July 7, 2023
Dear Interested Readers,
How Did We Develop Our Workforce Shortages?
Last week the Supreme Court finished its session by announcing several controversial decisions. None of them had a direct impact on healthcare, but at least two of the decisions probably will impact the future of healthcare in America by the way they influence our struggle to improve workforce issues. Workforce issues impact the quality of care and the cost of care. Workforce problems diminish the professional satisfaction of every provider. When providers are discouraged the care experience of patients is immediately impacted.
The first decision that concerns me was the decision against the affirmative action admission policies at Harvard and the University of North Carolina. If the justices had extended their reasoning to other diversity initiatives, the outcome could have been worse. A realistic concern is that such an extension could come in the future from this conservative court.
The ruling will prevent race from being a key factor in college admissions for all colleges except our military academies. Ironically, the Supreme Court has said that we need a diverse officer corps to have an effective military. During the debate before the court, the lawyers representing Harvard and North Carolina presented studies showing that diversity improves productivity in almost every collaborative endeavor. I assume their assertions include healthcare.
We should be grateful that the decision for the moment does not undermine all of the efforts to increase diversity, equity, and inclusion, but as an editorial in The Guardian states, many are concerned that this conservative-leaning court could go further in the future.
Diversity, equity and inclusion (DEI) initiatives have long been taken on by companies trying to diversify their employees and leaders, and after the racial reckoning following the police killing of George Floyd in 2020, many more businesses promised to prioritize diversity initiatives in hiring and retention. Even Chick-fil-A, a company long thought of as conservative for its stance on LGBTQ issues, voiced a commitment to diversity and created a new vice-president role for DEI.
But experts who work and study workplace DEI efforts are worried about what the court’s decision on affirmative action will mean for these initiatives as conservative groups take their fight against diversity efforts even further.
We have made great progress in some aspects of diversity since I entered medical school in 1967. My class of 120 initially had about a dozen women, one Asian American man, and two African American men. I have facetiously said that we had diversity. We had students from “elite” colleges and universities and some from state universities. We also had geographic diversity. We had students from every region of the country. I contributed to diversity in two categories because I was from the South and was a graduate of a state university. Medical school admissions have come a long way over the intervening years.
The Association of American Medical Colleges publishes data concerning medical school diversity. In the class admitted for the academic year 22-23, Black or African American matriculants increased to ten percent. Matriculating students of Hispanic, Latino, or of Spanish descent increased to twelve percent. American Indian or Alaska Native matriculants declined to 1%. The numbers still don’t match the reality of the population since African Americans are 13.6%, the Hispanic, Latino, or Spanish population is 19.1%, and the American Indian plus Alaskan Native populations constitute 2.9% of our population of 333,000,000. There is still room for improvement in all these groups since there are real advantages to having them represented equitably within the practice of medicine. We have made great progress with gender. Women now make up 54% of medical school matriculants. In my class about 10% were women.
What will happen in the coming years as colleges become less diverse is anybody’s guess. I doubt that there will be a positive impact on the diversity of medical practice where we know it makes a big difference in outcomes and the patient experience to have culturally aware clinicians involved in the care of the patient. Looking back on my own experience in practice, I was very lucky to have had a few African American colleagues. Just being with them made me better able to care for the African American patients in my practice.
The best piece that I have read about the damage of the decision and what it says about the declining enthusiasm for ending inequality in America was written as a Guest Essay in The New York Times last Friday, June 30 by Darren Walker who is president of the Ford Foundation. The piece is entitled “Repeal of Affirmative Action Is Only the Beginning.” Mr. Walker’s own life is a testimony to the potential power of affirmative action.
From his perspective, we have come a long way, but we have a long way yet to go. He warns us that this decision may just be the beginning of a cultural reversal. All of the gains of more than 65 years in the fight for civil rights and a reversal of the inequities of three hundred and fifty years of slavery and Jim Crow have met resistance and attempts to erode their original intent. Many people would like to say that attention to civil rights and diversity is no longer necessary. Didn’t we elect a Black president? The reality is that there have been effective efforts to undermine every “gain” in the fight for equality of opportunity from the passage of the 14th Amendment through Brown v. Board of Education of Topeka and the Civil Rights Act of 1964 and the Voting Rights Act of 1965. Those efforts to reverse progress continue in our current culture wars and impact the quality and outcomes of healthcare in ways we often find convenient to overlook. Mr. Walker writes:
I was a beneficiary because the firms and foundations that shaped my career embraced this obligation, to make right what their predecessors had done wrong, to open doors they had closed.
Those uprooting affirmative action seem content to leave intact systems that compound privilege, exacerbating inequality — like legacy admissions policies that disproportionately favor wealthy, white applicants — resulting in lower-income students and families of all races losing out.
The court’s decision also opens the door to numerous legal challenges of diversity programs across government, business and civil society — programs explicitly designed to mitigate what Justice Thurgood Marshall called a “legacy of discrimination” beyond the college campus.
Since healthcare outcomes have mirrored the unresolved racial inequities in our society, this decision will ultimately be yet another challenge in the long and difficult process of eliminating implicit biases in attitude and opportunity for patients and minority providers in healthcare. Wishing that we have solved our problems with race or tiring from thinking about them is not the same as realizing a society where Dr. King’s dream is a reality. I think that Mr. Walker has put the problem in the proper perspective.
The other big disastrous decision by the court was to rule President Biden’s partial forgiveness of student loans unconstitutional. Student debt is already a huge barrier to medical education. For some time it has been thought that debt drove specialty choices away from primary care. In a 2013 article by Albert L. Hsu, MD, and Kelly Caverzagie, MD in the AMA Journal of Ethics entitled “Educational Debt and Specialty Choice,” we read:
Many factors influence the choice of a medical specialty, including educational opportunities, role models, lifestyle factors, debt levels, and anticipated income. Between 2007 and 2012, at least one-fourth of medical school graduates consistently reported that their level of educational debt had a strong or moderate influence on their choice of specialty. Unfortunately, rising debt appears to have a negative impact on choosing primary care as a specialty, with one study reporting an “inverse relationship between the level of total educational debt and the intention to enter primary care” and finding a disinclination to enter primary care among students who owed more than $150,000 at graduation.
Again, it was a different world when I went to medical school. In the sixties, federal dollars seemed to be much more available to support medical education. We did not hear conversations about enormous student debt. I am an old man and maybe I am remembering a world that didn’t exist, but I had a very good experience with educational debt. I know that between scholarships which were generous and loans which were offered on very favorable terms my medical education was virtually free. I owed $10,000 dollars when I graduated in 1971. Between 1971 and 1981 while in training and during the first five post-training years of practice no interest accrued, and I was not asked to make any payments. When interest and payments did begin in 1981, the interest was 5.25% at a time when home mortgages were being offered at 16%. I know because I bought a home in 1981. Over the next ten years, I made 120 payments of $100.99 a month. By the time I had to begin repayment of my loan, the process had no impact on the living that I could provide my family.
The ease of financing my education made me feel that the country had made an investment in me with very few strings attached, and I think those feelings have given me a sense of responsibility to “pay it forward” that persists to this day. I know that as a nation we should be investing like we once did in the education of future generations. The fact that we are not supporting education should be added to a long list of ways in which we are heavily discounting the future for lower taxes on the wealthy, me included, today.
As you know, I have enjoyed asking ChatGPT questions recently. I have discovered that if the questions are well formulated the answers can be interesting and probably useful. I also know that the Bot will not take a political stand, and gives somewhat cautious answers to potentially sensitive questions. I knew that I would get facts only from ChatGPT about the Supreme Court decisions, but I was interested in what she, for some reason Chat GPT seems feminine to me, would say about the workforce issues in healthcare. I figured that the two decisions would further complicate our workforce issues so rather than ask about diversity or student debt I would ask Ms. Bot about workforce issues in healthcare which I think will get worse because of what the court has done. I was glad that I asked: [I bolded some of her points]
Can you describe the issue of “workforce shortages” in American medicine?
ChatGPT
Certainly! The issue of workforce shortages in American medicine refers to the situation where there is an insufficient number of healthcare professionals to meet the demand for medical services in the United States. This shortage can be seen across various healthcare sectors, including physicians, nurses, and other allied health professionals. Here are some key points to understand about this issue:
- Aging population: The aging population in the United States, primarily driven by the baby boomer generation, has increased the demand for healthcare services. As people age, they generally require more medical care, which places a strain on the healthcare workforce.
- Physician shortage: There is a significant shortage of physicians in many specialties across the country. This shortage can be attributed to factors such as the limited capacity of medical schools, a lack of residency positions, and the growing need for healthcare services.
- Nursing shortage: Nurses are a vital component of the healthcare workforce, providing direct patient care and filling important roles in hospitals, clinics, and other healthcare settings. The nursing shortage is influenced by factors such as an aging nursing workforce, high levels of burnout, and insufficient enrollment in nursing programs.
- Rural healthcare disparities: Workforce shortages are particularly pronounced in rural areas, where access to healthcare services is often limited. Rural communities face challenges in recruiting and retaining healthcare professionals due to factors such as geographic isolation, lower compensation, and limited resources.
- Impact on patient care: Workforce shortages can have adverse effects on patient care and outcomes. Longer wait times for appointments, reduced access to specialized care, and increased workload for healthcare professionals can all contribute to lower quality of care and patient dissatisfaction.
- Financial implications: Workforce shortages in healthcare can also have financial implications. For instance, hospitals and healthcare facilities may struggle to meet staffing needs, leading to increased costs associated with recruitment, retention, and temporary staffing solutions.
Addressing the issue of workforce shortages in American medicine requires a multi-faceted approach. Efforts are being made to expand medical education programs, increase funding for residency positions, improve working conditions and job satisfaction for healthcare professionals, and promote telemedicine and other innovative solutions to bridge the gap in underserved areas. Policymakers, educational institutions, healthcare organizations, and professional associations are working together to develop strategies that can help alleviate this critical issue and ensure access to quality healthcare for all Americans.
If you read these musings regularly, you know that I agree with all of her points. I think that her last paragraph is a little overly optimistic. I have some cynicism about how effectively “Policymakers, educational institutions, healthcare organizations, and professional associations are working together to develop strategies that can help alleviate this critical issue and ensure access to quality healthcare for all Americans.”
I was encouraged by her answers and decided to ask for some historical perspective. How did we get to the mess we are in? So I asked with a less pejorative tone: [Again, I added the bolding for emphasis]
How did the shortage of doctors that threatens access to care evolve in America?
ChatGPT
The shortage of doctors in the United States that threatens access to care has evolved over several decades due to various factors. Here’s an overview of how this issue has developed:
- Increasing demand for healthcare services: The demand for healthcare services has grown steadily over time due to multiple factors. These include the aging population, advances in medical technology and treatments, increasing prevalence of chronic diseases, and expanded access to healthcare through government programs like Medicare and Medicaid.
- Limited capacity of medical schools: The number of medical school slots has not kept pace with the increasing demand for physicians. The capacity to train new doctors is constrained by factors such as limited funding, faculty shortages, and the high cost of establishing and maintaining medical schools.
- Challenges in residency training: After graduating from medical school, aspiring physicians need to complete residency training to become fully licensed. However, the number of residency positions has not significantly increased, leading to a bottleneck in the training pipeline. This limitation is partly due to federal funding constraints and regulations that restrict the expansion of residency programs.
- Specialization and maldistribution: Physicians are increasingly opting for specialized fields rather than primary care, which exacerbates the shortage. Specialized medicine offers higher salaries and often a better work-life balance, leading to an imbalance between specialists and general practitioners. Moreover, there is also a maldistribution of physicians, with a disproportionate number of doctors practicing in urban areas compared to rural and underserved communities.
- Workforce demographics and retirement: The aging physician workforce is another factor contributing to the shortage. As many doctors near retirement age, the number of physicians leaving the workforce surpasses the number of new doctors entering. This trend reduces the overall number of practicing physicians and further strains the healthcare system.
- Burnout and job dissatisfaction: The demanding nature of medical practice, including long work hours, high patient loads, administrative burdens, and the pressure to provide quality care, has led to increased rates of physician burnout and job dissatisfaction. These factors contribute to physicians leaving clinical practice or reducing their working hours, further exacerbating the shortage.
Addressing the evolving shortage of doctors and ensuring access to care requires a multifaceted approach. Expanding medical school capacity, increasing funding for residency programs, promoting primary care and rural medicine, improving work conditions and physician satisfaction, and leveraging technology and telemedicine to enhance healthcare delivery are among the strategies being pursued to mitigate the impact of this shortage and improve access to care for patients.
Since one of the most significant factors in the increasing cost of care is the nursing shortage I felt Like I want Ms. Chatbot’s analysis of our nursing shortage:
How did the shortage of nurses evolve in America?
ChatGPT
The shortage of nurses in America has evolved over time due to several factors. Here’s an overview of how this issue has developed:
- Aging nursing workforce: One significant factor contributing to the shortage is the aging nursing workforce. Many experienced nurses are reaching retirement age, leading to a significant loss of nursing professionals from the workforce. This trend has been further amplified by a decrease in younger nurses entering the profession to replace retiring nurses.
- Insufficient nursing education capacity: The capacity of nursing education programs, such as nursing schools and colleges, has not kept up with the growing demand for nurses. Limited faculty resources, a shortage of clinical training sites, and budgetary constraints have hindered the expansion of nursing programs, thereby restricting the number of students who can be admitted and graduate as qualified nurses.
- High attrition rates and job dissatisfaction: Nursing can be a demanding profession, often involving long hours, high patient loads, and high levels of stress. These factors contribute to burnout, job dissatisfaction, and a higher attrition rate among nurses. Many nurses choose to leave the profession or reduce their working hours, further exacerbating the shortage.
- Increasing healthcare demands and complexity: The demand for healthcare services has been growing due to factors such as population growth, the aging population, and an increase in chronic diseases. The evolving healthcare landscape, technological advancements, and more complex patient needs have also increased the demand for nursing care. However, the supply of nurses has not kept pace with these demands.
- Specialty and geographic maldistribution: Similar to physicians, there is a maldistribution of nurses, both in terms of specialty and geography. Many nurses are drawn to specialized areas of nursing, such as critical care or specialized nursing practices, leading to a shortage of nurses in primary care and other essential areas. Moreover, rural and underserved areas often face challenges in attracting and retaining nursing professionals due to limited resources, lower compensation, and fewer career advancement opportunities.
Addressing the shortage of nurses in America requires concerted efforts from various stakeholders. Increasing the capacity of nursing education programs, providing incentives for nurses to enter and remain in the profession, improving working conditions, offering competitive compensation, and expanding opportunities for career advancement are among the strategies being pursued to mitigate the shortage. Additionally, efforts are underway to promote diversity in the nursing workforce, enhance nurse retention, and leverage technology and telehealth to optimize nursing care delivery.
If I could have one wish to fix one part of the workforce problem it would be to suddenly have more primary care physicians. My question further specified adult primary care but Ms. Bot chose to look at all of primary care. I thought her answer was pretty good.
How many more primary care doctors are required to meet the needs of adult primary care?
ChatGPT
The specific number of primary care doctors required to meet the needs of adult primary care in the United States can vary depending on various factors, including population demographics, healthcare utilization patterns, and the desired physician-to-patient ratio. Estimates and projections are subject to change over time based on evolving data and healthcare trends.
That being said, several organizations and studies have provided estimates regarding the shortage of primary care physicians. The Association of American Medical Colleges (AAMC) projected a shortage of between 21,100 and 55,200 primary care physicians by the year 2033. The Health Resources and Services Administration (HRSA) estimated that by 2025, there would be a shortage of approximately 23,600 primary care physicians.
It is important to note that these estimates include the overall primary care workforce, which encompasses general internal medicine, family medicine, and general pediatrics. Additionally, the estimates may not account for potential changes in healthcare delivery models, such as the increasing use of advanced practice nurses and physician assistants in primary care settings.
To accurately determine the exact number of primary care doctors required to meet the needs of adult primary care, a comprehensive analysis of population health needs, healthcare utilization, and other relevant factors would be necessary. This information helps inform healthcare policy decisions and workforce planning efforts aimed at addressing the shortage of primary care providers.
I decided that since policy changes that added more federal dollars to expand the production of healthcare professionals were highly unlikely to pass in an era of divided government, I would ask about using AI as a way of mitigating our professional shortages. I really don’t expect much to happen soon to beef up our output of doctors and nurses. AI is a new tool that individual healthcare institutions could utilize that might mitigate their delivery service problems and better leverage the staff that they do have. So I asked:
How can AI be best used to help close the workforce shortages in healthcare?
ChatGPT
AI (Artificial Intelligence) has the potential to play a significant role in helping to close the workforce shortages in healthcare. Here are some ways AI can be effectively utilized:
- Telemedicine and Remote Monitoring: AI-powered telemedicine platforms enable remote consultations, allowing healthcare providers to reach patients in underserved areas or those unable to access traditional healthcare facilities. Remote monitoring systems that utilize AI can track patient data in real-time and provide alerts to healthcare professionals, enabling timely interventions and reducing the need for in-person visits.
- Diagnostic Support: AI can assist healthcare providers in diagnosing and interpreting medical images, such as X-rays, CT scans, and pathology slides. Machine learning algorithms can analyze vast amounts of data, identify patterns, and assist in detecting abnormalities or providing differential diagnoses, enhancing the accuracy and efficiency of diagnostics.
- Decision Support Systems: AI can be employed to develop clinical decision support systems that provide evidence-based recommendations to healthcare professionals. By analyzing patient data, medical literature, and treatment guidelines, these systems can offer personalized treatment suggestions, helping healthcare providers make informed decisions and improve patient outcomes.
- Streamlining Administrative Tasks: AI technologies, such as natural language processing and voice recognition, can automate administrative tasks like documentation, data entry, and appointment scheduling. By reducing administrative burdens, healthcare professionals can focus more on direct patient care, increasing their efficiency and productivity.
- Predictive Analytics and Resource Management: AI can leverage predictive analytics to forecast healthcare demand, identify potential workforce shortages, and optimize resource allocation. By analyzing historical data, AI algorithms can help healthcare organizations predict patient volumes, plan staffing levels, and allocate resources effectively, ensuring efficient and timely care delivery.
- Virtual Assistants and Chatbots: AI-powered virtual assistants and chatbots can provide basic patient education, answer frequently asked questions, and offer guidance on self-care. This technology can help alleviate the workload of healthcare professionals by handling routine inquiries, enabling them to focus on more complex cases.
However, it’s important to note that while AI can augment and enhance healthcare delivery, it cannot completely replace human healthcare professionals. The ethical considerations, privacy concerns, and regulatory frameworks surrounding AI in healthcare must also be carefully addressed to ensure patient safety and maintain trust in the healthcare system.
Overall, integrating AI technologies thoughtfully into healthcare systems has the potential to mitigate workforce shortages, improve efficiency, enhance patient care, and optimize resource allocation in the face of increasing healthcare demands.
I took her answer to mean that even though she has passed her medical board exams she does not plan to take a job as a primary care provider.
I decided to be sure that she did not lean right or left. I did not want to ask about her party affiliation, so I asked if she was progressive or conservative. I did not expect a definitive answer, but with Chatbots it is free to ask. I was surprised to note that she has been programmed to recognize the potential for bias.
Do Chatbots have a political position? Progressive or conservative?
ChatGPT
Chatbots, including the AI-based language model used in this conversation, do not have inherent political positions or affiliations. They are designed to provide information, answer questions, and engage in conversation based on the data they have been trained on. Their responses are generated based on patterns and information in the training data, rather than having personal beliefs or political leanings.
The responses of a chatbot are shaped by the data it has been trained on, which typically includes a wide range of sources and perspectives. The goal is to provide accurate and objective information while being neutral and unbiased. However, it’s important to note that biases can inadvertently be present in the training data, as language models learn from human-generated text, which can reflect societal biases or perspectives.
When discussing political topics or controversial issues, it’s always recommended to seek information from multiple sources and consider different viewpoints to form a well-rounded understanding. Chatbots can provide general information and perspectives but should not be considered as authoritative or definitive sources on political matters.
“Just the facts Mam,” was what Detective Sargeant Joe Friday would always say on “Dragnet.” I guess that is the answer my Chatbot friend would also give. I just wish that our policymakers could be as objective as a Chatbot. I felt the need to ask one last question. What were her references?
What reports or publications have you sourced in your discussion of the workforce shortages and the solutions to the problem?
ChatGPT
As an AI language model, my responses are generated based on a mixture of licensed data, data created by human trainers, and publicly available data. I have not been directly trained on specific reports or publications related to workforce shortages in healthcare. I should note that while I strive to provide accurate and up-to-date information, my responses may not always reflect the most current research or policy developments in this specific domain.
I can provide general information on the topic based on my training, which includes a wide range of sources such as books, websites, research papers, and other texts, to generate responses that are broadly representative of the topic at hand. If you have specific questions or require information from a particular report or publication, I recommend referring to those sources directly or consulting healthcare organizations, government agencies, and reputable research institutions that specialize in healthcare workforce studies and policy analysis.
That was an evasive answer. I decided to push her a little harder.
Can you give me a list of references on workforce shortages in American healthcare?
ChatGPT
Certainly! While I don’t have direct access to a specific list of references, I can provide you with a list of reputable sources that discuss workforce shortages in American healthcare. These sources often publish reports, studies, and articles on the topic. Here are a few organizations and publications you can explore:
- Association of American Medical Colleges (AAMC) – Their website (https://www.aamc.org/) provides valuable resources on physician workforce shortages, including reports and publications.
- Health Resources and Services Administration (HRSA) – HRSA, an agency of the U.S. Department of Health and Human Services, offers information and reports on healthcare workforce shortages, including nursing and primary care. Their website (https://www.hrsa.gov/) is a valuable resource.
- National Academy of Medicine (NAM) – NAM publishes reports and studies on various aspects of healthcare, including workforce shortages. Their publications can be found on their website (https://nam.edu/).
- Kaiser Family Foundation (KFF) – KFF is a non-profit organization that conducts research and provides analysis on healthcare issues. They publish reports and articles on topics related to healthcare workforce shortages. Their website (https://www.kff.org/) is a reliable resource.
- American Nurses Association (ANA) – ANA provides information on nursing workforce issues, including shortages. Their website (https://www.nursingworld.org/) offers reports, publications, and resources related to nursing workforce challenges.
- American Association of Colleges of Nursing (AACN) – AACN focuses on nursing education and provides information on nursing workforce shortages. Their website (https://www.aacnnursing.org/) offers publications and reports on the subject.
These organizations can provide you with a wealth of information on workforce shortages in American healthcare and may have specific reports and publications related to the topic. Additionally, academic journals, government reports, and research institutions also contribute valuable insights into this issue.
That was enough for me. I think her answers were objective, accurate, and generally not evasive. I wish that our politicians and policymakers could find some way to agree that our healthcare workforce problems should be addressed as a critical problem that needed a bipartisan approach. The first step is agreeing on a common set of facts about the causes. I think that Ms. Bot has some answers that they could use. I doubt the Supreme Court will ever give her a chance to bend their minds.
The Hottest Fourth Ever!
Climate scientists have been recording the temperature of the whole earth since 1979. Tuesday, the Fourth of July, was the hottest day ever recorded and perhaps the hottest day in the last 125,000 years. On the Fourth in the Sunapee region of New Hampshire, we had heavy rain in the morning which cleared mid-day to give us a beautiful afternoon and evening which was even nicer than the day before when the header for this letter was taken. About sundown, the skies opened up for another dump of more than an inch of rain accompanied by thunder and lightning that was a natural fireworks show.
Making a case for cause and effect does not seem to accomplish much in terms of workforce shortages in healthcare or global warming even though both are measurable realities. Theoretically, it is still possible to do something to limit the damage from both challenges, but there is a big difference between what could happen and what will probably happen. It seems that it is possible that the challenges with both global warming and healthcare workforce shortages won’t be resolved. It doesn’t have to be that way, but what seems most likely is that with both of these pressing problems, we will be forced to develop strategies that allow some of us to live with increasing heat and violent weather as we live one day at a time and wait longer and longer to have our medical needs met.
Don’t let me spoil your weekend or summer. I hope that wherever you are this weekend it won’t be too hot or too wet, and that you will not have an urgent need to get medical care.
Be well,
Gene
