Fitzhugh Mullan, M.D.

Murdock Head Professor of Medicine and Health Policy

The George Washington University


DR. MULLAN: Thank you, Harvey, and I thank the Institute of Medicine (IOM) and the Rosenthal family for hosting this evening. I very much appreciate being included. I want to particularly welcome the members of the Health Policy Workforce class from GW, which happens to meet on Tuesday evenings from 6:00 p.m. to 8:00 p.m. We know you planned the Rosenthal Lecture around that. We just moved the class over here so welcome to all of you who are here.

What I want to do is talk about what I call the “hinged” world. I have spent a long time pondering and puzzling, as Kevin Grumbach has outlined and as Marla Salmon has reflected, on the U.S. workforce. I want to talk about the U.S. workforce in the context of the world. I am going to start with the global workforce.

The issues that drive both disease and migrants around the world are powerful, and they are much amongst us all the time. They are familiar to you, but it is interesting and a bit ironic that health professionals move, as do diseases, quite quickly. This has always been the case, but in this day and age—with modern travel and communications—it is especially true.

Of course, in terms of the economists and students of labor, there are push and pull factors affecting the opportunities that drive people to move. I suspect they are obvious and well appreciated by this audience. The pull factors that draw people to the north and the push factors that tend to drive them to the south are like reciprocals. I am going to talk more about these. I use here the shorthand that is used in global health constantly today—the north being the developed world and the south being the developing world.



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Fitzhugh Mullan, M.D. ❧ Murdock Head Professor of Medicine and Health Policy The George Washington Uniersity DR. MULLAN: Thank you, Harvey, and I thank the Institute of Medicine (IOM) and the Rosenthal family for hosting this evening. I very much appreciate being included. I want to particularly welcome the members of the Health Policy Workforce class from GW, which happens to meet on Tuesday evenings from 6:00 p.m. to 8:00 p.m. We know you planned the Rosenthal Lecture around that. We just moved the class over here so welcome to all of you who are here. What I want to do is talk about what I call the “hinged” world. I have spent a long time pondering and puzzling, as Kevin Grumbach has out- lined and as Marla Salmon has reflected, on the U.S. workforce. I want to talk about the U.S. workforce in the context of the world. I am going to start with the global workforce. The issues that drive both disease and migrants around the world are powerful, and they are much amongst us all the time. They are familiar to you, but it is interesting and a bit ironic that health professionals move, as do diseases, quite quickly. This has always been the case, but in this day and age—with modern travel and communications—it is especially true. Of course, in terms of the economists and students of labor, there are push and pull factors affecting the opportunities that drive people to move. I suspect they are obvious and well appreciated by this audience. The pull factors that draw people to the north and the push factors that tend to drive them to the south are like reciprocals. I am going to talk more about these. I use here the shorthand that is used in global health constantly today—the north being the developed world and the south being the developing world. 24

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2 FITZHUGH MULLAN While it is not entirely precise in geographic terms, it is a little less judgmen- tal than some of the other frequently used terms. For many years, the concern with health workforce on a global scene was very limited. Of course, there were issues around technologies, drugs, and systems development, as well as a lot around disease-specific efforts. The most popular one involved smallpox, but others included malaria and tuberculosis (TB), polio, and other diseases. However, it wasn’t until the acquired immune deficiency syndrome (AIDS) epidemic that workforce was brought to the fore. As antiretroviral drugs were developed and moved into price ranges that allowed all coun- tries to begin to embark on programs, it turned out that there was a new, emerging problem, which was different from smallpox and TB. Smallpox takes one shot once and TB takes directly observed therapy, short course (DOTS) treatment with observation. In contrast, antiretrovirals, which must continue for a lifetime once they are started, require treatment and management that includes the whole chain of clinical decisions, delivery, and follow-up. It is very human resource intensive, and no one was there. Metaphorically, we had the drugs on the loading dock, and literally, we had very few people to see that they were distributed, delivered, and man- aged appropriately over time. This problem brought the world’s attention to this question of global human resources. Two reports brought this issue “out of the shadows”: The Joint Learning Initiative, which was sponsored largely by the Rock- efeller Foundation in the field between 2004 and 2005, produced the first clever and evidence-based report, which highlighted the issue. In 2006, a second report followed, by the World Health Report, which was dedicated to human resources in health. You can fully appreciate the extent of the problem by looking at the sta- tistics. For example, the United States has about 280 physicians per 100,000 people, while Cuba and North Korea have many more. I have seen estimates that North Korea has 600-plus physicians per 100,000 people. I have no idea about their quality or functionality. Cuban physicians are pretty good and quite functional, but it ranges. European countries have more physicians than we do. Some other anglophone countries have fewer, on down to the lesser developed countries, which have in the case of India, 60; Ghana, 13; and Mozambique, 2. Obviously, when you are down in these ranges, your physician density is quite limited in terms of its ability to have much impact on the population. The evidence is very good that human resources at least correlate with good health. Obviously, economics correlates with human resources as well. If you take these three standard markers of human well-being and increase the number of health workers per population (including physicians, nurses, midwives, and birth attendants), all of these indicators

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2 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE improve. The correlation with wealth is not surprising: more wealth, more workers. It is a fairly linear relationship as you move up the intensity of workers and the wealth of the various countries. Migration plays an important role here. Anglophone northern coun- tries import about a quarter of their physicians. That is, approximately one-quarter of their physicians went to medical school elsewhere. They do not come from the developing world entirely, but if you look at the percentage of international medical graduates from nations designated by the World Bank as low- or lower income countries, in the United States 60 percent come from those; in the United Kingdom, 75 percent; and in other countries it is somewhat less. So this movement is heavily from lesser developed countries. If you look at this from a different perspective and pause for a mo- ment, the largest volume of physicians in this country and other devel- oped countries would tend to correlate somewhat with the size of those countries. But if you are a small, poor country and you are not producing a lot of physicians, it won’t take too many moving to practice in New York or London to deplete your workforce very substantially. When you look at this on a continental or global basis, it doesn’t seem like there are a lot of African physicians in the United States or the United Kingdom, but it is the sub-continent in Africa that is chronically the most affected, followed by the Indian sub-continent and the Caribbean. These are prime areas for migration or recruitment to the developed world. If you look within the countries you will see very high figures. Let me pause also on this for a moment. These figures are very conservative because I counted only individuals who showed up in the licensed workforce in the recipient country. When I talked to people in Ghana about 30 percent of their workforce having left, they laughed at me and said that it was much higher than that. I puzzled over this for a while. There are some explanations. One is that if you didn’t go to one of the four countries I measured, you were not counted. If you went to Germany or if you went to the Gulf or if you went to Nigeria, you were not counted. Second is that if you come to the United States and you are sitting for or attempting to pass the Educational Com- mission for Foreign Medical Graduates (ECFMG), you don’t count. If you have received a residency pass to ECFMG or gotten a residency but have not yet been licensed, you don’t count. If you went to the United States and did not pass or did not get a residency and are in business, it doesn’t show either. Many more have left than I was able to calculate, but even in my conservative estimates the numbers are quite substantial. Four out of 10 positions in Jamaica have left. Sri Lanka is actually a bigger donor than India, which is of course the largest in terms of numbers—as a whole, migration from the Indian sub-continent is substantial.

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27 FITZHUGH MULLAN The specifics of nursing migration are different: The issues are parallel except that in nursing the ability of hospitals and other organized recruit- ers to strip nurses out of countries is far more developed. Doctors typically go on their own along well-grooved paths, but there are not recruiting firms by and large, which bring in jumbo jets for the nurses. Granted, this is a bit of an overstatement, but not a huge one in the north in regard to nurses. As Marla Salmon described, we are extremely vulnerable. We would have to take every nurse trained in the developing world for the next two decades to fill our nursing shortage. It is a very substantial threat in terms of what is at stake. A quick primer on the U.S. physician workforce: The physician-to- population ratio has climbed roughly from 150 physicians per 100,000 people in the 1960s to almost 300 per 100,000 people today. We have effec- tively doubled the density of physicians over this period. We could spend the rest of the evening on why this is happening and what will happen, but one of the very important points is that this way of measuring physi- cians and probably other health workers—while being the best method we have—is not great. We are not counting automobile tires or widgets. What physicians do and what bearing they have on population health are quite different. What a family physician does and what a neurosurgeon does are quite different. One factor is that there are many specialties today that did not exist in 1960. You did not have sports medicine or interventional radiology, et cetera, et cetera. However you put the value on these disciplines, the fact is that they are out there occupying physician time, energy, brain power, and a portion of budget, and they were not before. While this seems quite clean, it is much more complicated than that, but on the other hand it is a point of departure for understanding what has happened and where we are going. Our training patterns have remained fairly stable, though. As you know, in order to get a license and be counted in the active workforce in this country, you have to have a residency. It doesn’t matter where you went to medical school; you must have a residency in the United States. Thus, looking at the graduate medical education component of our medi- cal system is where we can make the best projections about what the future of the workforce is going to be like. Frankly, by engineering what goes on at graduate medical education, one can have a significant—but not neces- sarily definitive—impact on what happens later. The number of medical residents in the country has remained fairly constant—around 100,000 for more than a decade—although it is trend- ing up a little bit in spite of a cap on Medicare payments for graduate medical education. This is a story unto itself: I am sure you are aware of it in general, but Medicare pays an average of $80,000 a year per resident

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2 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE in the United States. The amount was capped in 1997, but there has been some trending upward and a lot of discussion about what this means. A lot of evidence points to there being more fellows—that is, folks in essen- tially their second residency, sub-specialty residency, or prolongation of residency—and a diminution in primary care slots. This is the entry point for those “postgraduate year one” (PGY-1) folks who will be doctors in the system, numbering about 24,000 per year. If you look at the origin of physicians in terms of education, there are three major components: U.S. medical graduates, international graduates, and graduates of osteopathic schools (these being allopathic schools). U.S. medical graduates have been fairly steady, with a slight down trending in terms of total numbers, and international medical graduates have trended upward slightly. The osteopathic line has trended upward, and though the number of osteopaths is small, it has doubled over this period. Osteopathic education is growing rapidly, and the majority of osteopaths are now tak- ing residencies in allopathic hospitals. This is the work of Dr. Richard Cooper—Buz Cooper—who is well known in the workforce research field. Cooper has been the primary clarion call for the concern that we are going to have too few physicians. A crisis is at hand. He has been persuasive and certainly persistent in mak- ing these arguments. This is the essence of it: He argues that the demand for physician services is inexorably linked to our wealth as a nation. If you follow our fortune as a linear upward line in terms of our per capita income, compared to the curve of physician-to-population numbers, he projects that the demand is going to go on like this and be much higher in a decade or two than it is today. The workforce is “flattening out,” and Cooper factors a couple of things into this. One is the diminishing impact of physicians in terms of shorter work weeks, shorter work hours, shorter work lives, different lifestyles, and an increasing gender change in medicine (half of all physicians will soon be women, and it is well demon- strated that they work fewer years—about three less in a career). So these are downward pressures. The upward pressures of adding non-physician clinicians to the mix are a factor as well. In this case too, Cooper still an- ticipates a growing gap between the population demand and the number of physicians available. He says we are going to have a huge crisis and we need to start cranking out more physicians into the workforce as soon as possible. There are some who argue with him, but there is concern. You need to distinguish between more medical school slots and more graduate medical education slots, which is not done in the popular press and is rarely done among academics and medical educators. But this is a key question. The work of Dr. John Wenneberg’s Dartmouth Group shows the vast differences in many hospital referral regions for Medicare payments in the last 6 months of life: The numbers range from less than

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2 FITZHUGH MULLAN $4,000 to up toward $10,000 or $11,000 at the highest end of the range. Wenneberg’s work essentially shows the huge variation in the culture of medical practice in different areas. The areas that are most expensive correlate with more specialists and more hospital beds. The areas that are less expensive correlate with fewer beds and, effectively, more primary care. Adding to the evidence that well-balanced communities are a good primary care base and cost less, this was adjusted for age, socioeconomic status, et cetera. This is very powerful evidence that we have some major disparities and some major opportunities for recalibrating our system. It also suggests that we shouldn’t recalibrate with more sub-specialists, which is what our current system trains and what the Cooper line would bring into play. So you have Cooper on the one hand saying, “We need more.” On the other hand, you have Wenneberg saying, “If we are going to have more, it is going to make this worse.” This is a problem, so we better stop here and fix it before we put more sugar in our tea as it were. There has been a response on the part of medical schools. The As- sociation of American Medical Colleges predicts a 17 percent increase in the number of physicians through both expansion and new schools in the next 6 to 8 years. For the osteopathic community, the number is higher at about 25 percent. Put these figures together and you are talking about a 20 percent response. It is pretty much in the pipeline, which is good. This means 20 percent more U.S.-trained physicians (not 20 percent more residencies at the moment). When you consider the actual 2007 numbers, we are graduating (in rounded figures) about 18,000 osteopathic and allopathic graduates each year into the ranks of residency. We have about 24,000 PGY-1 internship slots. The delta is 6,000, and those are international graduates. That is a version of what has happened every year for the past half-century really, but it’s been at about this level for the past 10 years. About 6,000 inter- national graduates arrive to join the 18,000 U.S. graduates and make the 24,000 that go on through residency. Virtually all of them go into practice (although, of course, a few of the international graduates do go home, and a few of the U.S. graduates don’t go into medicine or don’t stay on). That is basically your workforce, your input. Now if we continue with this 20 percent increase over the next 6 to 8 years, and we don’t increase graduate medical education, you close the gap. On the presumption that most residency directors choose U.S. gradu- ates over international graduates, you can decrease the brain drain and diminish the vacuum that is pulling people into the country. Put aside for a moment what people think about that; you are not messing with immi- gration law, you are not putting restrictive anything on anybody, you are

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30 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE simply saying it is a market, and the market has changed because we are moving toward self-sufficiency. This is a good principle. If you take the lid off graduate medical education or you increase it by the same factor, you are now producing 27,000 if you have kept your role vis-à-vis the rest of the world the same—a very appreciable pull. If you believe what Cooper and others have suggested—that we need 30,000 graduates a year—you will increase the pull to almost 9,000 a year (or 400,000 physicians over the period). So you make the brain drain worse. This is what is out in front of us, and it is largely determined by what happens in graduate medical education. Currently, hospitals with Ac- creditation Council for Graduate Medical Education approval can create new residencies. As we have seen, what is going on is a little unclear. The new residencies tend to be on the specialty side. They go to teaching hospitals (as our workforce has done generally), since teaching hospitals have governed and are essentially that keyhole through which all must go in order to enter practice. It may not be the best mix, but at least there is not further federal support going into building a workforce that in the eyes of many is not in the best interest of the country. My own preference comes from the policy perspective that this rep- resents good domestic policy. We are giving more opportunities, we are moving toward self-sufficiency, and it is good global policy because we are beginning to be a good global citizen and not under-training and relying on our economic prowess to help ourselves to doctors from around the world. I think much the same could be said in nursing. In nursing, the educational ramp-up has many more challenges than in medicine. You have people being turned away in medicine who are eager to go to medical school. You have the capacity in U.S. medical schools to expand, which is happening, and it could happen even more robustly with better support on a federal level. For example, there is no new support for undergraduate funding. Title VII funds, which have been a historical vessel for funding, are diminished—almost eliminated now—and there is no movement as yet on those. More could be done, clearly. What to do? As I’ve said, lean is better. People will say there will be shortages, and there will be. There are evaluative clinical sciences, and a lot of the work being done on quality in outcomes will help us answer the questions of what works and what doesn’t. They need to help us develop better guidelines and better practice norms, so that those huge gaps in differential payments and differential cultures can be brought closer together. We are way ahead of the world in the use of non-physician clinicians: There are between 150,000 and 200,000 nurse practitioners and physician assistants practicing today among those 800,000 physicians. Non-physician clinicians are already a major component of our workforce, and I think the various strategies that Marla Salmon talked about—team

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3 FITZHUGH MULLAN building, medical homes, the use of an integrated workforce like this—will help us face the challenge of building a workforce that will meet an ag- ing population’s needs. And, by the way, the non-physician clinicians are moving briskly into specialties. It is not just a primary care phenomenon. They work well across-the-board. Indeed, as was suggested, we ought to move toward self-sufficiency and keep the cap on graduate medical edu- cation. There are fiscal reasons, which Medicare experts and those who are concerned with policy will argue, but from a workforce perspective keeping the caps on is an important thing to do. What to do abroad? There is already support through the President’s Emergency Plan for AIDS Relief (PEPFAR) and other initiatives for capac- ity development. We ought to promote what is called reverse flows. We need a U.S. Global Health Service Corps, and we have talked about it. An IOM-sponsored committee, which I was fortunate to chair a few years ago, recommended such a program and laid out a blueprint of how that would work. We should send more folks back to developing countries. There is one last idea I want to leave with you: We should track im- migration and set benchmarks for good practice. In the policy community we don’t talk about what our level of citizenship is in the world, particu- larly in regard to medicine and nursing. But these are items that people have talked about, and I would like to promote them. They come down to a question of an equity index. Codes of conduct have been proposed, particularly by some in the United Kingdom. I am not a great fan, but within these our country would say that we will not recruit in countries that do not invite us in. Particularly for nursing that works. In medicine, though, the movement is usually spontaneous so there is less applicability. But putting something on the books that says we wish to be good global citizens would be an important act of any country. We ought to know how many newly licensed physicians in the United States each year come from developing countries. That could be done, but we don’t track it. Are we taking more? Are we taking less? What are the trends? Also, how much capacity development funding do we do abroad? People talk about reparations—we will never do that, I don’t think it’s po- litically viable. But through PEPFAR and others we are investing abroad. What is that level? Is it growing? At what magnitude? How many of our folks are working abroad? The last study of this was done in 1984, and it was not a terribly good study. The data were not very good. We are in the process of designing a study, but we need funding for it if anybody has good ideas. We would look at the sectors of people abroad—government, nongovernmental organizations, both faith-based and secular organiza- tions, corporations, and universities. It would be a difficult study to do, but set a floor and look 5 years, 2 years, 10 years: How many are going and

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32 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE how do we compare to other countries? Finally, roll those all into an index and we could talk about various countries and how well they are doing. We have domestic issues, yes. But our domestic issues, as Marla Salmon has suggested, really have enormous import for the rest of the world. We need better metrics and a better sense of an ethical role for us as a country, which ought to be quantified in a way that we can talk about it explicitly. I think this is a challenge for the upcoming two years as we try to get it right with our workforce as well as workforces in the rest of the world. Thank you. DR. FINEBERG: Thank you very much. Kevin, welcome back up to the front of the room. The floor is now open for your questions and comments.