In a medical mecca like Boston, which is home to three medical schools and many world-class hospitals, you’d think that getting a timely appointment with a primary care physician or specialist would be a breeze. It isn’t. Finding a doctor is even harder in rural and underserved areas. Yet the public debate on health care remains focused on insurance and funding, and largely ignores the undersupply of health care professionals. Access to care means more than adequate insurance.
Many factors influence projections about the size of the health provider workforce, which have swung widely over past decades. How best to assess that workforce, from average wait times for appointments to number of physicians per population (both of which vary geographically and by specialty), is still an open question.
That said, it is clear that the growth and aging of the US population combined with an aging physician workforce translates into a need for more providers. The Association of American Medical Colleges has recently predicted a nationwide shortage of between 40,800 and 104,900 physicians by 2030.
Ironically, one of the biggest obstacles to improving access to health care providers is the profession itself, enabled by a plethora of public and private agencies that control licensing and certification. These often inadvertently limit access to care rather than enhance it.
The current system for training doctors dates to the early 20th century, when medicine transitioned from a largely ineffective and amateurish enterprise to one rooted in science. Physician training and licensing have certainly evolved since then, but at a disappointingly slow pace. Physician shortages are increasing as the population ages, while many enthusiastic and capable students and trained foreign-born caregivers are shut out of the profession.
Why has so little attention been paid to the number and quality of health care providers? Physician education, licensing, and credentialing are determined by an alphabet soup of organizations that change at a glacial pace. Their roles and interactions are difficult to delineate, even for a former dean of Harvard Medical School, and this complexity makes change difficult.
Worse, while the mission statements of these licensing organizations stress public health, they also serve the interests of incumbent professionals, who may be wary of new competitors. Tension between these conflicting interests produces a less innovative, less diverse, and less accessible workforce than could be the case.
Accreditation is regulated by the Liaison Committee on Medical Education, a body sponsored by the Association of American Medical Colleges and the American Medical Association and recognized by the Department of Education for accrediting programs leading to the medical doctor degree. It manages a rigorous process that, despite many benefits, raises the bar too high for creating new medical schools and slows the rate of educational innovation.
After completing medical school, graduates must pass a three-part exam and complete a one-year internship to become eligible for state licensing. Most physicians undertake further clinical training and specialization in hospitals, overseen by other certifying organizations. Hospital committees conduct evaluations before granting admitting privileges to carry out specific procedures or tasks.
Medical standards are essential. Can we develop more efficient approaches to ensuring them?
As my colleague Jared Rhoads and I argue in a white paper on the US health provider workforce, the key is to substitute competency-based assessments for the process-
driven approaches used today. Some costly exams and recertification processes have little or no evidence to support their use. Which schools a doctor has attended or exams she has passed matter far less than her competence. And please don’t misconstrue finding new ways to train and certify competent providers as lowering standards or expectations for quality — it’s quite the opposite.
The number of US medical schools and the size of each year’s class have increased over the past decade, but not enough to solve the pressing workforce issue. Nearly a quarter of currently licensed physicians — well over 200,000 — are foreign trained, and the care they provide equals that of graduates of US medical schools. They disproportionately practice in rural and underserved communities. Why not increase their numbers?
The Educational Commission for Foreign Medical Graduates certifies international medical graduates from legitimate medical schools, regulates access to the same exams that US graduates must pass, and authorizes the residencies required for licensing. But many more foreign medical graduates are eligible for residency positions in US hospitals than there are available slots for them.
If training slots are limited, why not allow fully trained foreign physicians to fill the void? Under current rules, to secure a license they must repeat in US hospitals the residencies and fellowships they already completed in their home countries. Many outstanding doctors will not do this. It would not be difficult to design a system through which hospitals and other health organizations facilitate and take responsibility for physician relocation.
Another indicator of the medical profession’s inadequate response to consumer demand is the rapid growth of nonphysician health providers. Nurse practitioners undertake advanced training that enables them to diagnose and treat disease, write prescriptions, and bill for services. They can practice independent of physician oversight in 21 states and the District of Columbia.
Today’s 234,000 licensed nurse practitioners can’t provide every health service. But for those they are able to perform, the quality of the care they deliver and patient satisfaction are equivalent to that provided by physicians. They fill major unmet needs, such as primary care. Yet some states still seek to limit the activity and independence of nurse providers.
Increased use of computers, artificial intelligence, telehealth, sensor technology, and health apps will someday transform the practice of health care. The only questions are when, and how training and licensing will adapt to these new realities. Consumers are now more actively involved in their own care, and are likely to support such innovations. Organized medicine should do the same. Perhaps, as has occurred in other industries, new entrants like Amazon, Apple, and Walmart will more aggressively seize opportunities to transform health care and how we train future professionals to deliver it.
While insurance and health expenditures continue to grab the headlines, let’s not ignore the vital role of health providers in the health care equation. We need more providers who are better suited to the challenges and opportunities of tomorrow’s world, and there is no legitimate reason why we shouldn’t start getting them today.Dr. Jeffrey S. Flier was dean of Harvard Medical School from 2007 to 2016. He is the coauthor of the new white paper“The US Health Provider Workforce: Determinants and Potential Paths to Enhancement,” published at the Mercatus Center at George Mason University. This column first appeared in STAT.