Transformation and the Health Care Workforce

By Shana Sandberg

Recent news reports of record numbers of applicants and enrollees at the nation’s medical schools have drawn attention to the future physician workforce. But questions remain as to whether the United States will have enough physicians to fill shortages exacerbated by the expansion of insurance coverage and by an aging population that increasingly suffers from chronic disease. Can transformations in training, payment, and care delivery help to solve our growing health care needs?

Over November and December, Health Affairs and Academic Medicine have partnered to produce special issues highlighting key workforce issues at stake within academic medical centers and beyond. While a comprehensive discussion of all the articles is impossible—together there are more than 50—it’s useful to reflect on some of the themes that run throughout. Academic medicine should respond wholeheartedly.

Straddling research and clinical practice, the academic medicine community is in a unique position to play a larger role in documenting, measuring, and assessing the way that transformations in health care payment and delivery today will affect our workforce needs tomorrow. As summed up by one commentator in the current issue of Health Affairs, “Workforce policy needs to be grounded in an understanding of how practice is changing in the trenches.”

Academic Medicine’s December collection on Training the Future Health Care Workforce addresses the critical role that medical schools play. Articles explore state patterns in medical school expansion, whether the expanded schools are likely to fill workforce needs, and the role of school culture in primary care specialty choice, among other topics. A commentary co-authored by AAMC President Darrell G. Kirch, MD, and others argues that medical school admissions should be a key component of health care reform because it entails selection of those who will form the future physicians who will work with others to carry out transformations in care.

While the spread of team-based care, telemedicine, and other delivery transformations has caused some to question whether we really need as many doctors and nurses as we think, another perspective piece cautions against making projections based on an “ideal system” of care that has not yet fully materialized; rather, the authors advise basing future projections on current needs and then adjusting over time.

The November Health Affairs issue on Redesigning the Health Care Workforce focuses primarily on practice redesign and its potential to alleviate shortages. A set of articles addresses debates about what a redesigned workforce would entail, including greater roles for physician assistants and nurse practitioners, behavioral health providers, pharmacists, and technology.

A piece that should spur more thinking at academic medical centers argues that training and education should more closely align with the actual delivery of care—and this seems to be equally true for medical students and residents and for physicians, nurses, and others who make up the current workforce.

Another debate centers on what workforce capacity gains can be made through redesigning care. One analysis and commentary piece urges workforce scholars to take into account increasing demands on the system in making projections, while several other pieces demonstrate the way that reducing waste and improving the efficiency of care can increase capacity, at least in primary care.

Ultimately, the articles in both issues demand further thinking about how transformations in care delivery are changing our workforce needs, and the role academic medicine can play in meeting these needs. As with most difficult problems, the best answer probably does not align neatly with one ideological side or the other, but lies somewhere in the middle—that is, we will need to train more doctors and explore ways to continue transforming care in order to improve access and make delivery more efficient. As Rob Cunningham, previous deputy editor at Health Affairs and author of a recent National Health Policy Forum issue brief on health workforce needs, wrote:

Some argue there are too few providers already; others say our current supply–demand problems lie with efficiency. But suppose both are correct? Perhaps the real challenge is to understand how physician practices are changing in response to market forces such as payment changes, provider distributions, and technology innovations.”

Thus, there is far more work to be done. Assessing how best to measure our future workforce needs and which models demonstrate concrete evidence of meeting those needs must become a national priority. No community is better equipped to lead in this endeavor than the community of clinicians and researchers who compose academic medicine.

Sandberg Photo 2012.10.02Shana F. Sandberg, Ph.D., is a researcher in the Center for Workforce Studies at the Association of American Medical Colleges.  Her recent work includes examining the effects of medical school expansion and trends in care delivery and payment reform on the health care workforce.  She can be reached at and @shanacws.