Building the Next Generation of Oncology PAs

Noam E. Shabani, MS, PA-C

As the scope of cancer care continues to widen, the need for well-trained professionals in all aspects of the treatment continuum, including oncology physician assistants (PAs), has become greater than ever. At Dana-Farber Cancer Institute in Boston, Massachusetts, administrators are aiming to add more skilled oncology PAs to the workforce with the development and implementation of their innovative PA oncology fellowship.

The Dana-Farber Postgraduate PA Oncology Fellowship is a 12-month program that offers fellows an immersive experience with extensive clinical training. Fellows receive training in all major oncologic areas, working alongside other PAs, physicians, and oncology nurses. Participants in the program also have the opportunity to attend teaching conferences to broaden their understanding of cancer care and research.

“In the past 10 to 12 years, Dana-Farber has been utilizing a greater number of PAs in the ambulatory space to provide critical comprehensive oncologic care,” Noam E. Shabani, MS, PA-C, said. “This includes seeing patients on clinical trials, ordering chemotherapy and immunotherapy, as well as collaborating with medical oncology, radiation oncology, surgical oncology, and various other teams. That’s nothing new, but our needs continue to grow and change. Integration of our PA Fellows into care teams around Dana-Farber allows us to provide an extra layer of care for patients, while fostering the growth of our future colleagues. We designed the fellow’s role to encompass the same scope of practice and medical privileges as staff PAs. That means the same credentialing process and therefore the ability to be fully immersed in clinic and work as autonomous providers.”

In an interview with Oncology Fellows, Shabani, the director of the Dana-Farber Postgraduate PA Oncology Fellowship, as well as a medical oncology PA and the ambulatory chief PA at Dana-Farber, discussed what defines the PA oncology fellowship and what makes an individual a good fit for the program.

Oncology Fellows: What makes the Dana-Farber PostgraduatePA Oncology Fellowship unique?

Shabani: The nature of cancer care is changing. Patients are living longer and better than ever before. The very natural history of cancer is changing before us. Combined with improved early detection and screening methods, as well as improved access to cancer care through our regional campuses, Dana-Farber’s clinical footprint is increasing significantly. We are taking care of more patients than ever before. To meet this demand while also maintaining high-quality cancer care, Dana-Farber has continued to support the growth of Advanced Practice Providers (APPs). The DFCI PA fellowship is something that has been in the works for approximately a decade and has gone through various stages of advocacy and buildup. It is part of the solution to the ongoing clinical growth Dana-Farber faces. This oncology fellowship is unique––we were the first in the Northeast and that is something that we are proud of.

We receive many competitive applications to ambulatory PA positions at Dana-Farber. However, lack of relevant experience can be a limiting factor for further consideration since the clinical work can be complex and layered. On the ambulatory side, it involves many different types of skills: acute triaging of sick patients, identifying when patients need to be admitted to the inpatient oncology service, a deep knowledge in the type of cancer patients have, and being able to differentiate treatment toxicities from acute issues and exacerbations of chronic illnesses. Additionally, our APPs are well versed in the management of chronic medical conditions, which inevitably come up during the care of oncology patients. In some cases, we are seeing patients every 2 or 3 weeks for treatment, and are therefore assumed to play an active role regarding primary care and other chronic medical issues.

Additionally, there is the rapid pace of clinic to consider – with visits typically taking place every 30 minutes. Putting that all together, there is a significant need for more experienced PAs in oncology at DFCI. We know that there are many PAs who are seeking specialty training in oncology as well. From their perspective, this fellowship helps fulfill that need in the PA workforce. Many PAs who are either new graduates or early career with experience outside of oncology report they do not feel comfortable taking care of this population of patients. Although many PA employment opportunities come with on-the-job training, 2 to 3 months of on-the-job training does not replace the type of experience gained by fellowship training.

What unserved needs can this program fill from a community oncology perspective?

The volume of patients at Dana-Farber and across the country is at an all time high. Part of that is because we are getting better at treating patients with cancer and they are living longer. That has implications in Massachusetts and in Greater Boston, but also nationally and internationally as we have patients coming from all over the world to receive care here.

Another aspect to consider is Dana-Farber’s identity as a world-renowned cancer research institute. In addition to patient-facing clinical care, DFCI physicians are active across multiple aspects of cancer care and research. From laboratory bench science, to clinical research, drug development, and more, physicians are active on multiple fronts. The integration of APPs into the care model provides physicians with the freedom to pursue those advancements while creating a team-based clinical model.

While DFCI PAs have made contributions in research, healthcare leadership, business development, and clinical operations, PAs continue to be most impactful at the bedside – taking care of our patients. However, they do not perform this task alone. PAs here are a part of a larger clinical team composed of an oncologist, a PA, a nurse practitioner, an infusion nurse, and a nurse navigator. That team approach to patient care helps patients feel like they have layers of people in their corner, and it reduces the burden of care on any one individual.

This model works well because PAs get to practice autonomously and independently within the framework of our collaborative system. This creates a sense of safety and high standards for all our providers and patients. For our fellows, this is the perfect opportunity to learn what team-based care is all about and to be immersed as a member. In fact, toward the end of fellowship, we identify disease centers who are experiencing temporary staffing shortages (medical or family leave, unexpected clinical changes, etc.) and integrate PA fellows to assist in seeing patients autonomously. We call this the Clinical Immersion rotation, and it offers both vital clinical training for fellows while also allowing disease centers to flex their clinical footprint. Given that fellows can see 20-30 patients per week for 4-6 weeks, that is an immediate and positive impact of the fellowship.

Last year, both of our fellows [who recently graduated] were integrated through the Clinical Immersion rotation into disease groups - one of them in the gastrointestinal oncology group the other in early drug development. Those two groups had some temporary staffing challenges, and the PA fellows were able to provider a bridge in clinical care until staffing returned to normal. All the while, this provided the fellows with vital training and clinical independence.

What advice would you have for someone interested in this program or being an oncology PA in general?

There are many ways to enter the world of oncology as a PA. At Dana-Farber, we also have a robust inpatient oncology service that is extremely well run and well positioned to train new graduate PAs... The inpatient PA role is truly unique as it provides experience in cancer care, acute care, palliative and end of life care, and much more. New graduate PAs can certainly apply to, and will likely be considered for an inpatient position. Experience on the inpatient service provides PAs with a lot of experience and a exposure to various situations.

However, depending on the clinical situation, it doesn’t always teach primary oncology management in the same way as ambulatory care. Often, patients who are getting inpatient care with a cancer diagnosis are being admitted for an acute exacerbation of cancer-related pain, oncologic emergencies, progression of disease, or a new acute issue. The care patients receive on the inpatient service is incredible and allows PAs to develop skills and knowledge unmatched by any other position at DFCI.

If inpatient PAs feel that in time they want to stretch out and apply for an ambulatory position, then there are also opportunities for them to move to the ambulatory space. However, the majority of our ambulatory PAs come from other institutions working in specialties that are adjacent to oncology. Individuals who worked in internal medicine, hospitalist medicine, primary care, urgent care, or emergency medicine, are typically in excellent positioning to be considered for an oncology job. This allows the next step in their clinical training to be focused on oncology.

For new graduate PAs not interested in an inpatient position, the fellowship becomes an attractive option since it provides year-long training that is unmatched by new-hire staff PA training. This is where the fellowship really shines – by offering new or early-career PAs an opportunity to work in oncology right out of school, and hopefully a means to jumpstarting a fulfilling career.

Reference

Postgraduate Physician Assistant Oncology Fellowship. Dana-Farber Cancer Institute Accessed March 29, 2024. bit.ly/43AXEgx