’s credo of “do more with less” is painfully evident. Clinical outcome and patient satisfaction metrics inextricably tied to physician reimbursement and reputation are added complexities, especially given the global reach of social media. Although these pressures can be stressful, they can also serve as sparks providing the impetus to explore potential new approaches for managing and mitigating the challenging clinical reality of today. With a fundamental end goal of a well-oiled system that delivers the highest quality of care to our patients, we should consider creative and nontraditional strategies to address the evolving expectations of providers in our value-based care environment. Possible avenues for streamlining the delivery of physician services and Reprint requests to: Neha Vapiwala, MD, Department of Radiation Oncology, 3400 Civic Center Boulevard, TRC 2 W, Philadelphia, PA 19104. Tel: (215) 662-7266; E-mail: [email protected] Int J Radiation Oncol Biol Phys, Vol. 98, No. 3, pp. 497e500, 2017 0360-3016/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2017.02.221
high-quality radiation therapy include increasing human resources in the form of “physician extenders” to meet RO-specific needs, maintaining human resources but relying on integrated automation to improve clinical efficiency, or shifting the use of human resources by restructuring the scope of work of the existing team members. Each strategy naturally comes with advantages and disadvantages. Hiring more radiation oncologists will not always be a remedy that is fiscally sound, effective, or both for the stressors and inefficiencies affecting individual practitioners. Furthermore, despite the acceptance of collaborative practice models for nurse practitioners (NP) and physician assistants (PA) as “gold standards” in oncology (5), the full potential of these advanced clinical providers has not been realized in RO, partly because of complicated billing regulations. Even if these roles are integrated eventually, they would not optimally meet the demands of rapid technological change and uptake that characterize RO. Automation has its place, but it cannot replace clinical judgment or satisfy patient preference for interpersonal connections. Finally, rethinking the distribution of workload can present challenges because the traditional duties and responsibilities of physician versus physicist versus therapist are clearly demarcated and fairly ingrained in the United States. When we look globally, however, some jurisdictions have created a more fluid and Conflict of interest: none
498
Vapiwala et al.
heterogeneous model, highlighting the uniquely interdisciplinary nature of radiation medicine. In today’s RO department, for example, radiation therapists typically constitute the largest proportion of human resources (6), with variable but specific exposure to treatment planning and delivery processes, systems, and goals. As such, and given the current climate where multiple competing priorities can place physicians in a “clinical-technical tug of war,” it seems logical to investigate mechanisms for developing the intellectual capital of this existing, plentiful, radiation-specific personnel and modifying conventional professional boundaries in a mutually beneficial manner. Ontario, Canada, just completed an impressive, decadeplus-long clinical specialist radiation therapist (CSRT) demonstration project, exploring a new healthcare provider (HCP) categorydadvanced practice radiation therapist (APRT)dthrough a system-wide, multiphase, evidencebased approach to measure the impact of these unique HCPs on system capacity, patient care quality, and acceleration of innovation (7-9). The APRT practice occupies a distinct intersection of the radiation treatment process, situated directly at the interface of patient and technology. It requires advanced theoretic, scientific, and experiential knowledge in radiation oncology, starting with a specialized undergraduate radiation therapy foundation. APRTs deepen pre-existing comprehension of radiation biophysics, radiobiology, and clinical oncology principles through graduate-level education and robust, supervised, and evaluated practical experience. Layered onto this are broader healthcare competencies such as physical examination, clinical reasoning, and participation in multidisciplinary cancer care teams. The validated definition of APRT represents a wholesale move to a higher cognitive level of practice, with resultant opportunities for higher levels of autonomy and accountability. Through the Ontario project, APRTs have developed competence across the patient care continuum, from taking histories at consultation and interpreting diagnostic data to recognizing indications for radiation therapy, performing complex and adaptive treatment planning, and monitoring patient response and tolerance from treatment through follow-up. APRTs typically specialize in specific populations (eg, patients with early-stage breast cancer or those receiving palliative care), but they can also develop a broader domain of expertise (ie, brachytherapy, stereotactic radiation therapy), all using a common, nationally validated competency profile that is universal to the role. Longitudinal data collected over 12 years from 25 CSRTs deployed across Ontario have demonstrated that APRT-facilitated models of care improve capacity, quality, and innovation (8). On the basis of the Ontario experience, APRTs can increase clinical throughput by seeing additional new patients per clinic (under physician supervision), conducting downstream nonerevenue-generating logistic activities that provide the physician increased time for higher-level clinical care, and participating in
International Journal of Radiation Oncology Biology Physics
multidisciplinary team activities and meetings as team representatives (10). Furthermore, a readily available APRT may competently, and in some cases autonomously, address issues such as anatomic changes visualized on cone beam computed tomography or on-treatment medication adjustments. Although APRTs certainly would not prevent every interruption or satisfy legal imperatives such as the U.S. Medicare-based requirement that a physician be “on site” while radiation is being delivered, they could facilitate more efficient use of human resources. For example, when APRTs manage ad hoc therapy-related issues, treatment rooms are not delayed and patients are not inconvenienced by waiting for the physician to call or physically travel to the treatment unit or planning area; in turn, the physician experiences fewer interruptions. APRTs have also been deployed to raise awareness of radiation therapy among community-based practices, round with palliative service teams at local hospitals to identify patients who could benefit from palliative radiation therapy (eg, “rapid response radiation therapy program”), and conduct “well” follow-up visits to track and document treatment side effects over time. These activities represent opportunities to increase network referrals rates and patterns and to provide needed care to the local community. Consequently, these capacity-building activities frequently improve care quality. More timely access to competent care can elevate patient satisfaction. Patients also noted and appreciated the increased time they could spend with the APRT so as to not “bother the very busy doctor.” APRTs can also boost care quality through enhanced consistency of technical aspects of treatment planning and delivery across a patient population (ie, technique selection, contouring of target and regions of interest) and quality assurance measures (ie, reduction in handoffs), all leading to improved safety, efficiency, and quality of radiation treatments (11). Furthermore, the Ontario Project also demonstrated the ability of APRTs to accelerate the pace of innovation locoregionally and nationally and contribute to new knowledge in radiation medicine globally. Traditionally, RO practice changes were dictated by other team members, but APRTs offer unique perspectives to the development of new radiation therapy techniques or processes. This model wholly engages APRTs as valued contributors to knowledge creation and translation and innovation within their team, which is presumably desirable in all practice settings, regardless of the presence of an academic career path. Notably, an alternative research career trajectory for therapists did emerge during the Ontario Project in response to APRTs’ productivity and has proved highly valuable, with a constant and steep increase in the number of APRT firstauthored manuscripts in peer-reviewed journals and in awards and presentations at scientific meetings and conference proceedings (8). Consequently, overall satisfaction with the creation of this new role has been tremendously positive, especially in
Volume 98 Number 3 2017
Advanced practice radiation therapist model
499
Table 1 Proposed potential “job description” components for advanced practice radiation therapist (ie, clinical specialist radiation therapist) Practice setting Community-based private practice
Community-based network practice (affiliated with larger health university)
Academic practice (part of university/medical school)
Tasks and responsibilities Provide timely care to noncomplex patients on treatment at point of care Interpret patient side effects against the treatment plan Monitor clinical outcomes in alignment with treatment delivered to date Provide consistency of contouring and treatment planning for given disease site Reduce number of handoffs required across the patient’s care trajectory (from decision to treat through to follow up) Improve quality and safety of treatment through peer-reviewed processes and chart rounds/audits Identify new patient populations through community connections/awareness All of the above plus: Serve as chart rounds liaisons between network and main center Perform quality assurance functions like rounds summaries and tracking/charting/ documentation Oversee knowledge translation activities such as training new staff or implementing new processes All of the above plus: Identify and implement best practices Identify and initiate research opportunities Participate in interprofessional teaching/mentorship Contribute in terms of service to local, regional, and national professional bodies Conduct supervised research projects Manage/evaluate/develop therapy practice guidelines
this time of unprecedented technological development and pressure to implement the “latest and greatest” into routine RO practice. Permanent integration of this new HCP into the existing radiation medicine team in Ontario is ongoing (7). This includes collaboration with the national certification body to create a national certification process for APRTs (12). Although the landscape of American practice presents different challenges from those in Canada and abroad, it also presents different opportunities. Payment models, billing requirements, and documentation regulations may seem like hurdles to the adoption of this model. But just as other advanced provider models are being evaluated and successfully implemented in oncology with billingcompliant delineation of separate versus overlapping scopes of practice (13, 14), so too might APRTs. They could contribute to the bottom line by enabling revenuegenerating HCPs to focus on clinical activities more appropriate to their level of training and expertise. And APRTs are well suited, if not better suited, to assume a variety of therapy-specific activities traditionally completed by higher-level providers (Table 1). So how do we even go about adopting Canada’s success stateside? As a start, a limited number of institutions in the United States with the requisite resources for program development could launch small-scale pilot programs to train a cadre of APRTs. These institutions may choose to expand and offer master’s degreeelevel curricula, but ultimately a handful of high-quality, high-volume training programs should suffice. The key to popularity of the
training, however, will be placement of the graduates in positions that capitalize on their additional training and credentials. These positions would be expected to offer compensation commensurate with the APRTs’ enhanced skillsets and capabilities. Establishing an employment pipeline for APRTs would require a change in our current paradigm of how an RO center operates. It would require buy-in from practice partners, academic department chairs, and health system CEOs to hire and develop these professionals to their maximal potential. More importantly, direct input and support from all relevant professional society organizations and licensing bodies in the United States to define APRTs’ scope of practice would be critical to identify both desirable and undesirable overlaps with the job descriptions of other advanced practice providers. Regulatory oversight of APRTs would also be required and determined at the state level. Hurdles notwithstanding, this innovative model of care should be considered among the potential strategies used to help doctors in the United States get back to doctoring; to enhance our realization of the tripartite mission of excellence in clinical care, education, and research; and ultimately to provide sustainable highquality care for our cancer patients.
References 1. U.S. Census Bureau. Population Estimates and Projections. Washington, DC: U.S. Census Bureau; 2015.
500
Vapiwala et al.
2. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Current Population Reports, P25eP1143. Washington, DC: U.S. Census Bureau; 2014. 3. Available at: https://www.cancer.gov/about-cancer/understanding/ statistics. Accessed January 31, 2017. 4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med 2016;165:753-760. 5. Towle EL, Barr TR, Goldstein M, et al. Results of the ASCO study of collaborative practice arrangements. J Oncol Pract 2011;7:278-282. 6. Radiation Therapists Occupational Outlook Handbook. U.S. Bureau of Labor Statistics. Available at: https://www.bls.gov/ooh/healthcare/ radiation-therapists.html. Accessed January 25, 2017. 7. Cancer Care Ontario: Radiation therapy advanced practice. Available at: https://www.cancercare.on.ca/ocs/clinicalprogs/radiationtreatment/ radiationtherapy. Accessed January 31, 2017. 8. Harnett N. CSRT sustainability project: Final report 2012/13. May 24, 2013. Available at: https://www.cancercare.on.ca/common/pages/ UserFile.aspx?fileIdZ287716. Accessed January 31, 2017.
International Journal of Radiation Oncology Biology Physics 9. Harnett N. Cancer Care Ontario. Clinical Specialist Radiation Therapist (CSRT) Sustainability Project: Summative Report 2015/16. Ontario, Canada: Ministry of Health and Long Term Care; 2016. 10. Harnett N, Lockhart E, Ang M, et al. It’s crunch time: Finding efficiencies with a new CSRT-mediated Model of Care. Poster presented at: Canadian Association of Radiation Oncologist Annual Scientific Meeting. September 15-17, 2016; Banff, Alberta. 11. Harnett N, Bak K, Zychla L, et al. A roadmap for change: Charting the course of the development of a new, advanced role for radiation therapists. J Allied Health 2014;43:110-116. 12. Canadian Association of Medical Radiation Technologists. Available at: http://www.camrt.ca/mrt-profession/professional-resources/advancedpractice/. Accessed January 25, 2017. 13. Moote M, Nelson R, Veltkamp R, et al. Productivity assessment of physician assistants and nurse practitioners in oncology in an academic medical center. J Oncol Pract 2012;8:167-172. 14. Moote M, Wetherhold R, Olson K, et al. Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center. Pract Radiat Oncol 2012;2:e31-e37.
Radiation Oncology biology
physics
www.redjournal.org
COMMENTARY
Advancing Our Practice Through the Advanced Practice Radiation Therapist Model: Catching Up With Canada Neha Vapiwala, MD,* Meredith Giuliani, MBBS, MEd, FRCPC,y and Nicole Harnett, MEd, MRT(T)y *Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, and y Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada Received Nov 14, 2016, and in revised form Feb 17, 2017. Accepted for publication Feb 27, 2017.
Contemporary radiation oncology (RO) practice is facing numerous competing pressures in this era of high-quality, high-value, high-volume care. An aging population and modern medicine’s conversion of many cancers into chronic conditions are expected to result in increased cancer incidence and prevalence, respectively (1-3). Complex, interdisciplinary patient management and survivorship needs are compounded by rapid and ongoing expansion of available treatments and technology in an environment of increasing budgetary considerations. Add intensive documentation requirements (4) amid the renewed emphasis on patient safety and care quality, and today’s credo of “do more with less” is painfully evident. Clinical outcome and patient satisfaction metrics inextricably tied to physician reimbursement and reputation are added complexities, especially given the global reach of social media. Although these pressures can be stressful, they can also serve as sparks providing the impetus to explore potential new approaches for managing and mitigating the challenging clinical reality of today. With a fundamental end goal of a well-oiled system that delivers the highest quality of care to our patients, we should consider creative and nontraditional strategies to address the evolving expectations of providers in our value-based care environment. Possible avenues for streamlining the delivery of physician services and Reprint requests to: Neha Vapiwala, MD, Department of Radiation Oncology, 3400 Civic Center Boulevard, TRC 2 W, Philadelphia, PA 19104. Tel: (215) 662-7266; E-mail: [email protected] Int J Radiation Oncol Biol Phys, Vol. 98, No. 3, pp. 497e500, 2017 0360-3016/$ - see front matter Ó 2017 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ijrobp.2017.02.221
high-quality radiation therapy include increasing human resources in the form of “physician extenders” to meet RO-specific needs, maintaining human resources but relying on integrated automation to improve clinical efficiency, or shifting the use of human resources by restructuring the scope of work of the existing team members. Each strategy naturally comes with advantages and disadvantages. Hiring more radiation oncologists will not always be a remedy that is fiscally sound, effective, or both for the stressors and inefficiencies affecting individual practitioners. Furthermore, despite the acceptance of collaborative practice models for nurse practitioners (NP) and physician assistants (PA) as “gold standards” in oncology (5), the full potential of these advanced clinical providers has not been realized in RO, partly because of complicated billing regulations. Even if these roles are integrated eventually, they would not optimally meet the demands of rapid technological change and uptake that characterize RO. Automation has its place, but it cannot replace clinical judgment or satisfy patient preference for interpersonal connections. Finally, rethinking the distribution of workload can present challenges because the traditional duties and responsibilities of physician versus physicist versus therapist are clearly demarcated and fairly ingrained in the United States. When we look globally, however, some jurisdictions have created a more fluid and Conflict of interest: none
498
Vapiwala et al.
heterogeneous model, highlighting the uniquely interdisciplinary nature of radiation medicine. In today’s RO department, for example, radiation therapists typically constitute the largest proportion of human resources (6), with variable but specific exposure to treatment planning and delivery processes, systems, and goals. As such, and given the current climate where multiple competing priorities can place physicians in a “clinical-technical tug of war,” it seems logical to investigate mechanisms for developing the intellectual capital of this existing, plentiful, radiation-specific personnel and modifying conventional professional boundaries in a mutually beneficial manner. Ontario, Canada, just completed an impressive, decadeplus-long clinical specialist radiation therapist (CSRT) demonstration project, exploring a new healthcare provider (HCP) categorydadvanced practice radiation therapist (APRT)dthrough a system-wide, multiphase, evidencebased approach to measure the impact of these unique HCPs on system capacity, patient care quality, and acceleration of innovation (7-9). The APRT practice occupies a distinct intersection of the radiation treatment process, situated directly at the interface of patient and technology. It requires advanced theoretic, scientific, and experiential knowledge in radiation oncology, starting with a specialized undergraduate radiation therapy foundation. APRTs deepen pre-existing comprehension of radiation biophysics, radiobiology, and clinical oncology principles through graduate-level education and robust, supervised, and evaluated practical experience. Layered onto this are broader healthcare competencies such as physical examination, clinical reasoning, and participation in multidisciplinary cancer care teams. The validated definition of APRT represents a wholesale move to a higher cognitive level of practice, with resultant opportunities for higher levels of autonomy and accountability. Through the Ontario project, APRTs have developed competence across the patient care continuum, from taking histories at consultation and interpreting diagnostic data to recognizing indications for radiation therapy, performing complex and adaptive treatment planning, and monitoring patient response and tolerance from treatment through follow-up. APRTs typically specialize in specific populations (eg, patients with early-stage breast cancer or those receiving palliative care), but they can also develop a broader domain of expertise (ie, brachytherapy, stereotactic radiation therapy), all using a common, nationally validated competency profile that is universal to the role. Longitudinal data collected over 12 years from 25 CSRTs deployed across Ontario have demonstrated that APRT-facilitated models of care improve capacity, quality, and innovation (8). On the basis of the Ontario experience, APRTs can increase clinical throughput by seeing additional new patients per clinic (under physician supervision), conducting downstream nonerevenue-generating logistic activities that provide the physician increased time for higher-level clinical care, and participating in
International Journal of Radiation Oncology Biology Physics
multidisciplinary team activities and meetings as team representatives (10). Furthermore, a readily available APRT may competently, and in some cases autonomously, address issues such as anatomic changes visualized on cone beam computed tomography or on-treatment medication adjustments. Although APRTs certainly would not prevent every interruption or satisfy legal imperatives such as the U.S. Medicare-based requirement that a physician be “on site” while radiation is being delivered, they could facilitate more efficient use of human resources. For example, when APRTs manage ad hoc therapy-related issues, treatment rooms are not delayed and patients are not inconvenienced by waiting for the physician to call or physically travel to the treatment unit or planning area; in turn, the physician experiences fewer interruptions. APRTs have also been deployed to raise awareness of radiation therapy among community-based practices, round with palliative service teams at local hospitals to identify patients who could benefit from palliative radiation therapy (eg, “rapid response radiation therapy program”), and conduct “well” follow-up visits to track and document treatment side effects over time. These activities represent opportunities to increase network referrals rates and patterns and to provide needed care to the local community. Consequently, these capacity-building activities frequently improve care quality. More timely access to competent care can elevate patient satisfaction. Patients also noted and appreciated the increased time they could spend with the APRT so as to not “bother the very busy doctor.” APRTs can also boost care quality through enhanced consistency of technical aspects of treatment planning and delivery across a patient population (ie, technique selection, contouring of target and regions of interest) and quality assurance measures (ie, reduction in handoffs), all leading to improved safety, efficiency, and quality of radiation treatments (11). Furthermore, the Ontario Project also demonstrated the ability of APRTs to accelerate the pace of innovation locoregionally and nationally and contribute to new knowledge in radiation medicine globally. Traditionally, RO practice changes were dictated by other team members, but APRTs offer unique perspectives to the development of new radiation therapy techniques or processes. This model wholly engages APRTs as valued contributors to knowledge creation and translation and innovation within their team, which is presumably desirable in all practice settings, regardless of the presence of an academic career path. Notably, an alternative research career trajectory for therapists did emerge during the Ontario Project in response to APRTs’ productivity and has proved highly valuable, with a constant and steep increase in the number of APRT firstauthored manuscripts in peer-reviewed journals and in awards and presentations at scientific meetings and conference proceedings (8). Consequently, overall satisfaction with the creation of this new role has been tremendously positive, especially in
Volume 98 Number 3 2017
Advanced practice radiation therapist model
499
Table 1 Proposed potential “job description” components for advanced practice radiation therapist (ie, clinical specialist radiation therapist) Practice setting Community-based private practice
Community-based network practice (affiliated with larger health university)
Academic practice (part of university/medical school)
Tasks and responsibilities Provide timely care to noncomplex patients on treatment at point of care Interpret patient side effects against the treatment plan Monitor clinical outcomes in alignment with treatment delivered to date Provide consistency of contouring and treatment planning for given disease site Reduce number of handoffs required across the patient’s care trajectory (from decision to treat through to follow up) Improve quality and safety of treatment through peer-reviewed processes and chart rounds/audits Identify new patient populations through community connections/awareness All of the above plus: Serve as chart rounds liaisons between network and main center Perform quality assurance functions like rounds summaries and tracking/charting/ documentation Oversee knowledge translation activities such as training new staff or implementing new processes All of the above plus: Identify and implement best practices Identify and initiate research opportunities Participate in interprofessional teaching/mentorship Contribute in terms of service to local, regional, and national professional bodies Conduct supervised research projects Manage/evaluate/develop therapy practice guidelines
this time of unprecedented technological development and pressure to implement the “latest and greatest” into routine RO practice. Permanent integration of this new HCP into the existing radiation medicine team in Ontario is ongoing (7). This includes collaboration with the national certification body to create a national certification process for APRTs (12). Although the landscape of American practice presents different challenges from those in Canada and abroad, it also presents different opportunities. Payment models, billing requirements, and documentation regulations may seem like hurdles to the adoption of this model. But just as other advanced provider models are being evaluated and successfully implemented in oncology with billingcompliant delineation of separate versus overlapping scopes of practice (13, 14), so too might APRTs. They could contribute to the bottom line by enabling revenuegenerating HCPs to focus on clinical activities more appropriate to their level of training and expertise. And APRTs are well suited, if not better suited, to assume a variety of therapy-specific activities traditionally completed by higher-level providers (Table 1). So how do we even go about adopting Canada’s success stateside? As a start, a limited number of institutions in the United States with the requisite resources for program development could launch small-scale pilot programs to train a cadre of APRTs. These institutions may choose to expand and offer master’s degreeelevel curricula, but ultimately a handful of high-quality, high-volume training programs should suffice. The key to popularity of the
training, however, will be placement of the graduates in positions that capitalize on their additional training and credentials. These positions would be expected to offer compensation commensurate with the APRTs’ enhanced skillsets and capabilities. Establishing an employment pipeline for APRTs would require a change in our current paradigm of how an RO center operates. It would require buy-in from practice partners, academic department chairs, and health system CEOs to hire and develop these professionals to their maximal potential. More importantly, direct input and support from all relevant professional society organizations and licensing bodies in the United States to define APRTs’ scope of practice would be critical to identify both desirable and undesirable overlaps with the job descriptions of other advanced practice providers. Regulatory oversight of APRTs would also be required and determined at the state level. Hurdles notwithstanding, this innovative model of care should be considered among the potential strategies used to help doctors in the United States get back to doctoring; to enhance our realization of the tripartite mission of excellence in clinical care, education, and research; and ultimately to provide sustainable highquality care for our cancer patients.
References 1. U.S. Census Bureau. Population Estimates and Projections. Washington, DC: U.S. Census Bureau; 2015.
500
Vapiwala et al.
2. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 to 2060, Current Population Reports, P25eP1143. Washington, DC: U.S. Census Bureau; 2014. 3. Available at: https://www.cancer.gov/about-cancer/understanding/ statistics. Accessed January 31, 2017. 4. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties. Ann Intern Med 2016;165:753-760. 5. Towle EL, Barr TR, Goldstein M, et al. Results of the ASCO study of collaborative practice arrangements. J Oncol Pract 2011;7:278-282. 6. Radiation Therapists Occupational Outlook Handbook. U.S. Bureau of Labor Statistics. Available at: https://www.bls.gov/ooh/healthcare/ radiation-therapists.html. Accessed January 25, 2017. 7. Cancer Care Ontario: Radiation therapy advanced practice. Available at: https://www.cancercare.on.ca/ocs/clinicalprogs/radiationtreatment/ radiationtherapy. Accessed January 31, 2017. 8. Harnett N. CSRT sustainability project: Final report 2012/13. May 24, 2013. Available at: https://www.cancercare.on.ca/common/pages/ UserFile.aspx?fileIdZ287716. Accessed January 31, 2017.
International Journal of Radiation Oncology Biology Physics 9. Harnett N. Cancer Care Ontario. Clinical Specialist Radiation Therapist (CSRT) Sustainability Project: Summative Report 2015/16. Ontario, Canada: Ministry of Health and Long Term Care; 2016. 10. Harnett N, Lockhart E, Ang M, et al. It’s crunch time: Finding efficiencies with a new CSRT-mediated Model of Care. Poster presented at: Canadian Association of Radiation Oncologist Annual Scientific Meeting. September 15-17, 2016; Banff, Alberta. 11. Harnett N, Bak K, Zychla L, et al. A roadmap for change: Charting the course of the development of a new, advanced role for radiation therapists. J Allied Health 2014;43:110-116. 12. Canadian Association of Medical Radiation Technologists. Available at: http://www.camrt.ca/mrt-profession/professional-resources/advancedpractice/. Accessed January 25, 2017. 13. Moote M, Nelson R, Veltkamp R, et al. Productivity assessment of physician assistants and nurse practitioners in oncology in an academic medical center. J Oncol Pract 2012;8:167-172. 14. Moote M, Wetherhold R, Olson K, et al. Physician assistant and nurse practitioner utilization in radiation oncology within an academic medical center. Pract Radiat Oncol 2012;2:e31-e37.