There is a growing chorus of calls for enlarging the size and number of the health schools of the nation. For three reasons we should give these calls special attention. First, the size of the US population will grow by over 40% by 2050, and during that time it will diversify to such an extent that many areas will be non-majority. Second, and more immediate, as the current population ages it will likely demand more care services which will put more pressure on a system that's already overtaxed. Finally, this aging population contains many health professionals of the Baby Boom generation who will soon begin to leave or slow down their practice, which will change the way care has traditionally been provided.
Before we rush to build new schools or training programs we should ask some even more fundamental questions such as, does the current system of care serve the nation's interest in terms of patient safety, quality of outcome, cost of care and access to care? If it doesn't, and if no one can conscientiously make the case that it does, then perhaps we should use the impending demand for growth to redirect the system in order to resolve some of these concerns.
The first question to ask is whether or not this issue has the same characteristics across all of the major health professions. For this discussion I will focus on selected allied health disciplines, dentistry, medicine, nursing and pharmacy. The size of the professional training programs in allopathic medicine have remained fairly constant, growing only about 3.5% from 1990 to 2004-2005, when a little over 67,000 students enrolled in 125 accredited schools. Osteopathic medicine has grown considerably since 1990, with the total class size almost doubling from about 6,600 to over 12,000 today and the number of schools growing from 15 to 20. The number of residency training positions in allopathic medicine, after remaining static for most of the 1990s, has modestly increased in the past five years. Dentistry and pharmacy have shown growth rates in the size of their student body of 14 and 47 percent respectively over the past fourteen years. Nursing education experienced a severe drop in demand between 1995 and 2001, with the number of first-time US candidates sitting for the national examination falling almost 29%. By 2004, about two-thirds of that loss had been recovered and the number of graduates sitting for the exam was approaching its 1995 level, though 160,000 RNs would be missing from future service before the drop in enrollment had been made. For allied health, there have been significant declines in the size and number of training programs in most disciplines, leading to shortfalls and high vacancy rates in critical areas of laboratory medicine, respiratory, and radiation therapy. Clearly the mandate for growth is not equal across the professions, and priority should be given to nursing and allied health where the problem seems the most severe.
The second question is whether or not we are getting the most out of the practitioners we currently have. This question is complex but is most heavily dependant on the education, regulatory and financing policies and practices that come together to create practice models. Clearly there is a great range in the patterns of use of practitioners. The gross numbers point to a pattern in medicine; in 2002 Idaho got by with 171 physicians per 100,000 residents while Massachusetts and Illinois had 427 and 265 respectively. Either the good citizens in Idaho are under-doctored or those in Massachusetts are over. After twenty years of experimenting with systems of care and more effective management of care it is probably time that we critically examine the substitution of other practitioners and technology as a way of addressing perceived shortfalls or mal-distribution before expensive new capacity is built. For instance, how far could existing resources be extended by substituting nurse midwives for obstetricians or ensuring that family physicians had admitting privileges for obstetrical care. What if primary care medicine was better integrated with specialty care so that patients received more care in the same location provided by a team of clinicians, not separate individuals? In pharmacy, how might the existing resource of pharmacists be stretched if we used robotic and information technology more extensively to deliver drug products, expand the functions of pharmacy technicians for more mechanical tasks, and reserve pharmacists for more interaction with other professionals and patients? These are of course complex questions that involve professional prerogatives, income, education, and tradition. Change will not come easily, but the task of improving the use of the existing resources before new capacity is built is imperative.
Finally, as we think about needed changes it is important that we focus in areas of emergent demand, not just general professional growth. For instance, much of the need in oral health care today and in the future is with underserved populations such as the elderly, the disabled, and within certain urban and rural settings. To get care to these populations perhaps the growth in positions for training new dentists should ensure that more of this new cohort will be prepared to take on this challenge. Similarly, most of the arguments for new physicians are driven by the specter of the needs of an aging population. If medicine grows perhaps it should be in those specialty areas that are positioned to respond to the needs of the aging population in a primary or basic manner.
Such focus of growth traditionally goes against the grain of independence in the education and professional bodies that govern them. However, with the continued costly dysfunction of the US health care system, perhaps it is time that we ask what is in the public's interest before we ask for more public dollars.