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The Business of Hospitalists


 

In March 2005, the Association of American Medical Colleges announced that America will face a shortage of between 85,000 and 200,000 physicians by 2020. The U.S. population is growing faster than the number of new physicians entering the workforce. How big the shortfall will be has been argued since last year, but most pundits expect there to be too few physicians—in total—to take care of the burgeoning population, especially the elderly.

If a shortage of physicians is to be anticipated, what effect might this have on hospitals and hospitalists?

Where Does the Number Come From?

The debate about the range of the projected shortfall of 85,000 to 200,000 physicians reflects several differing assumptions. All estimates are based on the ratio of physicians to the overall population. Different estimates are based on distinctive models for the necessary staffing of the medical enterprise. For example, prepaid medical groups that serve large populations of patients (e.g., Kaiser Permanente) have physician-per-capita ratios of up to 20% less than fee-for-service environments. A larger elderly population will likely demand more medical services per capita. So, the estimate of a shortfall depends on the model of medical care for 2020 anticipated to be predominant in 2020 and a calculation of usage rate per capita for services—again, especially among the elderly.

Work/life balance choices that recent medical school graduates make also add to the uncertainty of predictions concerning the relative size of the shortage in total and by specialty. Young men and women graduating today increasingly express a preference for reduced or more manageable hours of work per week, sometimes opting for shift work or other forms of more predictable workload. There is also an understanding that women physicians tend to work part-time in some stages of their career—especially when they are trying to balance the demands of starting and raising a young family. Many of their male spouses are making similar choices.

The Specialty Nature of the Shortfall

A relative shortfall in available physicians relates to the specialty choice of new residency graduates. From 1996 to 2002, for example, certain specialties experienced increases in the number of applicants to residency programs, such as anesthesiology, dermatology, and radiology; whereas, other specialties saw reduced demand for training slots, such as in family practice and general surgery. For example, U.S. medical school seniors filled 89% of the general surgery residency slots available in 1996, but only 75% of the available slots in 2002.

The relative number of physicians in certain geographies will also be affected by the attractiveness of that particular area of the country or practice location and style, such as rural versus urban or suburban.

Physicians’ retirement rates generate different estimates, too. Currently, 18% of physicians in the United States are older than 65—compared with 12.6% of the overall population. In certain states, the percentage of physicians older than 65 is substantially higher, in some cases more than 20%. Different analysts generate different expectations about how many physicians over age 65 will leave the workforce. The number of hours that doctors practice and their decisions about when they will retire, based on their personal financial circumstances, are quite varied. This makes calculations of the shortfall to be anticipated subject to a variety of interpretations

Substitution

There is a debate also over the question of substitution. If there are too few physicians in the United States, will a shortfall in supply be made up by increasing numbers of foreign medical graduates or by other non-physician practitioners?

New foreign medical graduates may make up perhaps as many as 6,000 positions nationally. This will not make up for the shortfall of between 3,000 and 10,000 per year of additional physicians who need to graduate and enter the workforce.

Substitution by non-physician practitioners will mitigate some of the effects of the shortfall. We can anticipate that the use of nurse practitioners, physician assistants, nurses, and health educators will increase in situations where they can substitute for lower intensity medical care—especially in primary care settings, outpatient environments, and as adjuncts to care delivered by proceduralists and surgeons of many types. This will make some difference in the overall expectation for reduced availability of physicians.

Given all of these inputs, all projections point to a shortage of physicians, but none of the analyses agree on the absolute size.

The Effects of the Shortage

In any event, the projected shortage will affect how hospitals support their various service lines and, thus, will impact on the work performed by hospitalists, intensivists, and other physicians who support that work in hospitals. Hospitals anticipate this effect at the intersection of the shortage with increasing demands for rapid throughput, thorough and safe care for patients, and accountability for clearly specified clinical outcomes. Hospitals are already worrying about how to staff neurosurgery, cardiology, and general surgery positions. Changes in how primary care is delivered will affect where patient referrals come from and hospitals’ relationship with their specialist physicians.

How Will a Shortage Affect Hospitalists?

Increasing demand for services: With fewer physicians choosing general or primary care practice, hospitalists will find increasing demand for their services as coverage for acute care. Fewer primary care physicians will be able to afford the luxury of inpatient practice and gravitate toward highly efficient outpatient office-based practice while referring acute care to their hospitalist colleagues and specialists to pick up the slack for specific procedures, hospital follow-up care and return on discharge.

Hospitalists will be responsible then for a larger population of inpatients, providing for comprehensive care management in coordinating the services for all the care needs of many different types of diagnoses.

Increasing span of influence: In addition, there will be increasing demand by procedure-oriented physicians for hospitalist coverage to improve their efficiency in providing acute specialty care. Some of this demand may spill into single-specialty outpatient and focused freestanding hospital environments. Hospitalists will be pulled to cover specialists, who find their efficiency and the volume of work required prohibits them from providing comprehensive inpatient care for complex patients. They will prefer to focus on procedural interventions. Orthopedic surgery, cardiac surgery, neurosurgery, and cardiology, in particular, are likely to be new clients for hospitalist services.

Increasing emphasis on multidisciplinary care: Given the demand for evidence-based outcomes, hospitalists will provide physician input into clinical care design for a greater variety of patients in an increasing span of clinical service lines. This will put a demand on hospitalists for skills related to teamwork, leadership, and management in group environments. It will also require hospitalists to become broadly knowledgeable about the skills and contributions of all other potential care providers.

The New Medical Staff

The looming physician shortage in the United States will significantly affect the demand for and the variety and scope of work that hospitalists perform. The number of medical specialties dependent on hospitalist services will broaden. And hospitals will turn to hospitalists as their primary medical staff partners, responsible for the majority of medical staff functions and responsibilities. TH

Mike Guthrie, MD, is executive in residence at the University of Colorado (Denver) School of Business, Program in Health Administration, and a faculty member of SHM’s Leadership Academy.

What about the Nurses?

Healthcare Workforce Data shows medical training not keeping pace with population growth

By Larry Beresford

California has more employed registered nurses—211,068—than any other state, but it has the fewest RNs per capita (588 per 100,000 population). That is one of the key findings in a new report, The United States Health Workforce Profile, released last November by the Center for Health Workforce Studies at the University of Albany, N.Y. The highest concentration of America’s 2.4 million RNs employed in nursing is in New Hampshire, with 1,283 per 100,000 people, followed by South Dakota, North Dakota, Massachusetts, and Maine. Arkansas employs the most licensed practical nurses per capita—461 per 100,000 people or 63 for every 100 employed RNs.

The survey also found that Massachusetts has the highest concentration of physicians—303 for every 100,000 people—followed by Maryland, Vermont, Rhode Island, Connecticut, and New York; Mississippi has the lowest. Vermont, Massachusetts, and Maine have the most primary care doctors per capita.

The workforce study used 2004 data from the U.S. Department of Labor’s Bureau of Labor Statistics, the Area Resource File of physician data produced by QRS, Inc., for the U.S. Health Resources and Services Administration, the Division of Nursing’s 2004 National Sample Survey of RNs, and other sources to capture state, regional, and national workforce trends for physicians, nurses, and about two dozen other categories of health providers.

The report tallied 8.5 million health professionals working in health service settings—including hospitals, nursing homes, home health agencies, offices, and clinics—and another 4.1 million working in non-healthcare settings such as schools and insurance offices. Add 4.4 million non-health professionals working in health service settings, and the U.S. health workforce exceeds 17 million—12% of the country’s civilian labor force.

The success of the healthcare system in the United States depends on having sufficient, qualified personnel to provide needed services, and this report offers an array of data to help planners and policymakers understand and address workforce trends, explains Jean Moore, director of the workforce center and one of the report’s authors.

“This report is the view from 30,000 feet,” she says. “It gives you a starting point for drilling down into issues of supply and demand.”

It will be up to state policymakers and health professional groups to interpret the results. “You should do employer demand surveys—who are they having the most trouble recruiting and retaining?” adds Moore.

Although the report does not break out individual medical specialties, focusing only on primary care as a whole the potential for future shortages of physicians in some categories and locales is an important concern. “Understanding physician supply and looking down the road to potential shortages suggests the need to think smart,” says Moore. “If you can’t find enough physicians, can you consider physician extenders? Looking at demographics as our population ages, I think the nature of healthcare will change—with a lot more focus on chronic disease management. But to what extent are we preparing future physicians for this role?”

John Nelson, MD, a hospitalist and consultant in Bellevue, Wash., and a columnist for The Hospitalist, agrees that the role of hospitalists is likely to evolve. “We’ve always said that hospitalists will have to adapt our scope of practice according to the changing demands of the systems we’re part of,” he says. “Workforce shortages in different categories will affect what we do.”

In some facilities, hospitalists would never admit neurosurgery patients, while in other places they do.

Hospital medicine could be considered the fastest growing medical field in history, adds Robert Wachter, MD, head of the hospital medicine service at the University of California-San Francisco. But even if hospital medicine remains a popular career choice for young physicians, overall shortages of primary care physicians could heighten competition with other care settings that need these doctors.

The physician workforce is aging, and medical training is not keeping up with the aging population, Dr. Wachter notes. Variations in geographic distribution are state by state but also occur in urban, suburban, and rural areas within a state. There is not enough organized manpower planning to ameliorate these inequities.

Other results of the workforce study:

  • The average age of working physicians is 50, while 18% are over 65;
  • Currently, 26% of physicians are female, but 49% of today’s medical school graduates are women;
  • Blacks and Hispanics/Latinos are substantially under-represented in both medicine and nursing;
  • Medical schools had 79,000 students enroll in 2004, up slightly from 73,000 in 1987, although most of this growth was in osteopathic medical schools. Graduation rates are not keeping up with population growth;
  • Advanced practice nurses were found in the highest concentration in Alaska, Washington, New Hampshire, and Delaware; and
  • The number of physician assistant degrees awarded grew 1,700% in the past decade to approximately 50,000, with the heaviest concentrations in the Northeast, Alaska, and South Dakota.

View a full copy of the 164-page report at: www.albany.edu/news/pdf_files/U.S._Health_Workforce_Profile_October2006_11-09.pdf.

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