Improving Accountability for the Public Investment in Health Profession Education: Title and subTitle BreakIt's Time to Try Health Workforce Planning

There is widespread discontent with today's health workforce and its training pipeline. Patients cannot find primary care physicians who are accepting new patients and have difficulty navigating care that is fragmented over increasingly specialized clinicians. Some organizations warn that there will soon be a large gap in the number of physicians required to meet projected increases in patient utilization.¹ Others point out that clinicians are ineffectively and inefficiently deployed across regions and predict that increases in the number of physicians will lead to an increase in expensive and marginally useful services that fail to improve health outcomes.² The primary care workforce has been depleted by a shift of generalists to specialist, hospitalist, and emergency department services; little relief should be expected from the youngest physicians, who have a declining interest in primary care.³ Attention of workforce planners to the role of nonphysician clinicians is perfunctory even as the numbers and autonomy of nurses and physician assistants increase. Programs demonstrated to be highly effective in attracting physicians to care for underserved populations remain underfunded.^{4 - 5} Little progress has been made in improving racial and cultural diversity in clinicians, and many programs charged with doing so have been eliminated.⁶

Just as nature abhors a vacuum, so does public policy. The troubled health workforce does not reflect misguided public policy but a near absence of policy. In the policy vacuum, outdated workforce programs are coupled with entrenched professional self-interests and political inertia to hinder desperately needed change.

Three articles in this issue of JAMA demonstrate the consequences of the workforce policy vacuum. Hauer and colleagues⁷ queried more than a thousand fourth-year medical students at 11 US medical schools about their decision making regarding internal medicine as a specialty choice. The study's most startling finding is that only 2% of the students planned a career in primary care internal medicine and that only 19% reported that the attractiveness of a career in general internal medicine was favorably influenced by their core medicine clerkship. Although international medical graduates can help fill the primary care training positions, the lack of interest by US medical students in primary care should sound warning bells for health systems and the already tenuous safety net.

The analysis by Ebell⁸ confirms his 1989 study⁹ and the view that “white follows green”¹⁰ by demonstrating a persistent strong correlation between US medical students' specialty choice and the overall mean salaries of those specialties. Only those with an uncritical trust in the medical markets will accept that the salaries paid to orthopedic surgeons, radiologists, and otolaryngologists signal their greater importance to patients than general internists, pediatricians, and family practitioners. Ironically, while these powerful economic forces are allowed to dictate the shape of the health workforce with minimal public influence, there are calls to increase the public subsidization of medical education.¹

The study by Salsberg and colleagues¹¹ tracks the changes in numbers of graduate medical education (GME) trainees during the past decade, a period when Congress constrained the increases in Medicare GME funds. After the 1997 Balanced Budget Act, increases in GME positions paused for 5 years and then resumed an upward direction. During 2002 to 2007, new physician GME entrants increased by 7.6%, with the largest relative increases occurring in nuclear medicine, neurology, plastic surgery, otolaryngology, and neurological surgery. The percentage of all residents likely to practice in primary care decreased from 28% to 24%.

These changes did not occur by conscious public design. In today's policy vacuum, workforce “planning” is the collective decisions of hundreds of teaching hospitals—to downsize the number of family medicine residents, to start a new otolaryngology program, or to expand the size of internal medicine subspecialty fellowships. Teaching hospitals do not have the necessary information and have never been charged with calibrating their training programs' size and specialties to public health or health system goals. Instead, decisions reflect institutional priorities, and patients are left with a workforce increasingly differentiated into terminal subspecialties.

Most other developed countries view public planning of the clinical workforce as an essential partner to the public funds that pay for medical education.¹² For example, public guidance joined together with market forces are essential to the functioning of the health care systems and medical education in both England and Germany. Planning in England's National Health Service (NHS) begins with identifying patient needs, followed by setting targets for staffing and training. The planning process is highly centralized with decisions about the clinician staffing of the NHS directly linked to the funding of medical schools and to postgraduate training positions.¹³ Although Germany has a more complex mixture of physician employment and payment, funding of health services is also publicly guided. Similarly, public policy strongly directs medical education, including medical education curriculum.¹⁴ This coupling of public medical education funding and workforce planning tempers medical school and hospital interests with broader perspectives about the numbers of physicians and specialties needed in the future. The results are never perfect, but when workforce policy in European countries misses the mark, new policies can be more quickly implemented than in the United States.

In the United States, the primary public body concerned with the medical workforce is the Council on Graduate Medical Education (COGME), which has served as the principal advisor to Congress on the physician workforce for 22 years.¹⁵ During that time, COGME has issued 19 reports that have discussed the full range of physician workforce issues with little visible impact on medical training. The most recent report from COGME raises its own concerns about the current policy structure and argues for greater GME oversight: “ . . . COGME recommends that the public good GME represents should be made explicit, accountable, and subject to regular and rigorous evaluation and management.”¹⁶ Recently the Association of Academic Health Centers has called for “establishment of an inclusive planning body to create a national workforce agenda and promote a sound national health workforce policy.”¹⁷

COGME limitations should be understood so that they are not repeated. COGME policy brief is limited to physicians and primarily to GME. There is no explicit charge to coordinate with other federal bodies concerned with clinical workforce, such as the National Advisory Council on Nurse Education and Practice and the Advisory Committee on Training in Primary Care Medicine and Dentistry. The composition of COGME is entirely physicians, largely from teaching hospitals, without meaningful representation of patient, public health, and delivery system stakeholders. The authorization for COGME expired in 2002 and its budget is currently at the discretion and the political influence of the Secretary of Health and Human Services.¹⁸ COGME relies on the Health Resources and Services Administration for staff support, although its expertise in the health workforce has almost vanished with the elimination of the National Center for Health Workforce Information and Analysis and federally funded regional workforce centers. In contrast, the Medicare Policy Advisory Council has robust staff support with 19 analysts to assist it in formulating its recommendations.

Major reform of the US health care system is once again on the political agenda. Successful reform will require more effective workforce planning. The United States should establish a permanent health workforce commission that can help overcome the current limitations of health professions training. Five principles should guide the commission's charter. First, the public interest in the workforce should be articulated. What should be expected for the national investment in the health workforce? The specific aims should be to craft evidence-based policy that improves access to care, quality of care, health outcomes, and the affordability of care.

Second, the membership of the commission should be broad and include experts in public health, patient-centered care, and epidemiology, as well as clinicians, consumers, innovative and efficient health systems, payers, and medical educators. Third, the commission should consider policy related to health clinicians of all types. Workforce planning requires inclusive consideration of clinicians required to meet patient needs.

Fourth, an evidence-based approach to workforce policy formulation requires a dedicated staff to develop the expertise for evaluating the workforce and the likely effect of policy recommendations. This staff needs to engage with health services researchers who are independent of the analytic groups of professional societies and trade associations that are potentially conflicted by changes in workforce policy.¹⁹ Fifth, Congress should provide the commission with an increasing degree of regulatory responsibility that insulates reform from the self-interests of training programs and clinicians.

The expected argument against accountability is that it is wiser to allow market forces to decide the fundamental questions of workforce size and composition. However, doing so practically assures maintaining the status quo. It is unreasonable to expect that market forces will self-organize an effective health workforce. It is time to try public health workforce planning.