It's hard to change things we do by rote. It's hard to think about things with which we are so familiar. It takes a tsunami, Japanese for a cataclysmic wrenching of the earth which produces a monumental and destructive wall of water, to get our attention and to set the stage for change.
The tsunami in health care is a generation of "baby boomers". Current generations in care or about to be in care are: The Silent Generation: born 1925 to 1942 and 63 million strong; Baby Boomers: born 1943 to 1961 and 77 million. The fore mentioned will/are cared for by Generation "X"; born 1962 to 1981, 44 million strong and Generation "Y"; born 1982 to 1998, 70 million. Baby Boomer characteristics: outlook - optimistic; work ethic - driven; view of authority - challenge; view of leadership - pay your dues; relationships - personal gratification; work/leisure balance - control freaks. Generation "X" characteristics: outlook - skeptical; work ethic - free agent; view of authority - unimpressed; view of leadership - competence; relationships - reluctant to commit; work/leisure balance - want it now. How the above translates into the education/training of a health care work force is all in the mix in the dialogue on health care reform. Distilled down to a sound bite at a recent health care conference: The health care industry is facing a high demand for health care, but a reduced and part time work force.
Almost 30 years ago, there were academic and government studies (including those of the Government Accounting Office- the watchdog and advisor to Congress) that showed there were going to be too many physicians and that Congress needed to act to restrict the number of medical schools and eliminate the immigration of Foreign Medical Graduates. Congress dutifully enacted such enabling legislation. A funny thing happened on the way to the fruition of that legislation. By 2017, there will not be enough doctors (short by 250,000), enough nurses, respiratory therapists, pharmacists, health aides, etc., etc., etc. How did this happen that there was such a miscalculation? Very easy it seems. One only has to have the power to control information, to convene a group of like-minded academics, who have a particular agenda (ala Hillary Clinton's efforts into health care reform, or the GAO taking surrogate markers for physicians practicing "defensive" medicine and telling Congress and the American public that such practice behavior represents less than 3% of the health care dollar), sprinkle in some media bias (money grubbing doctors, ie, numerically more Ear, Nose and Throat doctors leads to more tonsillectomies and ear tubes inserted) that the supply of doctors needed to be reduced, AND, used data of past performance of doctors, to project future needs.
Well my friends, if you cherry-pick your data, you can have it say anything you want, garbage in/ garbage out. If you don't have a mechanism in place to revise your assumptions as you go along, then you get institutionalization of ideas (read: politically correct), freeze health at an antiquated level, and the justification for such rigidity: "evidenced based medicine", no longer funding research that might produce a contrary opinion. An aside: CardioPulmonary Resuscitation for adults has been fixated and institutionalized as requiring a precise ratio of chest compressions and mouth breaths. 25 years ago, a large study in Seattle Washington demonstrated that ONLY chest compressions by a witnessing bystander lead to a desired patient outcome, walking out the hospital door retaining all previous faculties. Just last week, a news flash from a conference of the American Heart Association: mouth breathing and chest compressions are no better than chest compression alone. It seems the driving force for going back to the older data was the fact that most witnessing bystanders do not do mouth breathing and chest compressions, instead, they tend to either do just chest compressions, or worse still do NOTHING at all. Those witnessing bystanders who do just chest compressions, have the same outcome as waiting for EMT's who do both mouth to mouth resuscitation and coordinated chest compressions. 25 years of witnessed sudden cardiac event, and reluctant witnessing bystanders. Who would be alive and well today if the original data lead to revision of community education with a less disagreeable and simplified rescue process instituted?
Social contracts and priorities are contributing to the anticipated shortfall in health care workers. To encourage diversity in our physician work force, women and minorities have been courted to apply to medical school. What wasn't counted upon, those who graduate from medical school and finish residencies, that women would work 0.5 of a full time equivalent, instead of the the 0.9 FTE originally calculated as had been in the past. To recruit and retain minorities, medical schools have to provide an extended curriculum, and now, residencies are being asked to provide an extended residency experience. Instead of 3 years of Family Practice training, residency programs are being asked to extend up to 6 years of training. Many of current residents believe that more time away from training, will make for a better life style; they do not want to extend the time in residency though. The reality though is that some of the changes needed will be to address a more gradual educational experience, as well as to accommodate future physicians focusing on their life style, a more intermittent training schedule. Of the many unknowns with these changes, is what will be the loss of knowledge, skills, and professionalism during the time the person is out of the educational system. What changes in medical school curriculum and residency training are needed to bring people up to speed after their absence? When does the clock start ticking on their undergraduate and medical school loans? The medical educational system is based upon "bedside teaching": mentor and student side-by-side with the patient, using inquiry, examination, discussion, and implementation. There is role-modeling of professionalism: principle of patient welfare, principle of patient autonomy (Physician as an advisor), principle of social justice. Professionalism was the number one physician characteristic that health care consumers wanted in their physician. Even when on the consumer list of questions, physician life style was not a patient priority.
Oh by the way, these are not just the musings of a retired physician looking back at the good old days, rather, the conference I attended yesterday: MSU, "Health Care Policy and Issues:" Healthcare Legislative and Advocacy Training, Health Care Reform 2008, Physician Supply, Fiscal and Health Care Challenges (GAO), Physicians and Public Health, Health Information in the 21st Century. On April 15th I will be presenting my experiences of serving an indigent population at "Care Free" to the Ingham County Medical Society General Membership Meeting. And, May 2 - 4th, I am a Delegate at the Michigan State Medical Society House of Delegates, my committee assignment: Legislative Actions.
The cataclysmic event has already occurred with the birth of the Baby Boomers. The tsunami is already at the shore. Generation "X" are the immediate pending caregivers. Even graduating more physicians as well as other health care providers, the large number of care givers wanting a "balanced life style and work experience" means that there would need to be a doubling of the medical school graduates, just to maintain the present already expected physician shortfall.
What about physician extenders you ask? Nurse Practitioners? Physician Assistants? At the conference a representative from Michigan Public Health suggested, "why not do like China did during the "Cultural Revolution" and train "barefoot doctors"? People who would deliver traditional Chinese medicine (does anyone know what traditional Chinese medicine is?) In spite of nursing schools going to state legislators to expand the scope of practice for nurse practitioners so that they can provide care without a connection to a physician, the nursing schools stating that nurse practitioners would deliver care to the under served, rural and inner city, the location of the current 3 decades of graduates of Wayne State, Univ of Mich, MSU College of Nursing, all practice in Suburban locations, where the hours are fixed, the income guaranteed, and no/limited night call. Physician Assistant providers came about after the Vietnam War, when military corpsman, who had an enormous amount of clinical experience, but no formal educational training, left the military but wanted to continue in health care. Hence, the inauguration of 3 year Physician Assistant's education programs. One of the participants in the conference, director of training for Grand Valley State University Physician Assistants program, stated that the current incoming students, have NO clinical experience. Even after 3 years of formal PA training, those physicians who hire graduating PAs, will need to provide significantly more mentoring and supervision than they currently do, before a PA can work in a clinical situation.
How all of this will play out in the future is unknown. But, platitudes, and politically correct statements as you currently hear, are not sufficiently informative to effect meaningful change. In my view, in addition to expanding the health care work force, patients and families will be more accountable and provide for their own health care, and as a nation, re-investment into public health and preventative health practices are a viable strategy.
We have to remember the lessons of the past, that we have to have in place mechanisms to alter our course of action when new information becomes available. Just like the current sensationalism of "obesity": The data says, those who are over weight, BMI 26-30 live the longest; those with "normal" and desired BMI 19.5 to 25 live the SAME length of life as those with BMI 31-35. The new data says, no matter what your BMI, no matter what your medical complications are, diabetes, hypertension, heart disease, no matter what your family history, the best predictor of longevity, is what is your level of physical fitness. Escalating levels of fitness (as measured by METs an exercise calibrated test), lead to escalations in survival. Therefore, instead of channeling our energies into getting McDonalds to change their French Fries, maybe we should promote more walkable city planning (like Meridian Township Planning Commission attempts to do). Much less sexy, a lot less media hype and TV sound bites, but probably more in keeping with the data.
