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The Great Demographic TrapFrom the UMKC Department of Surgery, Kansas City, Missouri Correspondence: Charles W. Van Way III, MD, UMKC Department of Surgery, 2301 Holmes Street, Kansas City, MO 64108. Electronic mail may be sent to charles.vanway{at}tmcmed.org. As this is my last editorial as your editor, I thought it would be appropriate to range a bit more widely. To wit, what's going to happen to the system under which we all earn our living? Despite the undeniable fact that most of us feel we're "doing good," there is great discontent among politicians, journalists, and policy wonks about the functioning of the health care system in the United States. Even among the general public there is discontent, although paradoxically most (not all!) feel the system works well for them. Actually, this is worldwide. The British worry about the National Health Service, of which they are inordinately proud. Other Europeans are forever tinkering with their national systems. Even the Canadians think their system is poorly responsive and inadequately funded, but they still think it's a great system. Angst is widespread worldwide, at least in developed countries. Many say that health care is too expensive, too complicated, too unresponsive, or too hard to obtain. But theirs is still better than those over the border. Odd, isn't it? Everyone's unhappy. But everyone likes what they have. To an extent, that's a product of our postmodern outlook. The postmodern ethos is basically unhappy with everything. But that's sort of like saying we're unhappy because we're unhappy. Let's look for the deeper reasons. There are indeed flaws in the health care system. Consider the safety issue. Health care is not as safe as it could be. It's not as dangerous as some would have us believe, because many frightening estimates are simply overblown. And we can remove only some of the dangers. If you get an illness, or you get shot, or you're in an auto crash, there is a certain probability you're going to die, regardless of how good or safe your health care is. Still, it's wrong that people die or become ill from medication errors, failures of diagnosis, or management mistakes. There are many ongoing efforts to make things better by hospitals, health care professionals, accrediting bodies, and government at all levels. These efforts seem to be bearing fruit. But they aren't free, and for each physician or nurse employed to promote safety, that's one less professional to go to the bedside. Is that important? Yes, it is, and for reasons we'll see in a bit. I've written before about the economic issues of our health care system.1 We have a pretty good health care system, for 70% of us. For those without any insurance, or even those receiving Medicaid, well...as I've discussed before, health care is available, but the options are greatly limited. The problem of the uninsured is receiving a great deal of political attention recently. My prediction is that it will still be with us down the road, if only because Medicaid was the government's last effort to solve the problem, and it still doesn't work. But there's another problem that is more intractable and which is going to occupy us for the next couple of decades. Perhaps fortunately, the politicians haven't discovered it, so it may yet be solvable. This is the demographic trap. We are going into a generation-long time of increasing demand for health care services, combined with a decreasing number of people who are trained and able to provide services. The demographic trap will work to make the health care system more stressed, less responsive, and less accessible. How can I say these things? Well, the increasing demands for health care are well known. I'll spare you most of the statistics on Medicare, which are both dismal and boring. But consider this: The number of people over 65, now 36 million, will double to 72 million by 2030.2 And those older people will require progressively more health care as they live longer. So what's the trap? The demographic trap is that as the demand for health care is rising, the number of health professionals is decreasing. I've looked over some of the data on the 4 groups that concern the American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.): nurses, pharmacists, physicians, and dietitians. There are very good data on nurses, pretty good data on pharmacists and physicians, and fair data on the dietitian work force. The outlook, at least for the first 3, is not good. The nursing shortage has been recognized for at least 10 years. The nursing workforce is aging because insufficient numbers of young people are enrolling in nursing schools. This is despite the development of 2-year "associate" schools, which are shorter and less demanding than the last generation's 3-year "diploma" schools. About two-thirds of new RNs come from associate schools, with a third coming from 4-year baccalaureate schools. An actual drop of RNs per capita is forecast by 2020, with a shortage of around 20% from workforce requirements.3 Pharmacists comprise about 200,000 medical professionals, and that number is projected to be 225,000 by 2010. The government analysis4 indicates that there is now a shortage of pharmacists and that shortage will grow over the next 10–20 years. This is due to increased numbers of prescriptions, higher workloads, more specialty roles for pharmacists, and declines in professional school enrollment. These causes are basically similar for all health professions. The physician workforce is an interesting picture. Most observers find a shortage of physicians, most marked among medical specialties. Anyone who has tried to get an appointment with, say, a dermatologist, will relate to this. However, there was a great expansion of allopathic (MD) schools between 1960 and 1980. After that, several well-regarded studies predicted a surplus of physicians by 2000. Those making these predictions included GMENAC (Graduate Medical Education National Advisory Committee), COGME (Council on Graduate Medical Education), the Pew Commission, and the Institute of Medicine. Their methodologies varied, but all used a time-based approach. To greatly oversimplify their complex methodologies, they added up all the services that would be required in a population, assigned a time value to each, and calculated how many physicians would be required. Not only did they all fail to predict the shortage, they estimated that the surplus would be largely in specialties and subspecialties. This viewpoint was tenaciously held, even as it was proving to be in error, and persisted well into the mid-1990s.5 In some circles, like the U.S. Congress, it persists today. The basic mistake was to assume that the U.S. health system would become highly structured along the lines of existing health maintenance organizations (HMOs), such as Kaiser Permanente, or according to the hopes of the then-fashionable managed care organizations. This assumption was mostly wrong. Managed care has failed to produce increased efficiency, and HMOs have been similarly disappointing. Other assumptions, such as the amount of work each physician would do over a lifetime, were also greatly optimistic. Wishful thinking has always been with us, I suppose. Dr R. A. Cooper was one of the few who disagreed with the consensus. Using an approach based on actual trends in physician workforce and population growth, together with economic analysis, he now predicts a shortage of 200,000 physicians by 2020.6 It should be noted that the Association of American Medical Colleges is recommending a 30% increase in allopathic medical school graduation rates over the next 10 years.7 Osteopathic medical schools, although a much smaller percentage, have been in the process of increasing their enrollment and graduation rates. Registered dietitians (RDs) seem to be in sufficient number, with a couple of caveats. There are about 50,000 RDs employed in the United States. The number of graduates (and of new RDs), however, has actually declined slightly over the last decade. Only if the graduation rate stabilizes will the number currently being trained meet future demands. This does not take into account, however, the possibility of increasing demands for dietitians because of the aging population, the increasing incidence of diabetes, and the ballooning obesity problem.8 A word about the workforce in research: Research PhDs aren't involved in patient care, although many in A.S.P.E.N. are also qualified and involved in clinical specialties. However, the outlook is not especially rosy there, either. Or at least there is great concern that the scientific workforce doesn't match the projected demands over the next generation. In short, the environment of the health care system over the next 2 decades will be dominated by shortages of health professionals. We are seeing problems now, and they will become worse. Hospitals, especially in rural or underserved urban areas, will have increasing difficulties getting and retaining staff. The burden of growing shortages will fall most heavily on the poor. There will be significantly more employment of lesstrained health workers to either supplement or replace more-skilled professionals. One thinks of pharmacy technicians, physician assistants, nurses' aides, and dietary technicians. Maintaining standards in such an environment will be a significant challenge. To be sure, that's what A.S.P.E.N. does best. There will be a great need for efficiency, and for better ways of organizing the work. The demographic trap has been sprung, and we are all caught in it. With this, I hand the official editorial red pen, with its joys and its obligations, to Dr Paul Wischmeyer. He's young and energetic, a highly productive and respected scientist, and an anesthesiologist at a busy university hospital. Please join me in wishing him welcome to our journal. Received for publication June 12, 2007. Accepted for publication June 12, 2007.
Journal of Parenteral and Enteral Nutrition, Vol. 31, No. 5,
449-450 (2007) This article has been cited by other articles:
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