The Stressed and Strained Health Care Workforce

The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense – particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations – either in terms of funding or which actions should be done first.

In addition, while the report recognizes that the elderly in the coming decades will be healthier than those of 20 or 30 years ago, it doesn’t seem to fully address how this will change the healthcare services needed by the future elderly.

It seems to me, that one of the major challenges facing the healthcare system of the future is how to better manage chronic conditions – regardless of the patient’s age. Thus, rather than retrain clinicians (or train more caregivers) in geriatrics, there needs to be more across the board efforts in chronic care management and coordination among all levels of caregivers. This would benefit the growing elderly population – many, but not all of whom will have multiple chronic conditions – as well as the non-elderly with chronic diseases like diabetes, and the many neuromuscular degenerative diseases like MS or rheumatoid arthritis. This type of system-wide transformation seems like a better use of resources than segmental/specialized retraining and recruitment.

What are your thoughts?

2 thoughts on “The Stressed and Strained Health Care Workforce

  1. Stuart – Thanks for the great comments. I agree that clinicians of all levels who are under-trained – or practice beyond their capabilities – raise significant quality concerns. I do think that some technologies will help form better functioning teams of clinicians that will enable those who are highly specialized to focus on the most complex or unusual cases, while other clinicians help patients address more routine matters. This will increase efficiency, and should make both clinicians and patients lives better.

    Last year I worked on a project concerning a technology for remote monitoring and management of intensive care unit patients that demonstrated this concept. The technology promoted the integration of the teams via better and more effective communications, so that more experienced clinicians (both physicians and nurses with extensive ICU training and experience), could assist those with less training and experience, e.g. residents, non-intensivist physicians at community hospital ICUs, and less experienced nurses. This communication and collaboration helped extend the clinical value of the experienced clinicians across a larger number of ICUs and clinicians who benefited from their knowledge – and the data shows that patients received significant benefits, and costs were reduced as well.

  2. Coordination among clinicians is clearly a necessity, but one major problem in the system currently is the erosion of medical school as a requirement for those who would diagnose and directly treat medical illness. I’ve observed an increasing number of patients coming to see me for treatment of psychiatric and addictive illnesses that have worsened with treatment received from those other than physicians. I’m not blind to the fact that some physicians lack sufficient expertise to handle certain illnesses, and there’s much we can do to improve medical education and physician communication. But adding non-physicians to the mix has made this existing issue far worse. I’ve seen alcoholics treated with sedative-hypnotics, destroying their sobriety and resulting in relapse; those with depressive illnesses given multiple medications simultaneously resulting in a host of side-effects and recurrent symptoms of their disease; those with anxiety treated for extended periods of time with benzodiazepines resulting in rebound insomnia and worsening anxiety; etc. I have yet to meet an RN who decided to attend medical school afterward state that nurses without a medical degree should be diagnosing/treating illness without direct supervision by a physician.

    If I were to be a passenger in a commercial airline, I would not want a non-pilot flying the plane even if supervised and given superficial training as to how to fly. I’d want a real pilot up front. Similarly, if I want healthcare for a chronic illness, I want a physician directly providing the care, not someone else who has never attended medical school, especially since what passes for “supervision” is generally little more than a quick signature on dozens of presented charts.

    I’m aware that there are insufficient physicians, particularly specialists, but one cannot replace 4 years of med school, 4 years of specialty training, and a fellowship or two with a year or two of apprenticeship or other training. Much is lost in that translation.

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