Mar. 15, 2010
The Doctor Is Out: An Inside Look at the Doctor and Nursing Shortage
According to the Association of American Medical Colleges, an increase in the number of the nation's elderly and the aging population of doctors is causing a doctor shortage in the U.S. The association estimates that the demand for doctors will outstrip supply by 2020. The Association of Colleges of Nursing notes a similar dilemma for the nation's registered nurses. Dr. Fred Sanfilippo, executive vice president for health affairs at Emory University, CEO of Emory's Woodruff Health Sciences Center, and chairman of Emory Healthcare, believes the issue of doctor and nursing shortages is much more complex than many might imagine.
According to Dr. Sanfilippo, "There is an ever-changing cycle of shortages. Advances in technology and treatment can reduce or increase demand for specialists needed in one area or another much more quickly than it takes to train or absorb them." For instance, the demand for cardiac surgeons has slowed dramatically as a result of better medications and stents. Changes in insurance and Medicare/Medicaid reimbursement can also impact specialties, he says. "Since medical school graduates now carry so much debt, the specialty they choose is often influenced by potential income, which is most evident in the low numbers going into primary care."
As safety net medical facilities across the country struggle financially, Dr. Sanfilippo is concerned about another potential impact. "University affiliated hospitals provide a disproportionate amount of charity care, and these major teaching sites are critical to our supply of doctors and nurses. The intent of health care reform is to reduce uncompensated charity care. It must also take into account the costs of medical training, or we will exacerbate the problem of not being able to train enough doctors to care for those needing health care."
A Prescription for the Nursing Problem
As the age of the nurse workforce continues to increase each year, it also presents education issues. Linda McCauley, PhD, RN, FAAN, and professor and dean of the Nell Hodgson Woodruff School of Nursing at Emory University, notes, "Nurses in their 50's will be the largest segment of the nursing workforce by 2012. The nurse population will decrease significantly as these nurses retire." Considering this mass exodus of nurses from the profession, training the next generation of health care practitioners becomes even more critical.
In June, Faye Raines, the president of the American Association of Colleges of Nursing, spoke to President Obama and the U.S. Senate about the need for health care reform and a larger nursing workforce. The American Recovery and Reinvestment Act of 2009 did allocate $200 million to train an estimated 8,000 students and credentialed health professionals by the end of fiscal year 2010- enough to provide health care for an additional 2.2 million people. The Recovery Act, also known as the stimulus plan, dedicated more than $6 million in nursing scholarships for students from disadvantaged backgrounds. More than $13 million was set aside for loan repayment when nursing students choose to practice in critical shortage areas.
President Obama's budget recommends $715 million for health professions. McCauley says, "This could underwrite as many as 50,000 nursing students who otherwise would not have had the opportunity to take advantage of this program." She also points to other efforts to get health care personnel into underserved areas. For one, the 2010 Budget and the Recovery Act proposes the increase of the National Health Service Corps, putting thousands of health care professionals into needy areas.
Part of Raines's proposed plan calls for expanded nursing education and development. Currently, nursing schools face a shortage of nursing faculty. According to the American Association of Colleges of Nursing, schools in the United States turned away 48,948 qualified applicants to baccalaureate and graduate nursing programs in 2008 due to an insufficient number of educators. "The shortage of nursing faculty is limiting the number of nurses who can receive degrees," says Dean McCauley. The set-aside in the stimulus plan will also support nursing students who plan to teach nursing when they graduate.
Understanding a Team-Based Approach
For the moment, many Americans are still waiting for change, and, increasingly, they are waiting much longer to see a doctor. A recent survey of the Commonwealth Fund, a New York City-based private foundation focused on health care improvement, found that only 65 percent of adults under age 65 reports they have an accessible primary care provider. Only half of adults receive all recommended screening and preventive care and only 30 percent of the uninsured have received appropriate preventive care.
Primary care physicians were meant to handle this sort of need. But the internist or general practitioner is in short supply. Benjamin G. Druss, the Rosalynn Carter Chair in Mental Health in the Department of Health Policy and Management at Emory University's Rollins School of Public Health, believes that academic medical centers need to rethink their focus to increase the supply of certain types of doctors. He notes that medical schools remain committed to concentrating on cutting-edge specialties and the general practitioner or internist is sometimes forgotten. "Medical schools need to focus on training more primary care physicians," he says. "Models of payment also need to change to make it more attractive for students to go into primary care."
Establishing a hierarchical model for the medical team appears to be one way to more effectively use the services of a general practitioner. Dean McCauley notes, "health care professionals will have to join forces in order to enhance patient care. We will fall short of providing high quality care if the disciplines don't work together." A team-based medical approach, with physicians, nurses, and other medical professionals working in tandem, serves to resolve some of the problems in access to care, cost, quality and coordination of care.
The idea of an allied health care model can not only solve personnel shortages, it can also help with growing health care costs, says Charles D. Frame, executive director of the Emory Center for Healthcare Leadership at the School of Medicine and an adjunct associate professor of marketing at Emory University's Goizueta Business School. He notes, "We need more boundary-spanning physicians at the front end of medicine. We should also be using well trained nurse practitioners, physician assistants or neonatal physician assistants, for instance."
Change to the current health care paradigm will certainly result in pushback from some doctors, says Dr. Sanfilippo. However, he believes the changes will eventually be embraced once doctors realize they will get more time to concentrate on what they were trained best to handle. He concludes, "The initial resistance by doctors in the 1960s to physician assistants soon evolved to making them accepted members of a more diverse care team." Sanfilippo believes that as increasing knowledge and technology make health care delivery much more complex, "expanding the breadth and depth of the health care team will improve quality, access, and cost effectiveness-major goals everyone has for health reform."