Across most of the health professions, from medicine and dentistry to nursing and allied health, there is a growing chorus calling for increased numbers of professionals. In its policy assessment and recommendations, the Center for the Health Professions has led a number of the calls in these professions. However, before we go headlong into building new campuses, enlarging programs, and attempting to alter the labor market, it is vital to look at how effectively we are using the resources we currently have. Which professions are in need of expansion? Do we want to create new visions for the roles that exist today?
My concern is simple. Let's look at the system we have. It costs more than any other health care system in the world. It now approaches 16% of the gross domestic product and doesn't show signs of slowing its rate of growth. Annually there are 50,000 to 100,000 avoidable deaths and 43 million plus individuals who are uninsured. To say it performs sub-optimally would be an understatement. Both consumers and doctors are reporting dissatisfaction with the system. How can this equation be serving anyone? Why would we want to feed such a system with more workers who have the same old skills, competencies and expectations?
We could grow more and use the opportunity to grow them differently, perhaps even in a radical fashion. As "starving the beast" has become a prevalent and successful public policy and political strategy in the US today, I am tempted to apply it here to new practitioners. The reality however, is that advocating for expanding professional education will most likely be met with rhetorical, if not, budgetary support from the policy community. So, let me point to five ways in which we might shape the system differently in order to produce new types of practitioners.
One of the problems revolves around the organization of health care resources, particularly in that we don't have much flexibility or creativity in the ways we shape practices. The practice pattern or models are few: hospitalization, emergency room visit, clinic visit, dental office encounter, or retail prescription. While many of these work fine, increasingly they are burdensome and expensive to maintain, while poorly meeting the consumer's need for accessible service. If solo private practice dentists have little to offer inner city kids, where dental disease is a growing epidemic, shouldn't we start to think about how we could educate dental students in a way to more appropriately serve this community of need? Or, taking this a step further, maybe we need a new type of professional whose skills and competencies are developed to meet the needs of this population. I realize it sounds dangerous to train a subset of a profession differently or create a new profession to address a specific need. What if that need goes away? But don't we train our health professionals today to fit into a system that we know doesn't work and is in urgent need of change?
Related to the practice model question, though of a different perspective, is one ofcontext of care. Much professional care has been predicated on an expectation of independent practice, a practice governed by professionals from solos to large groups. How different would it be to have health professionals trained with the expectations that they would carry out their professional skills within an integrated system of care? Ideally, this system would still respect the needs of an individual patient, while looking at the needs of the population as well. Trained to be an actor in a system is, of course, anathema to an important part of the professional ethos: independence in the service of the patient. But why couldn't that commitment be translated through a system with care guidelines and protections? Would not such an approach gain us the best of both worlds?
Neither of these first two efforts to reframe the new professionals will get very far without ensuring that the skills, abilities and commitments to team delivery are in the genetic makeup of the next generation of health professionals. Let's be honest here. We have expended enormous efforts towards team education, practice and alignment with very little to show for it in practice or education. Interdisciplinary team education is a hothouse plant that quickly dies in the current environment of organization and delivery. There are notable exceptions of course, but these just add to the frustration by telling us that it is possible to communicate, respect, work, care and improve across the lines of the professions. This is not an easy undertaking. We need new approaches that start from the first day of training and focus on working collectively as the rule, not as the exception. To achieve such a new integration we will need to focus on the community and consumer and let their needs drive our education and practice. Finally, we need systems that reward team work because it produces better outcomes for the patient and the system.
New technology will help us in these efforts, but it will come in waves. We are already headlong into changes driven by information technology in the form of the electronic patient record. When this is fully developed we can better assess which inputs create better outcomes at lower costs. This will allow evidence-based switches to be thrown shunting care to the best model, system and team. As information technology combines with biomedical technology we will also have powerful new tools for diversifying the location of care and treatment. Older congestive heart disease patients won't find themselves being treated in the emergency room, but instead interacting daily with a nurse practitioner or even just a smart system that will better monitor their wellbeing. Such approaches are more satisfying, produce better outcomes and are a lot less expensive. Other systems will allow truly community-based systems of primary care to provide more onsite specialty services.
Finally, we will need new regulatory schemes that recognize these new realties. In licensing these will need to move out of the tradition of protecting the interests of the guild and more toward what serves the public's interest, broadly defined. This means new ways to experiment, new practice guidelines and a general commitment to flexibility and innovation. For the accreditors of education it will also be essential for them to be the source of innovation, not a barrier. In part this means changing what we do to and for existing schools. More importantly it means opening up opportunity for new players to enter into education from the service and proprietary education sectors.
I've never felt bad about "old wine in new bottles". I would just like to make sure we have some new bottles.