Kevin Grumbach, M.D.

Professor and Chair

Department of Family and Community Medicine

University of California, San Francisco


DR. GRUMBACH: Thank you very much, Harvey. It is a great pleasure to be here. I am pleased that the Institute of Medicine (IOM) has decided to focus this year’s Rosenthal Lecture on the health care workforce. Human resources, in my mind, are the single most critical ingredient in the health care system, yet health policy discussions often give short shrift to this issue. Those of us who do research and policy work in health workforce issues are partly to blame for this. We don’t seem to do a very good job in answering such basic questions as whether we have a physician surplus or a physician shortage.

I remember a meeting a decade ago when Dr. Fineberg’s predecessor, Ken Shine, was present for a session on the physician workforce. Dr. Shine told a story about riding a bus in Israel. A passenger dropped to the floor of the bus in cardiac arrest and three unemployed physicians jumped out of their seats and immediately started performing CPR. The driver of the bus slammed on the brakes, and the bus came to an abrupt halt. The driver stood up and announced, “My bus, my patient!”

In 2007 the pendulum has swung in the opposite direction, and now there is clamor about a possible shortage of physicians in the United States, with vocal proponents including Buz Cooper of the University of Pennsylvania and the Association of American Medical Colleges. The nation has actually increased the number of physicians per capita over the past 10 years, so if you are confused as to why we have a shortage in the face of this trend, I’m confused along with you.

What I’m not going to do in my presentation is to attempt to answer the question of how many physicians we need in the United States. I ac-



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Kevin Grumbach, M.D. ❧ Professor and Chair Department of Family and Community Medicine Uniersity of California, San Francisco DR. GRUMBACH: Thank you very much, Harvey. It is a great pleasure to be here. I am pleased that the Institute of Medicine (IOM) has decided to focus this year’s Rosenthal Lecture on the health care workforce. Human resources, in my mind, are the single most critical ingredient in the health care system, yet health policy discussions often give short shrift to this issue. Those of us who do research and policy work in health workforce issues are partly to blame for this. We don’t seem to do a very good job in answering such basic questions as whether we have a physician surplus or a physician shortage. I remember a meeting a decade ago when Dr. Fineberg’s predecessor, Ken Shine, was present for a session on the physician workforce. Dr. Shine told a story about riding a bus in Israel. A passenger dropped to the floor of the bus in cardiac arrest and three unemployed physicians jumped out of their seats and immediately started performing CPR. The driver of the bus slammed on the brakes, and the bus came to an abrupt halt. The driver stood up and announced, “My bus, my patient!” In 2007 the pendulum has swung in the opposite direction, and now there is clamor about a possible shortage of physicians in the United States, with vocal proponents including Buz Cooper of the University of Penn- sylvania and the Association of American Medical Colleges. The nation has actually increased the number of physicians per capita over the past 10 years, so if you are confused as to why we have a shortage in the face of this trend, I’m confused along with you. What I’m not going to do in my presentation is to attempt to answer the question of how many physicians we need in the United States. I ac- 

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 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE tually don’t consider that the most compelling question facing physician workforce policy or one that’s likely to have a meaningful answer. Instead, what I want to address is the question of how we transform the physician workforce and other health care workers. When I think about the issue of transforming the physician workforce and the health care workforce, I recall the comment that the Canadian health care economist Bob Evans once made about human resource plan- ning. To paraphrase Evans, before adding more sugar to your cup of tea, make sure you stir the sugar already in the cup. This idea of stirring the sugar that is already in the cup—thinking about how to more effectively and productively deploy our existing workforce—is the theme I will focus on. I will specifically examine this issue in the context of primary care. Let me begin with just a few introductory comments about primary care. It is now abundantly clear from accumulating research that a solid foundation of primary care is essential to a well-functioning health system. The IOM’s Committee on the Future of Primary Care defined primary care as “the provision of integrated accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” Primary care is provided by family physicians, general internists, general pediatricians, nurse practitioners, physician assistants, and oth- ers who work in the primary care sector. These clinicians are responsible for delivering accessible first-contact care; providing continuity of care through ongoing relationships; comprehensively addressing the major- ity of patient needs, whether they are urgent care problems, chronic care needs, preventive care needs, or psychosocial needs; and integrating specialty referrals and ancillary services to provide patient-centered, whole-person care. Now here is problem: The evidence is clear that patients and popu- lations benefit when they receive care in the primary care model. The problem is that the traditional practice model of delivering primary care is antiquated and completely ill-designed to deliver the goods. The data are very telling. For example, a group of researchers in the Department of Family Medicine at Duke University calculated how much time it would take a family physician with a panel of 2,500 patients to de- liver all the preventive and chronic care services needed by those patients, on the basis of evidence-based guidelines. This means ensuring that these patients get their Pap smears, colon cancer screenings, and immunizations, and that patients with diabetes get their lipids checked, their hemoglobin A1Cs measured regularly, and a pneumococcal vaccine. So what did the researchers conclude? They concluded that it would require 7.4 hours per day to deliver all the preventive services patients need in primary care. It

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7 KEVIN GRUMBACH would take an additional 10.6 hours per day to deliver all the evidence- based chronic care services that patients need. Now the good news about this is that it means that there are still another 6 hours left in the day for a dedicated primary care physician to actually attend to all the symptoms that patients have that need medical attention. But this is a recipe for clinician burnout; often primary care phy- sicians and other clinicians in the primary care sector feel overwhelmed by the daunting demands and expectations of primary care practice. It certainly is one of the factors turning students off from entering primary care careers. The other major issue is the widening gap in incomes between primary care physicians and specialists. Over the past decades, the number of U.S. allopathic medical school graduates entering family medicine residencies has dropped by 50 per- cent. A decade ago, half of all residents in internal medicine residency programs planned to practice primary care general internal medicine, but today only 20 percent plan to go into primary care. The same trends are apparent when you look at the nurse practitioner workforce and the physician assistant workforce: Fewer and fewer graduates are going into primary care fields. What are the policy options to respond to the apparent predicament of mismatch between demands for primary care services and the capac- ity of the primary care clinician workforce to respond to these demands? The traditional response would be to declare that there is a shortage of primary care physicians and that the nation needs a much greater number of primary care physicians in order to reduce the typical panel size to a level well below 2,000 patients per each primary care clinician. This policy option is in fact being played out in a somewhat perverse way in the United States today by what is known as boutique primary care medical practices. In these practices physicians limit themselves to a panel of 500 patients or even fewer and require these patients to pay cash for services in addition to an annual retainer fee. In return, the patients receive highly personalized care, often with physicians providing patients direct access to their cell phone numbers to be available 24/7. The problem with the boutique model is the other 1,500 patients who are left behind when a primary care physician limits his or her patients to 500 relatively affluent individuals who are willing to pay the premium for boutique care. What happens to them? To provide all Americans with this model of care would require a fourfold increase in the number of primary care clinicians in the United States, something that just doesn’t sound feasible, at least in the short or even medium term in this country. Interestingly, there is a country that has adopted the boutique model as a general matter of national policy. That nation is Cuba, which has more

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 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE than one family physician for every 500 Cubans. That’s an institutional- ized approach to boutique medicine. The other policy response to this predicament of primary care is to stir the sugar that is in the cup, to make more productive use of our existing primary care physician supply. The approach to this policy option begins by asking a question: Are primary care physicians working to their maxi- mum level of skill? Or are they doing tasks that don’t require a medical degree to perform? The answer is that primary care physicians are spending much of their time on tasks that someone with less training, or frankly even a com- puter, could do. By someone with less training, I’m including the patients themselves as a key part of the primary care team. Most of the activities that make up those 18 hours per day of preventive care and chronic care services that I mentioned are quite routine and can be driven by explicit protocols. Let me give you an example of how health information technology could transform preventive service delivery in primary care and make better use of precious physician and other clinician time. Here is a typical visit with prevention content as it transpires in the traditional family care practice, which may be disturbingly like your experiences as patients or clinicians: A patient schedules an appointment with a physician, nurse practi- tioner, or physician assistant. Two or 3 months later, the day of the ap- pointment actually arrives. The patient shows up, and the primary care clinician flips through a paper chart trying to determine what preventive services the patient actually needs. When was her last mammogram, has she had a colon cancer screen, when was her last pneumococcal vaccine? The physician and the patient then make a decision about what services are to be provided. The services are ordered, the tests are performed. The physician or other clinician reviews the tests as they become available and then sends a notice to the patient about the results of each test. Sound like your world? I don’t want to say electronic medical records are a panacea for all that ails the health care system, but I do think an advanced electronic medical record (EMR), particularly when it empowers patients to have access to their own EMR through a patient portal, really could transform aspects of primary care and free up a lot of precious physician time. What would this model look like? In this EMR-empowered model, patients would log on to their person- al HIPAA-compliant EMR web page. That web page would tell them what preventive services they are due for, based on their age and various other factors that determine what is appropriate for them. They could hyperlink under each of those recommendations to read more about prostate cancer

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 KEVIN GRUMBACH screening, colon cancer screening, and the risks and benefits of various other procedures. They could decide which ones they want to go ahead and obtain. They could potentially order those services directly online, go ahead and make an appointment to get a pneumococcal vaccine or a mam- mogram, and thus bypass the need to even have a visit with the primary care clinician. Patients could potentially e-mail questions about preven- tive care and could make an appointment to discuss particular questions after they had already been educated about recommended services. Once patients had the test, the results could be sent electronically to the primary care provider, who would review them and then authorize their release to the patients so that patients could log on and view the results of their tests. Think about how that alters the workload of the primary care clini- cian compared to the traditional model. On the same theme of stirring the sugar in the cup, another approach is to create genuine team models in primary care that allow each team member to work to his or her full potential. In most primary care prac- tices, other than physicians, nurse practitioners, and physician assistants, who’s the most common staff person you will find? It is not going to be a registered nurse; it is going to be a medical assistant. Although medical assistants usually join a practice after having received only a rudimentary level of vocational training, they are the main staff members in most pri- mary care practices. In most practices the role given to medical assistants is pretty basic. They check the patient in, take the blood pressure, room the patient, and wait for the patient to come out of the room after the visit with the physician. The medical assistant may then give the patient a shot or collect a urine specimen, and send the patient on his or her way. How does a chronic care visit for a patient with diabetes play out in the traditional, antiquated primary care model? The patient is roomed by the medical assistant, and then the physician or clinician thumbs through the chart for the most recent hemoglobin A1C level, the LDL cholesterol level, and the urine albumin results. It takes about five minutes to find all that information in the paper chart. The physician then compares the bottles of medication brought by the patient with what the physician thinks he or she has actually prescribed for the patient. That takes another five min- utes. The patient wasn’t able to actually get that ophthalmology visit for a routine annual retinal screening, and the physician is so frustrated that he or she calls and makes the appointment for the patient. The clinician then asks the patient to remove his or her shoes to do a foot exam, and because the patient is rather corpulent and arthritic, it takes another 5 minutes just to get the shoes and socks off. The clinician then gives a well-rehearsed 3- minute monologue to the patient about the need to change his or her diet, exercise more, and check sugars regularly. The clinician asks the medical assistant to give the pneumococcal vaccine and the flu shot. The clinician

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0 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE is about 10 minutes behind in the day’s schedule when the patient hap- pens to mention the chest pain he or she gets when walking up a flight of stairs. That is a typical chronic care visit in primary care. In the family medicine clinic at San Francisco General Hospital, where I work, my colleague Tom Bodenheimer is leading the implementation of a team innovation that he refers to as the “teamlet model.” In essence, this model empowers medical assistants and health workers to become genu- ine partners with clinicians in delivering primary care services to patients, empowered with support by training and protocols. The patient encounter in the teamlet model begins with a pre-visit with the medical assistant. Using the clinic’s EMR and guided by written protocols and standing orders, the medical assistant identifies the preventive and chronic care items for which the patient is due (e.g., a flu shot, a mammogram, a hemo- globin A1C blood test) and then proceeds to deliver or order those items. Patients are asked to bring their pill bottles with them, and the medical assistant goes over each of those medications, checks the EMR medication list to see what the patient has been prescribed, identifies discrepancies, and tries to identify issues of potential non-adherence. Then rather than simply rooming the patient, the medical assistant accompanies the patient into the actual visit with the clinician and remains present for that visit. The medical assistant fills out lab slips and referral forms as the clinician is working with the patient. The medical assistant helps with procedures, enters information in the EMR, and performs other tasks, which allows the physician to focus on the cognitive work of evaluation and management, such as evaluating new chest pain. After the encounter is completed with the clinician, the patient then has a post-visit session with the medical assistant. The medical assistant closes the loop with the patient by checking that the patient has under- stood the clinical decisions made during the visit, such as a change in medication or scheduling a diagnostic test. And because the medical assistant is actually present during the encounter with the clinician, the medical assistant knows what decisions were made and what the action plans are. It is remarkable how little attention is actually paid to developing teamwork in primary care practices. About 20 years ago, Harold Wise wrote a book called Making Health Care Teams Work, and he pointed out that football teams spend the whole week practicing for that 3-hour game. He observed that you are lucky to get teams in primary care to spend 2 hours a year practicing for something that they work on 40 hours a week. We don’t build in the structure for developing teamwork by thinking through practice processes or investing in the teamwork building and on-the-job training to make teams happen. Most of these models I am talking about are still in the experimental

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 KEVIN GRUMBACH stage. I can’t tell you that the teamlet model that we are piloting at my own clinic is actually going to be a success. There are real questions about these innovations. When you use more information technology (IT), when you use other team members, how does this play out for the patient experience in primary care? Is it okay for a physician to delegate more tasks to a medi- cal assistant, or do patients actually value that time with a physician that appears wasteful from the health systems point of view (in other words, might this actually be valuable time for patients to build a relationship with their primary care clinicians)? There are a lot of questions out there. What I can say is that most clinicians in primary care would agree that simply running faster on the treadmill of current practice models is simply not viable as a sustainable approach to primary care practice. Let me end by summarizing the state of this cup of tea known as pri- mary care. My first point is that the tea right now tastes bitter. Patients are not getting the primary care they need, primary care clinicians are over- whelmed, and there is decreasing interest in primary care among recently graduated clinicians. The question is then, do we need to add more sugar to the tea in order to substantially increase the supply of primary care clini- cians? Or do we need to stir the tea more vigorously and more creatively by being more innovative in the deployment of the existing primary care workforce so as to make the existing capacity more productive to improve patient care and make primary care careers more viable? I think both are needed to some degree. It may be that we need to stir better, and also add another dollop of primary care workforce to the mix. But I think that simply seeing this as a problem of numbers fails to ap- preciate the most important challenge for workforce policy, which is the theme of this session: namely, how to transform and rethink our practice models to create a much more efficient, productive, and effective model of health care. While we need some additional investment in the educa- tional pipeline to produce an adequate supply of primary care physicians, perhaps even more compelling is the need for payers and purchasers to invest in innovative practice models that can deploy primary care clini- cians more productively. Such investment will require dedicated resources for implementing and maintaining health IT systems in primary care, for hiring and training non-clinician staff for new team models, and for other similar types of infrastructure needs in primary care. Thank you. DR. FINEBERG: Thank you very much for that fresh perspective on what is needed in primary care. Our next presentation is by Marla Salmon. Marla Salmon is dean of the Nell Hodgson Woodruff School of Nurs- ing at Emory University and a professor of medicine as well as public

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2 TRANSFORMING TODAY’S HEALTH CARE WORKFORCE health. Her special interests cover a wide range and have included na- tional and international health policy, administration, public health, and workforce development. She has held a number of leadership positions in government as director of the Division of Nursing and as the chief nurse in the U.S. Department of Health and Human Services. She has been an adviser to our government at many levels in agencies and the White House. She has advised other governments in Caribbean countries and elsewhere in the world, and she has also served as an adviser to the World Health Organization and as a member of a number of IOM panels. She is a prolific writer and serves on the editorial boards of the Journal of Nursing Scholarship and Nursing and Health Policy Reiew. She is a member of the IOM and the American Academy of Nursing. Marla, the floor is yours. Let me mention that because Marla will have to leave shortly after the conclusion of her remarks, please have in mind any questions you would like to pose to her specifically, and we will take a few minutes for those at the conclusion of her remarks.