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OCR for page 29
Chapter 2
Challenges Facing the Health
System and Implications for
Educational Reform
Major challenges face today's health care system for which health professionals have to be
prepared. This chapter describes these challenges incorporating related evidence and the views
expressed by participants in the Health Professions Education Summit and examines the resulting
implications for the education of health professionals and its reform.
Current Challenges
The current quality crisis in America's heath care is well recognized. Numerous recent studies
have led to the conclusion that "the burden of harm conveyed by the collective impact of all of our
health care qualify problems is staggering" (Chassin et al., 1998:10054. Likewise, the President's
Advisory Commission on Consumer Protection and Quality in the Health Care Industry (1998: 21)
note that "today, in America, there is no guarantee that any individual will receive high-quality care
for any particular health problem."
The related figures are illustrative. Estimates of the number of Americans dying each year as a
result of medical errors are as high as 9S,000 more than those who die from motor vehicle
accidents, breast cancer, or AIDS (Institute of Medicine, 20004. The American public is dissatisfied
with chronic care; 72 percent of those surveyed believe it is difficult for people living with chronic
conditions to obtain the necessary care from their health care providers (Harris Interactive and ARIA
Marketing, 20004. Health professionals are also concerned: 57 percent of U.S. physicians surveyed
said their ability to provide quality care has been reduced in the last 5 years, and 41 percent stated
that they are discouraged from reporting or not encouraged to report medical errors (Blendon et al.,
2001~; 76 percent of nurses surveyed indicated that unsafe working conditions interfere with their
ability to deliver quality care (American Nurses Association/NursingWorId.Org, 20014. A survey of
29
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HEALTH PROFESSIONS EDUCATION
over 800 physicians found that 35 percent of
them reported errors in their own or a family
member's care (Blendon et al., 20024.
The committee that authored the Quality
Chasm report (Institute of Medicine, 2001),
speakers at the summit, health experts,
employers, and health professionals and
students have all identified reasons for this
disconnect between an ideal system and what
actually exists. These reasons include (1) poor
design of systems and processes, (2) the
system's inability to respond to changing patient
demographics and related requirements, (3) a
failure to assimilate the rapidly growing and
increasingly complex science and technology
base, (4) slow adoption of information
technology innovations needed to provide care,
(5) little accommodation of patients' diverse
demands and needs, and (6) personnel shortages
and poor working conditions.
What System?
The health care system can hardly be called
a system. Rather it is a dizzying array of highly
decentralized sectors. Although the size of
physician groups is growing, 37 percent of
practicing physicians are still in solo or two-
person practices (Center for Studying Health
System Change, 2002~. The health plan sector is
turning away from structures that can facilitate
integration and coordination, with the market
share of health maintenance organizations
(HMOs) falling and preferred provider
organizations (PPOs) becoming more popular
(Kaiser Family Foundation and Health Research
and Educational Trust, 20024. And even though
the hospital sector has been consolidating in
many markets ofthe 5,000 community
hospitals, more than 3,500 belong to some
network or system most of these arrangements
are focused on administrative rather than
clinical integration (American Hospital
Association, 2000; Lesser and Ginsburg, 2000~.
As Ken Shine, former president of the Institute
of Medicine (IOM), attested at the summit:
We operate our health care system
like a cottage industry, big, big
cottages with state-of-the-art
technologies to care for patients,
but infrastructure which is totally
inadequate, systems which don't
talk to each other (Shine, 2002~.
The absence of systems, or poorly designed
systems, and the resulting lack of integration are
apparent across sectors, as well as within
individual health care organizations. Such
systems can harm patients or fail to deliver what
patients need. A previous IOM report makes
abundantly clear that the inability to apply
knowledge about human factors in systems
design and the failure to incorporate well-
acknowledged safety principles into health care
(such as standardizing and simplifying
equipment, supplies, and processes) are key
contributors to the unpardonably high number
of medical errors that occur (Institute of
Medicine, 20004.
Mary Naylor, School of Nursing, University
of Pennsylvania, a panelist at the summit,
echoed this reality:
We have both a culture and
organization of care that separate
our care into distinct systems-
hospitals, home care, skilled
nursing facilities with little
formal communication,
relationships, or collaboration
between and among those
settings....And providers don't
necessarily see that they're
responsible for what happens to
people as they move from one level
of care to another. We don't pay a
lot of attention to issues of quality
assessment, particularly in those
difficult hand-offs or transitions
from one level of care to another
(Naylor, 20024.
The Quality Chasm report also stresses that
a redesigned system is predicated on
interdisciplinary teams. In the current system,
however, health professionals work together,
but display little of the coordination and
collaboration that would characterize an
interdisciplinary team. Many factors, including
differing professional and personal perspectives
30
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CHALLENGES FACING THE HEALTH SYSTEM
and values, role competition and turf issues
lack of a common language among the
professions, variations in professional
socialization processes, differing accreditation
and licensure regulations, payment systems, and
existing hierarchies, have decreased the
system's ability to function, causing defined
roles to predominate over meeting patients'
needs. The hierarchy in which physicians
dominate and the emphasis on assuming
individual responsibility for decision making
result in a reliance on personal accountability
and a failure to solicit the contributions of
others who could bring added insight and
relevant information, whatever their formal
credentials (Helmreich, 2000; Institute of
Medicine, 2001a).
The resulting lack of continuity and
coordination of care, miscommunication.
redundant and wasteful processes, and excess
costs have resulted in patient suffering (Institute
of Medicine, 2001 a; Larson, 19994. Patients
and families commonly report that caregivers
appear not to coordinate their work or even to
know what each other are doing. Patients spend
a great deal of time consulting with an endless
stream of physicians, nurses, therapists, social
workers, home care workers, nutritionists,
pharmacists, and other specialists, who too often
are ignorant of past medical histories,
medications, or treatment plans and therefore
work at cross purposes. When patients are
moved from one setting to another for
example, from hospital to rehabilitation center
to home fragmentation of care results in
overlapping or conflicting treatment that is
costly and confusing and, worst of all,
detrimental to the patient. In a recent survey, 85
percent of physicians surveyed stated that one
or more adverse outcomes result from
uncoordinated care, and more than half
suggested that a lack of coordination is usually
the cause of patients receiving contradictory
health information from providers (Partnership
for Solutions, 2002b).
Poor Accommodation of Patients' Needs
Americans are living longer, in part as a
consequence of advances in medical science,
technology, and health care delivery. As the
population ages, there will be more patients
with chronic conditions. In 2000, about 13
percent of the population (35 million
Americans) were over age 65; this proportion is
expected to rise to 20 percent (70 million) by
2030 (National Center for Health Statistics,
2002~. An estimated 125 million Americans
already have one or more chronic conditions,
and more than half of these people have
multiple such conditions (Wu and Green, 20004.
Moreover, although the majority of disease
burden and health care resources is related to
the treatment of chronic conditions, the nation's
health care system is organized and oriented
largely to provide acute care and is inadequate
in meeting the needs of the chronically ill
(Wagner et al., 20014. As William Richardson,
Kellogg Foundation, noted in his remarks at the
summit, "There are few clinical programs that
can provide the full complement of services
needed by people with heart disease, diabetes,
asthma, or other common chronic conditions
(Richardson, 20024.
Studies show that effective treatment of
chronic conditions needs to be continuous
across settings and types of providers.
Clinicians need to collaborate with each other
and with patients to develop joint care plans
with agreed-upon goals, targets, and
implementation steps. Such care should support
patient self-management and encompass regular
clinician follow-up, both face-to-face and
through electronic means (DeBusk et al., 1994
Von Korff et al., 1 997; Wagner et al., 200 1;
Wagner et al., 19964. Clinicians practicing in
such an environment need to be effective
members of an interdisciplinary team, provide
care that is patient-centered, and be proficient in
informatics applications.
A recent survey underscored issues faced by
the chronically ill, with about three of every
four respondents reporting difficulty in
obtaining medical care. Specifically, 72 percent
31
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HEALTH PROFESSIONS EDUCATION
had experienced difficulty in obtaining care
from a primary care physician, 79 percent from
a medical specialist, and 74 percent from
providers of drug therapy (Partnership for
Solutions, 2002b). This same survey indicated
that, as a result of the lack of coordination, the
chronically ill were receiving spotty or
contradictory information and facing avoidable
complications. At the summit, Mary Naylor
described a typical real-life example of the lack
of coordination for the chronically ill:
A 75-year old woman...had a
number of chronic conditions:
osteoporosis, hypertension,
diabetes, and heart failure, and...
was admitted to a hospital as a
result of a fall...and fracture....
We followed her...from hospital
admission, through one month's
time, and she was the subject of
about 20 major providers. That
does not include the numbers of
ancillary personnel and other
support people involved in her care.
While hospitalized, she interacted
with an orthopedic surgeon and his
team, a cardiologist, an
endocrinologist, a primary care
nurse, a physical therapist based in
the hospital, and a social worker
who helped facilitate her discharge
to a skilled nursing facility. At that
point, the hand-off was to a
physician in the skilled nursing
facility, a physical therapist, an
occupational therapist, and a
variety of other providers. Within
2 weeks' time, she was returned
home to home care follow-up by
the Visiting Nurse's Association,
and had a nurse, occupational
therapist, and physical therapist
engage with her in care in the
home.
Her care was characterized by poor
communication....Very little
attention twas paid] to her
preferences or the preferences of
her family members in decision
making about what care [she
should receive] and what site she
should go to, and what the plan of
care should be at each of those
sites. There was very poor transfer
of information from one site to the
other; in fact, critical pieces of her
care plan were not communicated
from the hospital to the nursing
home, resulting in an emergency
room visit within a couple of days
of discharge to the skilled nursing
facility. And there was no point
person, no broker of care, no one
there advocating for her, for her
family, and coordinating this entire
experience, all of which took place
in a very short period of time
(Naylor, 20024.
America's increasing chronic care needs
also highlight the importance of health
professionals being better prepared in
prevention and health promotion. It has been
estimated that approximately 40 percent of all
deaths are caused by behavior patterns that
could be modified (McGinnis et al., 2002~.
Prevention is also key in dealing with the
nation's emerging infections, both those that
occur naturally and those that are intentionally
introduced. Since the events of September 11,
2001, and the anthrax attacks that followed, the
once seemingly remote threat of a bioterrorist
attack in the United States has now become
plausible. The ability of health care
professionals to apply population-based
prevention strategies and activate the public
health system is crucial to an effective response
to such incidents. In a recent survey of health
professionals, however, only a quarter of
respondents said they felt prepared to respond to
a bioterrorist event (Chen et al., 20024.
In addition to the need for the health system
to be more responsive to those with chronic
conditions and more focused on prevention, the
system has not done a good job in
accommodating the diverse cultural needs and
varying preferences of racial and ethnic groups.
A recent IOM report that reviews a large body
of research concludes that racial and ethnic
minorities tend to receive lower-quality care
than Caucasians, even when one accounts for
differences in insurance status, income, age, and
severity of condition (Institute of Medicine,
32
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CHALLENGES FACING THE HEALTH SYSTEM
2002~. The IOM committee that prepared that
report outlined steps needed to close this gap,
including preparing health professionals to be
competent in providing care that is culturally
sensitive (Institute of Medicine, 20024. There is
added urgency to address such inequities given
that ethnic/racial minorities are predicted to
comprise a majority ofthe U.S. population by
2050 (U.S. Census Bureau, 20024.
Inability to Assimilate the Increasingly
Complex Science Base
Over the last 50 years, there has been a
steady increase in funding for biomedical
research that has resulted in extraordinary
advances in clinical knowledge and technology.
From a start of about $300 in 1887, the National
Institutes of Health (NIH) has been appropriated
nearly $23.4 billion for 2002 (National
Institutes of Health, 2002), while investment on
the part of pharmaceutical firms has risen from
$ 13.5 billion to $24 billion between 1993 and
1999 (Pharmaceutical Research and
Manufacturers of America, 20004. Likewise,
research and development in the medical device
industry, funded largely by private dollars,
totaled $~.9 billion in 1998 (The Lewin Group,
20004. Results of all this investment include a
doubling of the average number of new drugs
approved each year since the 1980s (The Henry
J. Kaiser Family Foundation, 2000) and
exponential growth in the number of clinical
trials from about 500 a year in the 1970s to
more than 10,000 a year today (Chassin, 1998~.
There are no signs that this growth is going to
abate any time soon nor would we want that to
happen.
Traditionally, it has been assumed that
health professionals are able to diagnose and
treat, evaluate new tests and procedures, and
develop clinical practice guidelines, all using
the training initially received from their
academic education and ongoing practice
experience. This assumption is no longer valid,
with human memory becoming increasingly
unreliable in keeping pace with the ever-
expanding knowledge base on effective care and
its use in health care settings. For clinicians,
just staying abreast of advances, let alone
obtaining active training in or experience with
new techniques and approaches, can be a
daunting task. As David Eddy, a prominent
quality expert, has said, the "complexity of
modern medicine exceeds the inherent
limitations of the unaided human
mind" (Millenson, 1997:754. Although no
practitioner needs to absorb the results of
10,000 clinical trials that span many areas of
specialty, rapid expansion of knowledge is
occurring even within specific areas. For
example, as William Richardson noted at the
summit, the number of randomized controlled
trials on diabetes published over the last 30
years increased from about 5 to more than 150
per year.
Few professionals are prepared to cope with
the continuously expanding knowledge and
technology base, and supports to help clinicians
access and apply this knowledge base to
practice are not widely available. Such supports
would include providing relevant information in
an accessible format at the point of care.
However, the literature is "replete with evidence
of the failure to provide care consistent with
well established guidelines for common chronic
conditions" (Institute of Medicine, 2001a: 28~.
And the lag between the discovery of more
effective forms of treatment and their
incorporation into routine patient care is, on
average, 17 years (Bales, 2001~. Obviously, the
health system needs to do better in this regard.
As William Richardson asked summit
participants, "If we can't keep up now, how will
we respond to the extraordinary advances that
will emerge during this new century?"
(Richardson, 20024. These advances include,
among others, the use of genomics to diagnose
and eventually treat disease; engineering
discoveries such as miniaturization and
robotics; and the application of advanced
epidemiological knowledge, especially as it
relates to bioterrorism, to large populations and
databases (Institute of Medicine, 2001 a).
33
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HEALTH PROFESSIONS EDUCATION
Slow Adoption of Information Technology
Information technology is poised to bring
about a significant transformation in the
nation's health system, with the Internet serving
as a major agent of change. The Quality Chasm
report stresses that the automation of clinical,
financial, and administrative transactions is
essential to improving quality, preventing
errors, enhancing consumer confidence in the
health system, and improving efficiency
(Institute of Medicine, 2001b). That report and
others, as well as the plenary address at the
summit by William Richardson, identify key
areas in which a communications and
information technology infrastructure could
contribute greatly to enhancing the health care
system (Institute of Medicine, 2001a; National
Research Council, 20004. These potential
contributions include enhancing clinical
decision making by making real-time data
available, increasing communication among
providers and with patients through such
approaches as remote medical consultations,
collecting and aggregating clinical information
and evidence into accessible information
databases, facilitating patient access to reliable
health information, and reducing medical errors.
Despite the range of areas in which
communications and information technology
could make a substantial contribution to
enhancing health care access, quality, and
service while reducing costs, the industry has
been slow to invest in and embrace such
technology. And while industries do differ in
their degree of capital intensiveness, the
differences in information technology
investment are striking. For example, in 1996
the health care industry spent only $543 per
worker on information technology, as compared
with $12,666 per worker spent by securities
brokers. Further, health care ranked 38th among
53 industries surveyed in terms of information
technology investment (IJ.S. Department of
Commerce, 20004.
Consequently, health care delivery has not
been touched to the same degree by the
revolution that has been transforming nearly
every other aspect of society (Institute of
Medicine, 2001a). Most clinical information is
still stored in a collection of poorly organized
and often illegible paper records (Staggers et al.,
200 1; Hagland, 200 1 ). Few patients have e-
mail access to their caregivers. Indeed, most
payment to providers is based on face-to-face
visits, and clinicians cannot get paid for the
kinds of alternative communication that
information technology offers and patients
desire. Most patients do not benefit from even
the simplest decision aids, such as patient
reminder systems. Finally, an unacceptable
number of medical errors occur because there
are few information systems in place to process
and check the vast amount of clinical data that
flows through the system (Godin et al., 1999~.
In short, existing systems typically do not
collect and store the right information; are not
sufficiently automated or computerized; are not
integrated or linked to each other; and lack the
hardware, software, and data entry support
necessary for retrieval and analysis of
information.
One impediment to the greater use of
communications and information technology is
the absence of national standards for the
capture, storage, communication, processing,
and presentation of health information (Work
Group on Computerization of Patient Records,
20004. Another is privacy and data security
issues. Regulatory requirements governing e-
mail use with patients, such as the Health
Insurance Portability and Accountability Act,
designed to help guarantee the privacy and
confidentiality of patient medical records, will
help somewhat in this regard. However, the
Quality Chasm report emphasizes that in the
absence of a national commitment and financial
support for building a national health
information infrastructure, progress in this area
will be painfully slow.
Failure to Address Growing Consumerism
Among Patients
There has been a growing consumerism in
health care, exemplified by increases in access
to health information on the Internet and other
34
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CHALLENGES FACING THE HEALTH SYSTEM
media (Calabretta, 2002; Frosch and Kaplan,
1999; Gerteis et al., 1993; Mansell et al., 2000;
Mazur and Hickam, 19974. Largely as a result
of the Internet, patients and their families are
now better educated and informed about their
health care. As a consequence, some patients
want to be able to make their own decisions
about diagnosis and treatment, bringing their
own information and values to bear, with the
expectation that, together with their health care
providers, they will manage their illness or
disease (Benbassat et al., 19984. In one survey,
only 16 percent had sought health information
via the Internet (Tu, 20034. While in another,
76 percent of respondents said they had
searched the Internet for health information
(Taylor, 20024. In that survey, 83 percent of
respondents said they would like the results of
their laboratory tests to be available online, and
69 percent expressed their desire for online
charts for use in monitoring their chronic
conditions over time. An annual Harris
Interactive Survey spanning 1998-2002 shows a
steady rise in adults who sometimes look for
health information online. One survey showed
that individuals span the education and income
spectrum (Taylor, 2002) while another showed
that higher educated individuals are more likely
to search the Internet for health information (Tu,
20034.
Many patients, however, have expressed
frustration with their inability to participate in
decision making, to obtain the information they
need, to be heard, and to participate in systems
of care that are responsive to their and their
families' and caregivers' needs and values
(Partnership for Solutions, 2002a). Studies have
demonstrated substantial shortcomings among
health professionals in understanding and
communicating with patients (Laine and
Davidoff, 1996; Meryn, 1998; Stewart et al.,
1999), as well as in their ability to provide
adequate information for informed decision
making (Braddock et al., 19994. An early
important study revealed that in 69 percent of
visits, physicians did not allow patients to
complete their opening statement of symptoms
and concerns, interrupting after a mean time of
1 ~ seconds. Patients were given the opportunity
to state their full list of concerns in only 23
percent of visits (Beckman and Frankel, 1984~.
A later study on the same topic revealed similar
results, with failure to obtain the patient's
complete agenda resulting in late-arising
concerns and missed opportunities to collect
potentially valuable information (Marvel et al.,
19994.
At the summit, Myrl Weinberg, National
Health Council, attested to the problems from a
patient's perspective:
What are the complementary
alternative s , treatments , over-the -
counter kinds of treatments that
people are taking that [are] never
asked about? So often, no one ever
asks. And if people are asked...
they don't understand the question,
and they think they're not taking
any other prescription drugs and
that's the end of it....Some of the
studies are showing that the reason
people pay billions of dollars for
complementary alternative products
through health food stores is
because they feel a sense of shared
values; that there's a holistic
approach for some of these other
health care providers or treatments.
And they feel more comfortable
there than they do any longer with
individuals in the more traditional
health care systems....It's not often
the health care provider says, "Gee,
I can't know it all, there's no way,
there are other great educational
sources, and here are some places
you can go or Web sites that you
can trust, to find out more about
your condition so that we can
discuss it when you're here
(Weinberg, 20024."
Workforce Shortages and Discontent
Health care has always been subject to
trends in oversupply and undersupply of various
health professionals, but the current shortage of
nurses is different, with many experts saying it
will not be resolved quickly (Buerhaus, 2000~.
In the year 2000, the nursing shortage was
35
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HEALTH PROFESSIONS EDUCATION
estimated at 6 percent, with 1.89 million full-
time registered nurses in the workforce and
demand projected at 2 million. If trends
continue, the shortage is predicted to skyrocket
to 29 percent by 2020 (Health Resources and
Services Administration, 2002~. Fully 75
percent of all current vacancies at hospitals are
for nurses (American Hospital Association,
20014. Though enrollments in entry-level
baccalaureate programs in nursing increased in
fall 2001, ending a 6-year period of decline, the
number of students in the educational pipeline is
still insufficient to meet the projected demand
for the million new nurses needed over the next
10 years (American Association of Colleges of
Nursing, 2002~. These problems are
exacerbated by an increasing shortage of
nursing faculty. According to the American
Association of Colleges of Nursing (AACN), of
more than 9,000 faculty at AACN-member
nursing schools, only slightly more than 50
percent have a doctorate, and there is a large
decrease in the number of nursing students with
a master's degree who are pursuing academic
careers (Berlin and Sechrist, 2002~.
Nurses also are increasingly dissatisfied
once they are on the job. A 2001 survey reveals
that 40 percent of nurses working in hospitals
are dissatisfied with their jobs, and 1 of 3
hospital nurses under the age of 30 is planning
to leave his or her current job in the next year
(Aiken et al., 20014. Sources of dissatisfaction
include working conditions, such as inadequate
staffing and higher use of less-skilled workers;
heavy workloads; increases in overtime; a lack
of sufficient support staff; and inadequacy of
wages (U.S. General Accounting Office, 2001~.
The nursing shortage and dissatisfaction of
registered nurses with their work environments
have taken a toll. An increasing number of
studies have shown that patient safety issues
and adverse health outcomes result, including
patient deaths, as well as increased stress
(physical and psychological), burnout, and
frustration among health professionals (Aiken et
al., 2002; Blegen et al., 1998; Buerhaus, 2000;
Flood and Diers, 1998; Kovner and Gergen,
1998; Lichtig et al., 1999; Sochalski, 20024.
The shortages have resulted in fragmentation of
care, with fewer opportunities for one-on-one
contact between patients and health
professionals.
Shortages in pharmacy are also pressing and
have been characterized as "dynamic," with
demand for pharmacy services increasing in
recent years despite a steady growth in supply
(Department of Health and Human Service,
2000; Knapp and Livesey, 2002~. The shortage
is attributable to a number of factors, including
patients' increased use of medications;
expansion of pharmacists' traditional roles to
include patient education, counseling, and
medication management; limited use of
technology and pharmacy technicians, as well
as poor work design; and greater numbers of
female pharmacists, who work fewer hours than
their male counterparts (Cooksey et al., 2002~.
There are conflicting reports on whether the
shortage will be long term (Cooksey et al.,
2002; Bureau of Labor Statistics. Pharmacists,
2000; Knapp, 19994.
While experts disagree about whether there
is a shortage of physicians (Cooper, 2002;
Cooper et al., 2002), physicians are increasingly
dissatisfied with their work life. Of some 1,900
recently surveyed physicians, 27 percent
anticipated leaving their practices within 2
years, with 29 percent of those being aged 34 or
younger (Pathman et al., 20024. In another
survey, 31 percent expressed worry that they
were "burning out" as physicians (Shearer and
Toedt,2001~. In Massachusetts, substantial
numbers of physicians surveyed were planning
to leave the state, change careers, or retire early
as a result of the current practice environment
(Massachusetts Medical Society Online, 2001~.
While there are shortages of some health
professionals, there is an increasing number of
professionals in other disciplines now joining
the ranks who are redefining care delivery.
Nurse practitioners, certified nurse midwives,
physician assistants, optometrists, podiatrists,
and nurse anesthetists have all increased in
number significantly in recent years (Cooper et
al., 1998), though poor national data hamper
accurate tabulations (Phillips et al., 20024.
36
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CHALLENGES FACING THE HEALTH SYSTEM
Regardless, such professionals' responsibilities
are increasingly overlapping with or
complementing those of physicians and nurses.
This situation is resulting in tremendous Fiction
among the professions over practice control and
compensation (Phillips et al., 2002), some of
which gets played out in legislative battles over
scope of practice.
Implications for Health Professions
Education
The challenges highlighted above call for
new roles and new approaches on the part of
health professionals. For one thing, to care
effectively for patients, the successful health
professional in this century will need to master
information technology, using its capabilities to
manage information and access the latest
evidence. Moreover, as patients arrive with
better and more information from the Internet
and increasingly insist that their desires, needs,
and values be met, health care professionals will
be called upon to modify their roles to include
those of counselor, coach, and partner.
Providing the high levels of coordination and
collaboration needed for the chronically ill
while addressing staff shortages will require that
health professionals work in interdisciplinary
teams, learning how to allocate responsibility
effectively and provide the appropriate skill mix
in a variety of settings and situations. Health
professionals must also have a grasp of design
and quality improvement principles so they can
streamline and standardize processes for better
safety and quality.
effectiveness of a system in responding to
patient needs depends upon a variety of
factors-facilities, supplies, state of knowledge,
information technology but such inputs are
meaningless without appropriately educated
professionals working within and continually
redesigning the system to adapt to ongoing and
future challenges. Implementing the agenda set
forth in the Quality Chasm report will
necessitate fundamental changes in health
professions education. Health professionals,
both those in academic settings and those
already in practice, must be educated differently
so that they can function as effectively as
possible in a reformed health care system one
focused on enhancing quality and safety. Most
important, professionals will need to break
down the silos that exist within the system, and
seek to understand what others offer in order to
do what is best for the patient. Further, health
professionals must be given the tools that will
empower them to make ongoing changes in the
system that will continuously enhance care for
patients. Although the need is pressing, major
challenges face those who would reform health
professions education. A number of those
challenges are cited in the Quality Chasm report
(Institute of Medicine, 2001a) and were echoed
at the Health Professions Education Summit:
.
As emphasized in the Quality Chasm report,
health professionals are working in a system
that often does not support them in delivering
the highest-quality care based on the latest
science, let alone care that pleases patients
(Institute of Medicine, 2001a). The report sets
forth a framework for how the system might be
transformed to close the chasm that exists
between what we know to be good-quality care
and what the system actually provides.
At the core of a redesigned health care
system are health professionals. The
A lack of funding to review curriculum and
teaching methods and of the resources
required to make needed changes
Too much emphasis on research and patient
care in many academic settings, with little
reward for teaching
A lack of faculty and faculty development to
ensure that faculty will be available at
training sites and able to teach students new
competencies effectively
No coordinated oversight across the
continuum of education, and fragmented
responsibilities for undergraduate and
graduate education
No integration across oversight processes,
including accreditation, licensing, and
certification
37
OCR for page 38
HEALTH PROFESSIONS EDUCATION
· The lack of an evidence base assessing the
impact of changes in teaching methods or
curriculum
· A shortage of visionary leaders
· Silo structures and long-standing disciplinary
boundaries among and across the professions
· Unsupportive culture and norms in health
professions education
· Overly crowded curricula and competing
demands
· Insufficient channels for sharing information
and best practices
In short, these challenges have prevented
the educational system from doing a better job
at meeting the requirements of the delivery
system. Leaders and managers of hospitals,
health plans, and health care practices cite
increasing skill deficits in their workforces,
including technical and computer skills, critical
thinking, communication, management,
delegation, supervision skills, and a systems
perspective (Allied Health Workforce
Innovations for the 21st Century Projects, 1999;
Institute of Medicine, 2000; National Council
for State Boards of Nursing, 2001~. Recent
graduates of educational programs cite similar
skill deficits in their preparation for modern
health care careers (Blumenthal et al., 2001;
Cantor et al., 1993~.
Conclusion
The above review of the dominant
challenges facing health care suggests several
key findings:
.
.
Poor systems design has led to
errors, poor quality of care, and
dissatisfaction among patients and
health professionals.
The needs of the chronically ill are
not being adequately met.
Addressing those needs requires the
reform of systems of care and
greater coordination and
collaboration among health
.
professionals, as well as more
attention to prevention and the
behavioral determinants of health.
Technological advances in
information technology and an
expanded evidence base gained from
research on clinical practice have the
potential to transform health care,
but such advances have not been
adequately harnessed.
· Patients and consumers are now
increasingly informed about their
health. As a result, there is a need
for a new relationship of shared
decision making between patients
and health care providers. Providers
also need to be more attentive to
patient values, preferences, and
cultural backgrounds.
· Workforce issues related to
.
shortages and effective deployment
of existing professionals need to be
addressed before quality of care is
further compromised.
Health care employers and recent
graduates cite gaps between the way
health professionals are prepared
and what they are called upon to do
in practice, gaps that are
attributable to many factors,
including a lack of funding to
revamp curricula and a limited focus
on teaching in academic health
centers.
The Quality Chasm report, echoed by each
of the plenary speakers at the summit, calls
upon the clinical education community to
provide transformational leadership in response
to the challenges outlined above. At the
summit, Don Berwick, Institute for Healthcare
Improvement, described the purpose of the
health care system initially articulated by the
President's Advisory Commission on Consumer
Protection and Quality in the Health Care
Industry as continually reducing the burden of
illness, injury, and disability and improving the
health status and functioning of the U.S.
38
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CHALLENGES FACING THE HEALTH SYSTEM
population. He added:
The success of the American
professional "health] education
system is its ability to achieve this
and nothing else. It's asking the
American "health] professional
education community to adopt this
as 'true North' (Berwick, 20024.
Also at the summit, Ken Shine called upon
health professionals to establish themselves as
leaders on behalf of the American people by
improving the quality of care. He added:
Doing that is not just a self-serving
activity. It's one which all of
society will cherish and benefit
from, and I believe it's a message
which our students will respond to
if they are properly motivated and
have the proper insights (Shine,
2002).
These statements were intended to be a
catalyst for health summit participants as they
identified strategies and actions at both the
institutional and environmental levels for
bringing about educational reform in line with
the vision for a 21St-century health system set
forth in the Quality Chasm report. Don
Berwick acknowledged the tremendous
difficulties involved in bringing about change in
the environment of health care and clinical
education, but underscored the importance of
the effort:
You can't just say the environment
won't let you do it. You just can't.
It's passing the buck a step beyond
what a proud set of professionals
ought to be doing. We need to own
it. We need to change it. We just
need to change it. And if the
environment is throwing us a curve
ball, we just need to learn how to
hit curve balls.
References
Aiken, L.H., S.P. Clarke, and D.M. Sloane. 2002.
Hospital staffing, organization, and quality of
care: Cross-national findings. International
Journalfor Quality in Healthcare 14 (1~:5-13.
Aiken, L.H., S.P. Clarke, D.M. Sloane, J.A.
Sochalski, R. Busse, H. Clarke, P. Giovannetti,
J. Hunt, A.M. Rafferty, and J. Shamian. 2001.
Nurses reports on hospital care in five countries.
Health Affairs 20 (3~:43-53.
Allied Health Workforce Innovations for the 21st
Century Projects. 1999. "The Hidden Health
Care Workforce: Recognizing, Understanding
and Improving the Allied and Auxiliary
Workforce." Online. Available at http://
futurehealth.ucsf. edu/AHexecsum.html
American Association of Colleges of Nursing. 2002.
"Enrollments Rise at U.S. Nursing Colleges and
Universities Ending a Six-Year Period of
Decline." Online. Available at http://www.aacn.
nche. edu/Media/NewsReleases/enrlO l .htm
[accessed 20023.
American Hospital Association. 2000. Resource
Center Fact Sheet. Fast Facts on U.S. Hospitals.
Hospital Statistics, 2000. Chicago, IL: Health
Forum - An American Hospital Association
Company.
American Hospital Association. 2001. The hospital
Workforce shortage: immediate and future.
Trend Watch 3 (2~: 1-8.
American Nurses Association/NursingWorld.Org.
2001. "On-line Health and Safety Survey: Key
Findings." Online. Available at http://
nursingworld.org/surveys/keyf~nd.pdf [accessed
20023.
Balas, E.A. 2001. Information systems can prevent
errors and improve quality. Journal of the
American Medical Informatics Association 8
(4~:398-99.
Beckman, H.B., and R.M. Frankel. 1984. The effect
of physician behavior on the collection of data.
Annals ofInternalMedicine 101 (5~:692-6.
Benbassat, J., D. Pilpel, and M. Tidhar. 1998.
Patients preferences for participation in clinical
decision making: A review of published surveys.
BehavorialMedicine 24~2~:81-88.
Berlin, L.E., and K.R. Sechrist. 2002. The shortage
of doctorally prepared nursing faculty: A dire
situation. Nursing Outlook 50 (2~:50-56.
Berwick, D. 2002. "Crossing the Quality Chasm:
Next Steps for Health Professions Education;
Keynote Address." Online. Available at http://
w w w . k a i s e r n e t w 0 r k . o r g / h e a 1 t h _ c a s t /
hcast_index.ctm?display=detail&hc=601
~2 cat
OCR for page 40
HEALTH PROFESSIONS EDUCATION
[accessed Nov. 12, 20023.
Blegen, M.A., C.J. Goode, and L. Reed. 1998.
Nurse Staffing and Patient Outcomes. Nursing
Research 47 (14:43-50.
Blendon, R.J., C.M. DesRoches, M. Brodie, J.M.
Benson, A.B. Rosen, E. Schneider, D.E. Altman,
K. Zapert, M. J. Herrmann, and A.E. Steffenson.
2002. Views of practicing physicians and the
public onmedicalerrors. NEnglJMed 347
(244: 1933-40.
Blendon, R.J., C. Schoen, K. Donelan, R. Osborn, C.
M. DesRoches, K. Scoles, K. Davis, K. Binns,
and K. Zapert. 2001. Physicians views on
quality of care: A five-country comparison.
Health Affairs 20 (3~:233-43.
Blumenthal, D., M. Gokhale, E.G. Campbell, and J.
S.Weissman. 2001. Preparedness for clinical
practice: Reports of graduating residents at
academic health centers. Journal of the
American Medical Association 286 (94: 1027-
34.
Braddock, C.H.3., K.A. Edwards, N.M. Hasenberg,
T.L. Laidley, and W. Levinson. 1999.
Informed decision making in outpatient practice:
Time to get back to basics. Journal of American
Medical Association 282 (244:2313-20.
Buerhaus, P. 2000. A Nursing Shortage Like None
Before. Creative Nursing 6 (2~:4-8.
Bureau of Labor Statistics. Pharmacists. 2000.
Occupational Outlook Handbook. Washington,
DC: U.S. Department of Commerce.
Calabretta, N. 2002. Consumer-driven, patient-
centered health care in the age of electronic
information. Journal of Medical Library
Association 90 (14:32-37.
Cantor, J.C., L.C. Baker, and R.G. Hughes. 1993.
Preparedness for practice. Young physicians
views of their professional education. JAM~4
270 (94:1035-40.
Center for Studying Health System Change. 2002.
"CTSonline: Physician survey results. " Online.
Available at http://www.hschange.com/index.
cgi?file=ctsl [accessed 20023.
Chassin, M.R. 1998. Is health care ready for Six
Sigma quality? Milbank Quarterly 76~44:565-
91, 510.
Chassin, M.R., R.W. Galvin, and the National
Roundtable on Health Care Quality. 1998. The
40
urgent need to improve health care quality.
Journal of the American Medical Association
280 (11~:1000-1005.
Chen, F.M., J. Hickner, K.S. Fink, J.M. Galliher, and
H. Burstin. 2002. On the frontlines: family
physicians preparedness for bioterrorism.
Journal of Family Practice 51 (94:745-50.
Cooksey, J.A., K.K. Knapp, S.M. Walton, and J.M.
Cultice. 2002. Challenges to the pharmacist
profession from escalating pharmaceutical
demand. Health Aff(Millwood) 21 (54:182-88.
Cooper, R.A. 2002. There's a shortage of
specialists: Is anyone listening? Academic
Medicine 77 (84:761-6.
Cooper, R.A., T.E. Getzen, H.J. McKee, and P.
Laud. 2002. Economic and demographic trends
signal an impending physician shortage. Health
Affairs 21 (1~:140-54.
Cooper, R.A., T. Henderson, and C.L. Dietrich.
1998. Roles of nonphysician clinicians as
autonomous providers of patient care. Journal
of the American Medical Association 280
(94:795-802.
deBusk, R.F., N.H. Miller, H.R. Sup erko, C.A.
Dennis, R.J. Thomas, H.T. Lew, W.E. Berger
3rd, R.S. Heller, J. Rompf, D. Gee,et al. 1994.
A case-management system for coronary risk
factor modification after acute myocardial
infarction. Annals of Internal Medicine 120
(94:721-9.
Depardnent of Health and Human Service. 2000.
"The Pharmacist Workforce: A Study of the
Supply and Demand for Pharmacist. " Online.
Available at Pcp://ftp.hrsa.gov/bhpr/
nationalcenter/pharmacy/pharmstudy.pdf
[accessed 20023.
Flood, S.D., and D. Diers. 1998. Nurse staffing,
patient outcome, and cost. Nursing
Management 19 (54:34-43.
Frosch, D.L., and R.M. Kaplan. 1999. Shared
decision making in clinical medicine: Past
research and future directions. American
Journal of Preventive Medicine 17 (4~:285-94.
Gerteis, M., S. Edgman-Levitan, J. Daley, and T.
Delbanco, editors. 1993. Through the patient
Eyes. Vol. San Francisco, CA: Josey-Bass.
Godin, P., R. Hubbs, B. Woods, M.M. Tsai, D.B.
Nag, T.M. Rindfleish, P.P. Dev, and K.L.M.
OCR for page 41
CHALLENGES FACING THE HEALTH SYSTEM
Melmon. 1999. New paradigms for medical
decision support and education: The Stanford
health information network for education.
Topics in Health Information Management 20
(2~:1-14.
Harris Interactive and ARIA Marketing. 2000.
"Healthcare Satisfaction Study--Final Report."
Online. Available at http://www.
harrisinteractive. coin/news/downloads/
HarrisAriaHCSatRpt.PDF [accessed Oct., 20023.
Health Resources and Services Administration.
2002. "Projected Supply, Demand, and
Shortages of Registered Nurses: 2000-2020."
Online. Available at http://bhpr.hrsa.gov/
healthworkforce/rnproject/default.htm [accessed
Aug. 28, 20023.
Helmreich, R.L. 2000. On error management:
Lessons from aviation. British Medical Journal
320 (7237):781-85.
Institute of Medicine. 2000. To Err Is Human:
Building a Safer Health System. Linda T.
Kohn, Janet M. Corrigan, and Molla S.
Donaldson, eds. Washington, DC: National
Academy Press.
. 2001a. Crossing the Quality Chasm: A New
Health System for the 21st Century.
Washington, DC: National Academy Press.
200 lb. Improving the Quality of Long-
Term Care. GS Wunderlich and Peter O Kohler.
Washington, DC: National Academy Press.
Institute of Medicine. 2002. Unequal Treatment:
Confronting Racial and Ethnic Disparities in
Health Care . Washington, DC: National
Academy Press.
Kaiser Family Foundation and Health Research and
Educational Trust. 2002. "2002 Employer
Health Benefits Survey." Online. Available at
http ://www.kff.org/content/2002/20020905a/
[accessed Sept. 13, 20023.
Knapp, K.K. 1999. Charting the demand for
pharmacists in the managed care era. JAm
Pharm Assoc (Nash) 39 (44:531-6.
Knapp, K.K., and J.C. Livesey. 2002. The
Aggregate Demand Index: Measuring the
balance between pharmacist supply and demand,
1999-2001. JAm Pharm Assoc (Wash) 42
(3~:391-8.
Kovner, C., and P.J. Gergen. 1998. Nurse Staffing
Levels and Adverse Events Following Surgery
in U.S. Hospitals. Image: Journal of Nursing
Scholarship 30 (4):315-21.
Laine, C., and F. Davidoff. 1996. Patient-centered
medicine. A professional evolution. Journal of
American Medical Association 275 (2~: 152-6.
Larson, E. 1999. The impact of physician-nurse
interaction on patient care. Holistic Nursing
Practice 13 (2~:38-46.
Lesser, C.S., and P.B. Ginsburg. 2000. Update on
the nations health care system: 1997-1999.
Health Affairs 19 (6~:206-16.
Lichtig, L., R.A. Knauf, and D.K. Milholland. 1999.
Some aspects of nursing on acute care hospital
outcomes. Journal of Nursing Administration
29 (24:25-33.
Mansell, D., R.M. Poses, L. Kazis, and C.A.
Duefield. 2000. Clinical factors that influence
patients desire for participation in decisions
about illness. Archives of Medicine 160:2991 -
96.
Marvel, M.K., R.M. Epstein, K. Flowers, and H.B.
Beckman. 1999. Soliciting the patients agenda:
Have we improved? Journal of the American
Medical Association 281 (3~:283-87.
Massachusetts Medical Society Online. 2001.
"Physician Satisfaction Survey 2001." Online.
Available at http://www.massmed.org/pages/
physiciansatisfaction.asp [accessed 20023.
Mazur, D.J. and D.H. Hickam. 1997. Patients
preferences for risk disclosure and role in
decision making for invasive medical
procedures . Journal of General Internal
Medicine 12:114-17.
McGinnis, J., P. Russo, and J. Knockman. 2002.
The case for more active policy attention to
hearth promotion. Health Affairs 21 (2~:78-93.
Meryn, S. 1998. Improving communication skills:
To carry coals to... Medical Teacher 20
(4~:331-37.
Millenson, M. L. 1997. Demanding Medical
Excellence. Chicago: University of Chicago
Press.
National Center for Health Statistics. 2002. "Health,
United States 2002, with health and aging
chartbook." Online. Available at http://www.
cdc.gov/nchs/data/hus/husO2cht.pdf [accessed
20023.
41
OCR for page 42
HEALTH PROFESSIONS EDUCATION
National Council for State Boards of Nursing. 2001.
Report of Findings from the 2001 Employers
Survey. Chicago, IL: National Council for State
Boards of Nursing.
National Institutes of Health. 2002. "An Overview."
Online. Available at http://www.nih.gov/about/
NIHoverview.html [accessed Aug. 11, 20023.
National Research Council. 2000. Networking
Health: Prescriptions for the Internet.
Washington DC: National Academy Press.
Naylor, M. 2002. "Crossing the Quality Chasm: Next
Steps for Health Professions Education; Panel
Discussion." Online. Available at http://www.
kaisernetwork. org/health_cast/hcast_index. cam?
display=detail&hc=601 [accessed Nov. 12,
2002].
Partnership for Solutions. 2002a. "Multiple Chronic
Conditions: Complications in Care and
Treatment." Online. Available at http://www.
partnershipborsolutions. org/pdf_files/2002/
multiplecoitions.pdf [accessed July 30, 2002a].
. 2002b. "Physician Concerns: Caring for
People with Chronic Conditions." Online.
Available at http://www.partnershiptorsolutions.
org/pdf_files/2002/physicianccern.pdf [accessed
Oct. 8, 2002b].
Pathman, D.E., T.R. Konrad, E.S. Williams, W.E.
Scheckler, M. Linzer, and J. Douglas. 2002.
Physician job satisfaction, dissatisfaction, and
turnover. JournalofFamily Practice 51
(7):593.
Pharmaceutical Research and Manufacturers of
America. 2000. "PhRMA Annual Report, 2000-
2001." Online. Available at http://www.phrma.
org/publications/publications/annual2000/
[accessed Nov. 11, 20003.
Phillips, R.L. Jr, D.C. Harper, M. Wakefield, L.A.
Green, and G.E. Fryer, Jr. 2002. Can nurse
practitioners and physicians beat parochialism
into plowshares? Health Affairs 21 (5~:133-42.
Presidents Advisory Commission on Consumer
Protection and Quality in the Health Care
Industry. 1998. "Quality First: Better Health
Care for All Americans." Online. Available at
http://www.hcqualitycommission.gov/final/
[accessed Sept. 9, 20003.
Richardson, W. 2002. "Crossing the Quality Chasm:
Next Steps for Health Professions Education;
Plenary Session." Online. Available at http://
w w w . k a i s e r n e t w o r k . o r g / h e a 1 t h _ c a s t /
hcast_index.ctm?display=detail&hc=601
[accessed Nov. 12, 20023.
Shearer, S., and M. Toedt. 2001. Family physicians'
observations of their practice, well being, and
health care in the United States. Journal of
Family Practice 50 (9):751-6.
Shine, K. 2002. "Crossing the Quality Chasm: Next
Steps for Health Professions Education; Plenary
Session." Online. Available at http://www.
kaisernetwork. org/health_cast/hcast_index. cam?
display=detail&hc=601 [accessed Nov. 12,
20023.
Sochalski, J. 2002. Nursing shortage redux:
Turning the corner on an enduring problem.
Health Affairs 2 1 (54: 1 57-64.
Stewart, M., J.B. Brown, H. Boon, J. Galaj da, L.
Meredith, and M. Sangster. 1999. Evidence on
patient-doctor communication. Cancer
Prevention Control 3 (14:25-30.
Taylor, H. 2002. "The Harris Poll: Cyberchondriacs
Update." Online. Available at http://www.
harrisinteractive. com/harris~oll/index. asp?
PID=299 [accessed 20023.
The Henry J. Kaiser Family Foundation. 2000.
Prescription Drug Trends - A Chartbook.
Menlo Park, CA: The Henry J. Kaiser Family
Foundation.
The Lewin Group, I. 2000. OutlooLfor Medical
Technology Innovation: Will Patients Get the
Care They Need. Report #1: The State of the
Industry. Washington, DC: Health Insurance
Manufacturers Association.
Tu, H.T. and J.L. Hargraves. 2003. Seeking health
care information: most consumers still on the
sidelines. Issue Brief Cent Stud Health Syst
Change (61):1-4.
U.S. Census Bureau. 2002 . "National Population
Projections." Online. Available at http://www.
census. gov/population/www/proj ections/natsum.
html [accessed Fall, 20023.
U.S. Depardnent of Commerce. 2000. "Falling
Through the Net: Toward Digital Inclusion. A
Report on American's Access to Technology
Tools." Online. Available at http://www.ntia.
doc.gov/ntiahome/digitaldivide/ [accessed Sept.
30, 20023.
U.S. General Accounting Office. 2001. "Nursing
42
OCR for page 43
CHALLENGES FACING THE HEALTH SYSTEM
Workforce: Emerging Nurse Shortages Due to
Multiple Factors." Online. Available at http://
www.gao.gov/new.items/dO 1944.pdf [accessed
Fall, 20023.
Von Korff, M., J. Gruman, J. Schaefer, S.J. Curry,
and E.H. Wagner. 1997. Collaborative
management of chronic illness. Annals of
Internal Medicine 127 ~ 12~: 1097- 102.
Wagner, E.H., B.T. Austin, C. Davis, M. Hindmarsh,
J. Schaefer, and A. Bonomi. 2001. Improving
chronic illness care: Translating evidence into
action. Health Affairs 20 (6~:64-78.
Wagner, E.H., B.T. Austin, and M. Von Korff.
1996. Organizing care for patients with chronic
illness. [Review] [121 refs]. Milbank Quarterly.
74 (44:511-44.
Weinberg, M. 2002. ""Crossing the Quality Chasm:
Next Steps for Health Professions Education";
Panel Discussion." Online. Available at http://
w w w . k a i s e r n e t w o r k . o r g / h e a 1 t h _ c a s t /
hcast_index.ctm?display=detail&hc=601
[accessed Nov. 12, 20023.
Work Group on Computerization of Patient Records.
2000. Toward a National Health Information
Infrastructure: Report of the Work Group on
Computerization of Patient Records.
Washington, DC: U.S. Department of Health
and Human Services.
Wu, S., and A. Green. 2000. Projection of Chronic
Illness Prevalence and Cost Inflation.
California: RAND Health.
43
OCR for page 44
Representative terms from entire chapter:
health professions
