By Erik K. Alexander, MD
Author is a member of our Clinician Nexus Advisory Group
The United States spends more per capita on health care than all other countries in the world.
While the resulting care is quite often outstanding and embraces cutting-edge breakthroughs, it can also vary widely as so many social determinants of good health are overlooked.
Of the many factors influencing the optimization of U.S. healthcare delivery, the most vulnerable is perhaps the health care workforce itself – the pressures over the last ten (and particularly last five) years have been profound. We simply don’t have enough health care workers to provide the level of care Americans expect and desire.
Understanding our physician workforce exemplifies this issue. Despite an abundance of outstanding and available post-baccalaureate candidates, acceptance rates for any applicants into medical school stands below 50%. Paradoxically, graduate medical education (GME) training needs – such as interns, resident physicians, and clinical fellows – far outpaces the number of graduating medical students. This requires about 25% of available GME training spots to be filled by non-US graduates.
Even when full physician training is complete, the U.S. still finds itself short of physicians in numerous specialties such as primary care, psychiatry, obstetrics and pediatrics. In short, our system lacks the ability to harness the vast interest in the medical field evident in our younger generation to meet our demands despite survey after survey confirming that US citizens desire improved medical access and care.
The workforce pressures on other clinical roles are equally high – yet manifest themselves in different ways. Nurses and advanced practice providers play critically important roles in health care delivery. When turnover is high and individuals move from organization to organization, it can be very costly and disruptive. This has been particularly notable through the COVID-19 pandemic as these clinicians have increasingly gained influence to modify their hours, working conditions, and pay. Similar trends are occurring with a myriad of other roles as well – including speech pathologists, laboratory technicians, surgical assistants, and more.
The reasons for this are many and simply beyond the scope of this article. But regardless of cause, such pressures will ebb and flow ahead but will not go away. They will likely change the US health care system and its workforce training process as we move forward.
There are three paradigms likely to gain traction in the years ahead:
1. Educate to Hire
Medical training involves graded access and entrustability in the clinical environment. Learners are initially closely watched and taught with greater oversight, but over time gain skills that demonstrate growing abilities. And with such expanding ability comes greater affordances to participate in clinical care with less supervision. Indeed, through this process of teaching and learning, the faculty and the hospital system quickly understand which trainees are moving along the educational continuum as expected and which trainees embrace the clinical and professional standards of the institution itself. Assessments of such learners – whether formal or informal – are far more durable given the duration and repetition of oversight. Thus, it is likely that medical centers and other health care institutions will increasingly rely on their own education tracks to attract, retain and expand their clinical workforce. Accurate and reliable data on learners will be critical, and such metrics and processes have vastly improved over the last decade.
2. Competency-Based Assessment
Physician training is a long endeavor. It takes 8-12 years after college graduation before a physician is independent and fully licensed. The process has lengthened throughout the last several years as medical school admissions have toughened and advanced specialty training has increased. In contrast to a generation ago, many physicians are still training into their late 30s or beyond. And as greater personal demands, desires, and significant life choices come hand in hand with aging – perhaps none bigger than the desire for children and balanced work schedules – many believe that the current physician training paradigm is simply not sustainable and may diminish interest in the field moving forward. The solution likely lies in a shift toward competency-based advancement in training as opposed to time-based advancement. Instead of a set four years for medical school or three to seven years for GME training (pending specialty), the idea that competency can be reliably assessed is taking hold. Some medical students may be ready for internship after three years of medical school rather than the traditional four. Conversely, some students may require five years. Embracing individual competencies and allowing ‘promotion in place’ will become a major factor as organizations look to build a more sustainable pipeline of talent.
3. Rethinking the Financial Complexities
With such as long runway for completing physician training, medical school debt can become overwhelming and unpayable for many doctors. With a dramatic increase in the number of physician extenders and allied health professionals, salary comparisons between these roles and that of residents and fellows are increasingly common. Issues such as these have stimulated notable financial changes now rippling through the physician training process. Notably, many medical schools are trying to limit debt – with some even going tuition-free for all attendees. Separately, salary and benefits for graduate medical trainees are increasing. These forces will continue to be important in shaping the future of our physician workforce ahead.
Conclusion
Together, these three paradigm shifts begin to exemplify some of the important forces at play that will inevitably impact our physician workforce well into the future. Medical schools, GME-based training programs, and hospitals alike will be forced to adapt to this ‘new normal’ stay ahead of the curve. While being a physician is one of the most wonderful of professions, we must continue to attract a strong pipeline of trainees in order to keep the system afloat.