The Medical Education Futures Study Blog

As President Elect Obama prepares to assume office he faces unprecedented challenges, including the worst economic crisis in decades, military conflicts and a volatile international arena.   Winning with a platform promising change, government accountability and educational and health equity for all, expectations for the new president are unlike any before.

As this new administration begins to build a domestic policy agenda, health reform - and its choking economic impact- will be a first priority. We now know this effort will be capably lead by soon-to-be Secretary Tom Daschle.  If he can keep to his core vision that any re-crafting of our health system must be comprehensive and heavily weighted in favor of outcomes and effectiveness, then efforts to address lack of health insurance, high (and rising) costs of care, access to care, improving quality and reducing medical errors, may be within our collective reach.  However, central to addressing any and all of these broken, costly components of our health care system is, having an adequate number of scientifically well-trained, culturally – competent, racially and ethnically diverse health professionals.   

Today we have a significant , and  in some cases and places, desperate shortage of health professionals in nursing, medicine, pharmacy, public health and other health professions.

To make our healthcare system “work” – to make it a cost effective, outcomes driven system that can deliver quality care to ALL our citizens,  policy reforms are needed that can begin to immediately address this lack of trained manpower.

The increasing diversity of our nation’s population makes it imperative that efforts be made to develop a health workforce which is more diverse – racially, ethnically, and culturally.   One of the commentaries in The Sullivan Commission 2004 report, Missing Persons: Minorities in the Health Professions, was “the fact that the nation’s health professionals have not kept pace with changing demographics may be an even greater cause of disparities in health access and outcomes than the persistent lack of health insurance for tens of thousands of Americans.” 

Just last Friday, December 12^th, 2008,  a new report released by the Institute of Medicine, HHS in the 21^st Century, Charting a New Course for a Healthier America  identified “Strengthening  the HHS and U.S. public health and health care workforces” as one of   five key areas for recommended action.   

We have a new administration with a public commitment to develop a diverse, well trained health professions’ workforce to support our citizens in the 21^st century.

I am personally encouraged by the steps being taken by the President Elect and his senior leadership to engage the country in this crucial process.  I look forward to supporting policy changes that will directly and immediately begin to address and to close significant gaps in our nation’s health care workforce.

Louis W. Sullivan, M.D.

Chairman

The Sullivan Alliance 

With support from the Kellogg Foundation, The Sullivan Alliance was formed in 2005 to address the need for more diversity among the nation’s health professionals in efforts to improve access to health services for medically – underserved populations

In 1954, Darrell Huff wrote a book entitled, “How to Lie with Statistics” which suggests the way statistical analyses are chosen and presented can bend the truth.  This month’s Health Affairs web exclusive suggests we could all use a review of this lesson.

On Dec. 4, Health Affairs released a package of web exclusives - a sort of point-counterpoint examining the relationship between physician supply, workforce composition and health care quality.  Buz Cooper’s article: States with More Physicians Have Better Quality of Health.  Baiker and Chandra’s response: Cooper’s Analysis is Incorrect.

For the non-statistician, Baiker and Chandra’s arguments are at times confusing and Cooper’s graphics appear compelling.  Cooper finds that states with more physicians per capita generally rank higher in state health care quality rankings.  He also finds that states with more specialists are associated with higher state incomes per capita. 

But, does this mean that more specialists result in better quality (Figure A) or does it mean that higher income results in better quality and incidentally more specialists (Figure B)?  Where is the true causal relationship?  Are more specialists only a representation of higher income and otherwise unrelated to quality?

In this case, income might be considered a “confounding factor” – in other words, income is related to both quality and the number of specialists, and the failure to control for income in the analysis may lead to an inaccurate conclusion that more specialists equals better quality.  These are hypothetical arguments.  I have not done the analysis either to support or negate Cooper’s arguments.  However, Baiker and Chandra find that when they compare areas with the same number of total physicians, areas with higher generalist to specialist ratios have better quality and lower costs.