The Reason Counting Heads Is Not Enough

By: Karyn B. Stitzenberg, MD, MPH, assistant professor, Surgical Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill School of Medicine

The science of modeling the physician workforce is far from precise. For decades, stakeholders have argued over whether the nation will face a surplus or shortage of physicians, often drawing differing conclusions from the same data. The attempt by Dr. Holmes and colleagues to refine the methodology for workforce projections is laudable and an important step forward.

Their work is based on the concept that specialty is a poor surrogate for a physician’s scope of practice. In other words, the scope of services provided by physicians of different specialties often overlap. At the same time, two providers of the same specialty with the same educational and training background may provide very different services in practice. The implication is that the health care needs of two different populations may be met by entirely different configurations of specialists.

In my own field, surgery, this is seen very clearly. Many types of specialists receive base training and board certification in general surgery, yet the services they ultimately provide in practice can be quite variable. There are many factors that influence how a physician develops his or her scope of practice. Many general surgeons pursue additional training in subspecialties, such as transplant surgery, surgical oncology, vascular surgery, etc. Yet, even without additional training, most general surgeons narrow their scope of practice over time. Lifestyle demands, local health care needs, physician age, and other factors influence what services a surgeon chooses to provide. Some general surgeons become surgical hospitalists providing acute care and trauma surgery only. Others may focus on bariatric surgery or wound care or breast care. When measuring the capacity of the workforce to meet local demand, a simple head count of general surgeons doesn’t capture this variation in practice.

Using breast health as a specific example, in many settings the majority of breast care is provided by general surgeons.However, if a community has a large supply of surgical oncologists interested in breast health, it is likely the local general surgeons will provide a relatively smaller proportion of breast care. Conversely, if there are relatively few general surgeons in a community, gynecologists in the area may assume a larger portion of the care for breast diseases. This plasticity, as termed by Holmes and colleagues, will allow different communities to meet local health care demands in different ways. As a result, two communities may have physician workforces that are composed of very different types of physicians, yet in both settings demand will be adequately met. Or in contrast, two communities may have identical physician workforces, yet the demands in one community may be satisfied much more adequately than in the other community.

The article by Holmes and colleagues highlights the important need to learn more about plasticity and the evolution of physician scope of practice to develop better methodologies for physician workforce planning. I look forward to seeing how incorporation of the concept of plasticity into workforce models will enhance our ability to make meaningful workforce projections.

1. Stitzenberg KB, Chang Y, Louie R, Groves JS, Durham D, Fraher EF. Improving Our Understanding of the Surgical Oncology Workforce. Ann Surg. Oct 28 2013. [ePub ahead of print].

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