Health Care Personnel
At the core of the work that AHCPR has asked the IOM to do lie two complex problems: (1) forecasting appropriate numbers and characteristics of future health services researchers, and (2) determining how best to produce them. Similar problems must be addressed for the entire health care work force as well. To that end, health services research can offer considerable insights about a variety of topics, such as: cost-effective mixes of different types of health care providers; specialist-to-generalist ratios in different localities and practice settings; the work force implications of managed care; the desirability and feasibility of substituting nurse practitioners and physician assistants for physicians; and the costs associated with reducing the use of resident physicians-in-training to staff hospitals.
WORK FORCE AND TRAINING ISSUES
Each of the topics introduced in this statement requires building new theory, methods, and tools. To do so requires a research infrastructure. One element of such an infrastructure clearly involves having a cadre of investigators of sufficient number, education, disciplinary mix, and experience to be able to move a field forward. The production of such a cohort of researchers presupposes the existence of educational and employment structures through which to pursue appropriate training and a relevant career path.
A recent National Research Council (NRC) report from the Office of Science and Engineering Personnel recommended a large increase in support for training in health services research to be provided through National Research Scientist Award grants (NRC, 1994). This is clearly a necessary step in forming and maintaining an adequate health services research infrastructure. This committee, in its remaining work, plans to build on the NRC's report, going beyond it in certain ways. In particular, the committee expects its final report to address the match of supply and demand by looking at the
number and distribution of experienced health services researchers, training program capacity, and met and unmet needs for health services research analysis and discussion.
Supply of Professionals Trained in Health Services Research
The committee—a group representing a wide array of research and practice settings —has made some early observations about areas in which it believes that recruiting and retaining adequate numbers of researchers of sufficient quality are likely to be difficult. These preliminary views are based on discussions at the first committee meeting about the experiences of leading investigators in hiring junior researchers or finding collaborators and about the experiences of leaders in the private sector or industry, who cannot identify enough well-trained health services researchers to manage new research units. Documenting more fully the extent to which these views are accurate and determining whether other types of personnel may also prove to be in short supply in the future are tasks for the full study. To accomplish those tasks, the committee will conduct limited surveys of sites where health services education and research take place and secondary analysis of available work force data to explore such indicators as the number of unfilled posted positions and unstudied significant topics, and the amount of unclaimed grant funds. The committee will pay particular attention to certain types of personnel that already are perceived to be in short supply—generalist and specialist clinicians, social scientists with experience or interest in health services research, and quantitative experts in physical, behavioral, and subjective measurement.
Dimensions of Education and Training
The committee's recommendations about health services research training in its final report will focus specifically on the training support options open to
AHCPR. Here the committee presents some thoughts on various dimensions of training concerns that it believes will need to be taken into account in a broader effort to fill expected future personnel gaps.
Health services research is a multidisciplinary field of inquiry, encompassing both applied and basic research. Thus, special problems arise in specifying the most appropriate preparation for future health services researchers. The questions that health services research needs to answer frequently require a knowledge base derived from many disciplines, and training personnel from disciplines not usually associated with health services research poses extra difficulties. Are there common courses and educational experiences that each discipline should contain if it is to prepare researchers to address the extremely varied subjects of the field? What is the best way to train people accustomed to working independently to facilitate their constructive participation in a multidisciplinary or interdisciplinary environment?
The multidisciplinary efforts required by health services research call for team efforts. Still, it is appropriate to ask how important team approaches are to health services research. Are there models of collaboration or team functioning that can guide the development of interdisciplinary approaches to health services research? What are the skills necessary for teams to function effectively? Is it possible to design educational experiences that include approaches to understanding other disciplines and that enhance team skills in research?
Academic qualifications loom large in the committee's future deliberations. It will need to explore, for instance, the appropriate levels of academic training for health services researchers. Is a doctoral degree—or a master's degree—necessary in all cases? Should the type and level of training differ from discipline to discipline? For example, in conducting a cost-effectiveness study, should some participants, such as clinicians, have different levels of health services research skills or training than, say, the economists, statisticians, or behavioral scientists involved in the research?
Academic qualifications are indivisible, conceptually, from the academic programs that produce the types of personnel sought. Thus, the committee will need to consider the advantages and disadvantages to training taking place at different stages in researchers' careers. For example, should academic training be accomplished within a baccalaureate education, graduate work immediately following college, after clinical training, or as second-career training? What are the strengths and limitations of full-time and part-time training programs? What might be the role of worksite training? What role can clinical training play in health services research? Are there other training and education modalities that have not yet been explored? Are fellowship and other training stipends adequate to recruit the caliber of trainee the field deserves?
Related to the topic of academic programs and qualifications is another that might be characterized as “centers of excellence.” Today, a relatively small number of major research universities receive the bulk of the research and training monies that AHCPR awards. If health services research training is to be made more accessible to people from a variety of disciplines at various possible points in a career, then one must determine how best to expand these opportunities. One consideration, for example, is whether concentrated training through seminars or at specialized health services research institutes can provide the requisite coursework and on-the-job training needed for a variety of disciplines.
The committee's definition of health services research calls attention to issues relating both to individuals and to populations. With respect to populations, the committee believes that it will need to address questions related to the representation of women and minorities in the field today. Would having more minority researchers improve our understanding of culturally sensitive issues? More broadly, the basic issue of how to increase the number of women and minorities trained in health services research will need to be solved.
The committee's definition of health services research specifically refers to both “basic” and
