US medical training must adapt to reflect modern needs, say workforce planners

BMJ 2010; 341 doi: (Published 17 November 2010) Cite this as: BMJ 2010;341:c6566
  1. Bob Roehr
  1. 1Washington, DC

Increasing the number of doctors will not by itself be enough to assure the quality of healthcare in the United States, a workforce expert has said. Also needed will be a change in the roles of supporting workers to meet the evolving healthcare environment.

Edward Salsberg, director of the National Center for Workforce Analysis within the US Department of Health and Human Services, was speaking at a briefing on the medical workforce held for congressional staff members on 15 November.

Thomas Ricketts, a health policy analyst at the University of North Carolina School of Medicine, said that healthcare reform legislation enacted in early 2010 “mainly reauthorised a lot of existing programmes” for training healthcare providers. It did so in a way “that did not reflect very much on their past performance.” While many of the programmes seem to work well, he said, “we don’t know which ones work best and which ones we might get rid of or deal with in a different way.”

He said that certain areas of medicine, such as trauma care and transplantation, have embraced a multidisciplinary approach of coordination and integration of care “for which we are able to show excellent outcomes and impact—and they are implemented in a cost conscious way.”

Dr Ricketts told the BMJ that the technical demands and need for coordination in these fields are unusual in medicine. Another factor is that they generally are not covered by traditional reimbursement. “Part of it is the sociology [of those teams], and it hasn’t crept out into politics—it is very professionally dominated right now.”

However, he doubts that many of these lessons can be transferred to primary care, “because it is such a different beast.” He added, “It [primary care] is real retail medicine, and there are great inefficiencies in retail. But it is what people are demanding more of.”

Jay Crosson, a senior health policy executive with the large health maintenance organisation Kaiser Permanente, said that the federal government’s Medicare health insurance programme for people aged over 65 years is the largest payer of doctors’ education in the US. It contributes $9.5bn (£6bn; €7bn) a year.

The Medicare Payment Advisory Commission issued a report on medical education in June 2010. It focused on areas such as whether hospital based training is as relevant today as it used to be, now that medicine is moving increasingly to outpatient delivery of care by primary care doctors. It also looked at the balance of specialists and family doctors in light of the particular shortage of the second group and at the need to shift from the current fee for service method of reimbursement.

Kaiser Permanente surveyed its own supervising doctors about recent graduates it has hired. Dr Crosson said that although the general quality of new graduates was seen as excellent, the survey found that “they often lacked basic office practice skills.” About a third of supervisors said that new graduates were often poor at coordinating care, particularly for patients with chronic diseases, and that two thirds needed better preparation in continuity of care.

The panellists at the briefing acknowledged that it will be difficult to change the current system of training doctors and other healthcare personnel but that it must be done to meet the need for more capable primary care doctors who will manage the growing burden of chronic diseases and complex interventions.


Cite this as: BMJ 2010;341:c6566

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