Response to the 2011 Question of the Year
The rapidly expanding U.S. population will result in a critical shortage of physicians for both routine and specialized health care. Evidence of underserved areas, by both geographic region and medical specialty, is widespread.1 Other factors contributing to the looming doctor shortage are the cost of medical education, the diversification of medical specialties, the changing demographics of the workforce, the altered career goals with part-time employment, shortened careers, the administrative requirements, and the physician quotas established by specialty societies. The consequences of a doctor shortage are delays in health services, a focus on acute care rather than prevention, and decreased competition with increased health care costs. Although an obvious solution is the training of more physicians, resources are not forthcoming with the current budget deficits and a weakened U.S. economy.
Market forces have already begun to fill the void, with ever-increasing participation by a nonphysician workforce that includes nurses,2 physician assistants, pharmacists, chiropractors, psychologists, audiologists, and practitioners of alternative/complementary medicine. Although many physicians see this as an alarming trend, it is inevitable that physicians will constitute a smaller proportion of the health care workforce in the future. Nonphysicians already provide comparable care for many routine health problems (well visits, routine childbirth, hearing loss, sports injuries, etc.) at reduced cost without substantive changes in quality.
The era of “one patient, one doctor” is coming to an end, and so today's trainees will practice in collaborative teams rather than individually. The shift toward team-based medical care is driven in part by an exploding knowledge base and a realization that a team-based model results in better outcomes for patients, especially those with chronic or complex diseases. Evidence-based medicine will result in the standardized management of some chronic conditions, such as hypertension and adult-onset diabetes mellitus, further ensuring consistent quality. In such a model, the physician assumes the role of team leader, managing the activities of multiple physicians and other health care providers. The physician is a facilitator and communicator and must make decisions about the allocation of health care resources, evaluate the evidence for best practices, and monitor quality of care.
The limits of medical education must be redefined as physicians become a more limited resource. The next generation of physicians will need to have an expanded skill set that borrows from the curricula of other disciplines, specifically training in business practices. Executive training provides the necessary leadership skills and fosters strategic thinking. Knowledge of health care economics is important for optimal utilization of limited resources and alignment of health care practices with business principles. An understanding of process control in industry can be applied to maximizing the efficiency of health care dollars and to monitoring outcomes with enhanced quality of care. Training in human resources provides the people skills necessary to manage a team and communicate effectively with a diverse patient population. Decision modeling results in a more analytical approach to complex decisions and the incorporation of factors (quality of life, risk valuation) that are important to patients. Service marketing teaches a patient-oriented approach that maintains focus on the patient (consumer) rather than on the profit. A business school approach fosters a “big picture” mentality that challenges physicians to think about the societal issues of health care that have widespread benefits.
Physicians need to embrace the new health care workforce and harness their capabilities to provide services that do not require the prolonged training and expertise of a physician. Rather, physicians should manage health care teams while continuing to provide highly technical aspects of medical and surgical care. Although many medical schools offer opportunities for combined MD-MBA degrees, realignment of teaching goals will be required to integrate these concepts throughout the curriculum in medical school as well as residency for all trainees.
The full benefits of such a model will not be apparent for years. Early benefits, however, include reduced costs of care, increased availability of health care, improved quality, and a focus on wellness rather than disease management. Long-term benefits include increased involvement of physicians in all aspects of health care administration, with younger physicians leading changes in health care delivery.
2 Fairman JA, Rowe JW, Hassmiller S, Shalala D. Broadening the scope of nursing practice. N Engl J Med. 2011;364:193–198.