Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century

Executive Summary

A New World for Health Care American health care is experiencing fundamental change. What was recently conceived as a set of policy changes for reform is now being lent the form and weight of institutional reality by the enormous power of the trillion dollar health care market. In five brief years the organizational, financial and legal frameworks of much of the U.S. health care industry have been transformed to emerging systems of integrated care that combine primary, specialty and hospital services. These systems attempt to manage the care delivered to enrolled populations in such a manner as to achieve some combination of cost reduction, enhanced patient and consumer satisfaction, and improvement of health care outcomes.

Within another decade 80-90% of the insured population of the U.S. will receive its care though one of these systems. By the end of this century these forces will interact in such a manner as to produce an American health care system that, in general, will be:

         more managed with better integration of services and financing

         more accountable to those who purchase and use health services

         more aware of and responsive to the needs of enrolled populations

         able to use fewer resources more effectively

         more innovative and diverse in how it provides for health

         more inclusive in how it defines health

         more concerned with education, prevention and care management and less focused on treatment

         more oriented to improving the health of the entire population

         more reliant on outcomes data and evidence.


The Impact on the Nation's 10 Million Health Care Workers

This demand-driven system in health care and health professions practice will create difficult realities for many health professionals and great opportunities for others. Some of these realities will be:

CLOSURE of as many as half of the nation's hospitals and loss of perhaps 60% of hospital beds

MASSIVE EXPANSION of primary care in ambulatory and community settings

SURPLUSES in the supply of physicians - 100,000 to 150,000, as the demand for specialty care shrinks; nurses - 200,000 to 300,000, as hospitals close; and pharmacists - 40,000, as the dispensing function for drugs is automated and centralized

CONSOLIDATION of many of the over 200 allied health professions into multi-skilled professions as hospitals re-engineer their service delivery programs

DEMANDS for public health professionals to meet the needs of the market-driven health care system

FUNDAMENTAL ALTERATION of the health professional schools and the ways in which they organize, structure and frame their programs of education, research and patient care.


The Implications for the System that Produces Health Professionals

Because health care is a labor-intensive enterprise, the next stage in our present cycle of change will demand a rapid transformation in:

         how health professionals are prepared for practice

         how that practice is regulated

         the educational programs that prepare them for practice.

The knowledge, skills, competencies, values, flexibility, commitment and morale of the health professional workforce serving the systems of care will become the most important factors contributing to the success or failure of the system. In response to these circumstances, the system that produces health professionals and the structures in which they work will shift away from its supply orientation and toward a demand-driven system. This situation will create four challenges to the ways health professionals practice and are educated and trained:

CHALLENGE 1: Redesigning the ways in which health professional work is organized in hospitals, clinics, private offices, community practices, and public health activities.

CHALLENGE 2: Re-regulating the ways in which health professionals are permitted to practice, allowing more flexibility and experimentation, but ensuring that the public's health is genuinely protected.

CHALLENGE 3: Right-sizing the health professional workforce and the institutions that produce health professionals. For the most part this will mean reducing the size of the professions and programs.

CHALLENGE 4: Restructuring education to make efficient use of the resources that are allocated to it.


The Recommendations of the Commission

This report is intended to be a guide for surviving the transformation and thriving in the emerging health care culture. It is an attempt to balance market-driven realities, institutional prerogative and public need. Failure to take up these challenges by institutional, professional or policy leaders is an abdication of their responsibilities to their patients, their students and ultimately to the public they are obligated to serve.


The Commission makes the following recommendations for all health professionals:

A1: All health professional schools must enlarge the scientific bases of their educational programs to include the psycho-social-behavioral sciences and population and health management sciences in an evidence-based approach to clinical work.

A2: While legitimate areas of specialized study should remain the domain of individual professional training programs, key areas of pre-clinical and clinical training must be integrated as a whole, across professional communities, through increased sharing of clinical training resources, more cross-teaching, more exploration of the various roles played by professionals and the active modeling of effective team integration in the delivery of efficient, high-quality care.

A3: The next generation of professionals must be prepared to practice in more intensively managed and integrated systems. Specifically, the clinicians of the future will be required to use the sophisticated information and communications technology to promote health and prevent disease, to sharpen their skills in areas ranging from clinical prevention to health education to the effective use of political reforms to change the burden of disease, to be more customer- or consumer-focused and to be ready to move into new roles that ask them to strike an equitable balance between resources and needs.

A4: There is a substantial body of literature which concludes that culturally sensitive care is good care. This means two things for all health professional schools. First, they must continue their commitment to ensure that the students they train represent the rich ethnic diversity of our society. Important investments and many successes have been achieved, but this is an obligation that must be continued at each institution until it is no longer an issue. Second, diversifying the entering class is not sufficient to ensure understanding and appreciation of diversity. Cultural sensitivity must be a part of the educational experience that touches the life of every student.

A5: Every professional school must be willing to develop partnerships and alliances that have not been a part of education in the past - partnerships with managed care for training, clinical research, and tertiary care referrals; with computer and software companies to develop information and communications systems; partnerships with integrated systems to support health services research; and partnerships with state government to determine the best ways to meet the health needs of the public.

A6: All health professions must recognize that the current health professions regulatory system needs to change. Health professionals must work with state legislators and regulators to ensure that regulation is standardized where appropriate; accountable to the public; flexible to support optimal access to a competent workforce; and effective and efficient in protecting and promoting the public's health, safety and welfare.


The Commission makes the following recommendations for Allied Health:

B1: Restructure the mission and organization of allied health education programs to focus on local community health needs identified through partnerships with delivery systems, professional associations, educators, regulators, consumers, and the public.

B2: Focus allied health curriculum on related discipline clusters, multi-skilling and interdisciplinary core curricula.

B3: Improve student and professional articulation and career ladders within disciplines and between professions.

B4: Improve education-practice linkages with diverse care delivery environments, such as managed care, home health care, and ambulatory care, for the benefit of both faculty and students.

B5: Increase recruitment of minority, disabled and disadvantaged students and practitioners.

B6: enhance faculty leadership skills and competence in clinical outcomes and effectiveness research.

B7: Establish innovative collaborations among professional associations.

B8: Improve the collection, evaluation and dissemination of data and innovations related to allied health education, training, practice, and regulation.


The Commission makes the following recommendations for Dentistry:

C1: Maintain the entering dental school class size at its 1993 level (4,001 students).

C2: Create the opportunity for a post-graduate year of training for all graduating general dentists. New opportunities should be developed in private practice and managed care settings.

C3: Accomplish the training for a dental degree and the one year of post-graduate training in four years of post-baccalaureate training.

C4: Create adequately funded, managed dental care partnerships between dental schools and their clinics and the emerging integrated health care system.

C5: Change the clinical training of dentists to reflect a broader orientation to the efficient management of quality dental care.

C6: Integrate dental education more thoroughly with that of the other health professions.

C7: Increase the productivity of dentists through the efficient and effective use of dental hygienists and dental assistants.

C8: Decrease the tuition dependency of dental schools, and subsequent student indebtedness by developing efficiently managed dental school clinical models and the creation of endowments, scholarships and loan programs for students.


The Commission makes the following recommendations for Medicine:

D1: Decrease the number of graduate medical training positions to the number of U.S. medical school graduates plus 10%.

D2: By 2005 reduce the size of the entering medical school class in the U.S. by 20-25%. This would mean a reduction from the 1995 class of 17,500 to an entering class size of 13,000 to 14,000 for 2005. This reduction should come from closing medical schools, not reducing class size.

D3: Change immigration law to tighten the visa process for international medical graduates, ensuring that they return to their native countries for service upon completion of training.

D4: Redirect graduate medical training programs (6,951 programs as of 1991) so that a minimum of 50% of them are in the primary care areas of family medicine, general internal medicine and general pediatrics by the year 2000.

D5: Move training of physicians at the undergraduate and graduate levels into community, ambulatory and managed-care based settings for a minimum of 25% of clinical experience.

D6: Create a public-private payment pool for funding health professions education that is tied to all insurance premiums and is designed to achieve policy goals serving the public's health.

D7: establish an enlarged National Health Service Corps to attract graduate physicians into service roles currently being met by the excessive number of residency positions


The Commission makes the following recommendations for Nursing:

E1: Recognize the value of the multiple entry points to professional practice available to nurses through preparation in associate, baccalaureate and masters programs; each is different, and each has important contributions to make in the changing health care system.

E2: Consolidate the professional nomenclature so that there is a single title for each level of nursing preparation and service.

E3: Distinguish between the practice responsibilities of these different levels of nursing, focusing associate preparation on the entry level hospital setting and nursing home practice, baccalaureate on the hospital-based care management and community-based practice, and masters degree for specialty practice in the hospital and independent practice as a primary care provider. Strengthen existing career ladder programs in order to make movement through these levels of nursing as easy as possible.

E4: Reduce the size and number of nursing education programs (1,470 basic nursing programs as of 1990) by 10-20%. These closings should come in associate and diploma degree programs. These closings should pay attention to the reality that many areas have a shortage of educational programs and many more have a surplus.

E5: Encourage the expansion of the number of masters level nurse practitioner training programs by increasing the level of federal support for students.

E6: Develop new models of integration between education and the highly managed and integrated systems of care which can provide nurses with appropriate training and clinical practice opportunities and which can model flexible work rules that encourage continual improvement, innovation and health care work re-design.

E7: Recover the clinical management role of nursing and recognize it as an increasingly important strength of training and professional practice at all levels.


The Commission makes the following recommendations for Pharmacy:

F1: Reduce the number of pharmacy programs (75 schools and colleges in 1995) by 20-25% by the year 2005. These closings should target institutions exclusively offering the professional baccalaureate degree.

F2: Recognize the need to evenly distribute these closings to accommodate underserved areas, but to close those programs that remain oriented toward the Bachelor of Pharmacy degree.

F3: Focus professional pharmaceutical training even more on issues of clinical pharmacy, system management and working with other health care providers.


The Commission makes the following recommendations for Public Health:

G1: Create new public health education programs that bring together the traditional public health disciplines with the clinical professions. These programs should be created in conjunction with state governments, local governments, managed care organizations and other non-academic institutions.

G2: Develop partnerships to apply population health management skills to the problems that are now faced by highly managed and integrated systems of care. These partnerships should include research, service and training components.

G3: Build programs at the federal, state and managed care organization levels to continue and enlarge the support base for a broad range of psycho-social-behavioral research and training.

G4: Reframe public health as a basic science in the personal and clinical health sciences and incorporate the new knowledge, skills and competencies related to the analysis of health care as a system, and to the re-design of work for the continual improvement and innovation of care.

G5: Recognize the obligation at the state and federal level to adequately fund public health education and practice institutions, particularly in an era of market-driven health care.