Predicting medical workforce supply and demand has historically been a challenging endeavor. The methodology consists of estimating the future medical provider workforce as well as modeling future demand for medical services. This month's Research Corner focuses on two articles: One presents a unique medical workforce supply model that includes physician assistants (PAs) and nurse practitioners (NPs) as well as physicians, and the other documents the exclusion of PAs and NPs from state workforce assessments.
Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advanced practice nurses, and physician assistants. J Am Coll Surg. Published April 4, 2011. doi:10.1016/j.jamcollsurg.2011.03.005.
Background: Based on the goals of health care reform, growth in the demand for health care will continue to increase the demand for physicians and, as physician shortages widen, advanced practice nurses (APNs) and physician assistants (PAs) will play larger roles. Together with physicians, they constitute a workforce of "advanced clinicians." The objective of this study was to assess the capacity of this combined workforce to meet the future demand for clinical services.
Study Design: Projections were constructed to the year 2025 for the supply of physicians, APNs, and PAs, and these were compared with projections of the demand for advanced clinical services, based on federal estimates of future spending and historic relationships between spending and the health care labor force.
Results: If training programs for APNs and PAs grow as currently projected but physician residency programs are not further expanded, the aggregate per capita supply of advanced clinicians will remain close to its current level, which will be 20% less than the demand in 2025. Increasing the numbers of entry-level (PGY1) residents by 500 annually will narrow the gap, but it will remain 15%.
Conclusions: The nation faces a substantial shortfall in its combined supply of physicians, APNs, and PAs, even under aggressive training scenarios, and deeper shortages if these scenarios are not achieved. Efforts must be made to expand the output of clinicians in all three disciplines while also strengthening the infrastructure of clinical practice and facilitating the delegation of tasks to a broadened spectrum of caregivers in new models of care.
Morgan P, Strand De Oliveira J, Short NM. Physician assistants and nurse practitioners: a missing component in state workforce assessments. J Interprof Care. Published November 2, 2010. doi:10.3109/
13561820.2010.501917.
Due to current or predicted health workforce shortages, policy makers worldwide are addressing issues of task allocation, skill mix, and role substitution. This article presents an example of this process in the United States (US). Health workforce analysts recommend that US physician workforce planning account for the impact of physician assistants (PAs) and nurse practitioners (NPs). We examined 40 state workforce assessments in order to identify best practices for including PAs/NPs. Most assessments (about 60%) did not include PAs/NPs in provider counts, workforce projections, or recommendations. Only 35% enumerated PAs/NPs. Best practices included use of an accurate data source, such as state licensing data, and combined workforce planning for PAs, NPs, and physicians. Our findings suggest that interprofessional medical workforce planning is not the norm among the states in the US. The best practices that we identify may be instructive to states as they develop methods for assessing workforce adequacy. Our discussion of potential barriers to interprofessional workforce planning may be useful to policy makers worldwide as they confront issues related to professional boundaries and interprofessional workforce planning.
DISCUSSION
Medical workforce projections have a history of inaccuracy. Enumerating the number of clinicians currently in practice is in itself an inexact science. Additionally, accurately projecting the number of clinicians likely to be in practice at some time in the future is subject to several unpredictable variables. Predicting future medical workforce demand is an even greater challenge, as the practice of medicine itself, the changing population, the political landscape, and changes in society's expectations all may impact future demand.
The most recent example of inaccurate medical workforce prediction was the Graduate Medical Education National Advisory Committee (GMENAC) Report of 1980, which predicted a surplus of approximately 70,000 physicians by 1990 and recommended a 10% reduction in US medical school enrollment as well as policies to severely restrict entrance of foreign medical graduates into the physician training pipeline.1 Multiple problems in the GMENAC Report methodologic approach were later described that contributed to its lack of accuracy, which was best illustrated by the fact that physician surpluses were not observed over the ensuing decade.
Another shortcoming of past medical workforce projections was the lack of inclusion of PAs and NPs. Although this might have been justifiable in 1980, when PAs and NPs were a small proportion of the medical workforce, currently any accurate workforce projection requires their inclusion.
Cooper and colleagues first reported on the projected impact of PAs and NPs on medical workforce supply and demand in data published in 1998.2,3
In 2002, Cooper and colleagues utilized an economic model to predict future medical workforce demand using the assumption that as societies become wealthier, they spend a greater proportion of their wealth on health care.4 Utilizing this model, it was predicted that the United States would experience increasing medical provider shortages in both primary care and specialties in less than a decade, even when PAs and NPs were included in the supply stream. Although controversial at the time of publication, this approach to medical workforce prediction has gradually gained acceptance.
The article by Sargen and colleagues updates data on allopathic and osteopathic physicians, physician assistants, advance practice nurses, optometrists, podiatrists, and practitioners of alternative and complementary medicine. These data are analyzed utilizing various levels of enrollment increases in physician residency positions and PA/nurse practitioner enrollment to predict the likely medical workforce supply in the future. These assumptions are combined with various levels of predicted growth rates for demand for medical services based on the economic growth model previously explored by Cooper and colleagues. The article goes into great detail explaining the challenges in obtaining accurate data and the methods used to address them, as well as the many limitations. Several assumptions are made in the estimation of the number of workforce providers, which the authors admit are likely to overestimate the number of physicians and APNs; thus, these predictions are likely to underestimate predicted workforce supply shortages. Taking these limitations into account, the authors predict that the United States will experience substantial shortages of physicians, PAs, and APNs over the next 15 years even if aggressive training scenarios are achieved and deeper shortages if expanded training efforts are not accomplished. The authors also realistically caution that substantial expansion of training efforts may not be possible because of several limiting factors, including the saturation of clinical training resources.
The article by Morgan and colleagues systematically documents that PAs and NPs are commonly excluded from state medical workforce assessments. Specifically, about 60% of surveyed assessments did not include PAs or NPs, and only 35% enumerated PAs or NPs. Thus, many of those workforce reports likely contain inaccuracies and, if utilized to direct policy, may misdirect resources designed to address medical workforce shortages. Additionally, several states simply do not collect accurate data on nonphysician providers, thereby contributing to inaccuracies in collecting aggregate national data that cast doubt on the accuracy of workforce assessments based on such data. Best practice recommendations encourage states to collect workforce data on all medical professionals at the time of licensure and license renewal, and the states with the best quality data utilize this process. This article questions the accuracy of some state reports of medical profession population data and illustrates that in order to improve workforce predictions, data collection and distribution of the current population of medical providers need to be improved and standardized.
The Sargen and colleagues article provides an important window into the complicated US medical workforce and is noteworthy because it integrates nonphysician providers with physicians into the study of medical workforce projections and uses an economic growth model to determine the future supply and demand relationship. The conclusion from this body of work is loud and clear, and is consistent with current consensus on this topic: the United States faces substantial future shortages in medical workforce supply even despite effort to increase enrollments in training, and attempts to increase training are limited by the saturation of clinical training sites. The Morgan and colleagues article reminds us that reliable and valid data are essential to accurate workforce predictions, as demonstrated by the Graduate Medical Education National Advisory Committee experience. JAAPA
Rick Dehn is a professor in the College of Health and Human Services and chair of the Department of Physician Assistant Studies at Northern Arizona University, Flagstaff. He is a member of the JAAPA editorial advisory board. The author has indicated no relationships to disclose relating to the content of this article.
REFERENCES
1. Report of the Graduate Medical Education National Advisory Committee—Volume I: summary report. DHHS Publication No. (HRA) 81-651. Washington, DC: US Government Printing Office; 1980.
2. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA. 1998;280(9):788-794.
3. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. JAMA. 1998;280(9):795-802.
4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff. 2002;21(1):140-154.