Health ManpowerrPlanning Without Objectives Stanford A. Roman, Jr., MD, MPH Boston, Mass
Health manpower developments of the past decade have resulted in an absolute increase in the number of health personnel, the expansion of the roles of some traditional categories of personnel, and the introduction of new professional categories. Inherent in these developments has been the acceptance of the principal that the relative and absolute increase in manpower would result in an increased availability of health services. Unfortunately, in the last decade, the correlation between increased numbers and increased services is not a strong one. The failure to link manpower needs to specific service objectives and to identify appropriate rates of substitution among professional types has resulted in a wastage of funds and energies. A framework for future planning must now be developed which (1) defines service priorities, (2) delineates the functions required to deliver those services, and (3) defines appropriate manpower categories with their rates of substitution to perform those functions. Training programs must be coordinated to allow appropriate linkages among categorical types of personnel. The maldistribution of health care service must be viewed as a result of the demographic maldistribution among the health professions as well as the maldistribution of organizational and financial incentives for provision of priority services as well as utilization of priority services. As we view health manpower needs in the future, it is essential that we develop an analytical framework so that programs and demonstrations fall into a rational scheme. Such an approach can allow the planner and the policymaker to realize appropriate utilities and thereby effect substitutions and complementarities in personnel. Although past manpower development has acknowledged a shortage, this realization has been dissipated
Presented at the Conference on Health Manpower Development for U nderserved Areas of New England, Harvard University School of Public Health, March 30, 1976. Requests for reprints should be addressed to Dr. Stanford A. Roman, Jr., Director, Ambulatory Care, Boston City Hospital, 818 Harrison Avenue, Boston, Mass 02118.
into arguments between that school which recognizes an absolute shortage, ie, inadequate numbers, and that school which acknowledges a relative shortage, ie, adequate numbers of personnel but either inappropriate utilization or distribution. My hypothesis is that although such discussions may be cogent in the development of shortterm solutions, they are not relevant in long-term health manpower planning. Inherent in the provision for and planning of a supply to meet an expressed medical care demand are both quantity issues and productivity issues. Isolation of these variables has no meaning. Long-term manpower development must address two basic issues, namely the utilization and distribution of personnel - it is only after these factors
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
have been adequately addressed that a quantity can be specified. Unfortunately, initial health manpower efforts were in the direction of quantity definition. Such indices as personnel-to-population ratios were heralded as an index of supply. Unfortunately, these indices conveniently assume a homogeneity of productivity and utilization that is not inherent in health care delivery. Also, utilization of such measures for forecasting ignores underlying factors in future demand for manpower such as rising incomes, rising educational attainment, increased urbanization, and advances in medical sciences - all of which variously impact on medical care demand and manpower utilization. Current manpower developments have occurred in the absence of overall objectives except that of increasing the numbers of personnel. While demonstration projects have stimulated innovative programming, such programming in the absence of an overall framework has led to further fragmentation. The training of nonphysician providers has mushroomed into a myriad of categories, often distinguishable only by title. Each category has developed a form of chauvinism that prohibits analysis of substitutability or complementarities. The few studies that do exist, while occasionally documenting the impact of a categorical manpower type on physician care, rarely document crosscategorical comparisons. Is the physician associate more, less, or equally as effective as the nurse practitioner? Is the Emergency Room technician more effective than one receiving a more general training? Given current economic constraints, these are questions which must be addressed in the imminent future. 351
The original reliance on numbers rather than on utilization and distribution has resulted in a failure to relate manpower to services except as an afterthought. Although the demand for primary care services has provided a type of framework for most recent manpower planning, the lack of consensus as to what is primary care, and as to what organizational requirements facilitate such services does not lend clarity to the argument. Three directions of improvement in supply and demand estimates of personnel in health occupations becomes apparent: (1) Supply and demand estimates should first be made in terms of manpower services rather than mere quantitative categories; (2) There is an important need to develop estimates of productivity change and of the rate of substitution between different types of personnel and between manpower and non-labor inputs; and (3) health manpower supply and demand estimates must take into account relationships of complementarity and substitutability among different health occupations rather than focusing on one profession at a time. Although the provision of subsidies and economic assistance is a recognized mainstay in stimulating a given manpower category, this is but one determinant of the number of entrants into a given profession. Others which must be considered are: 1. The non-monetary attraction of entering a given profession relative to other professions, such as pleasantness or challenge of work, opportunity to help others or to be of service to society, prestige attached to the profession, etc. 2. The relative economic status of the profession as reflected in lifetime earnings relative to training costs, ie, by rates of return or by present value of lifetime earnings. 3. The availability and dispersion of accurate information on cost and length of training associated with entry into a profession, the probability of admission into the profession, and on economic and psychic gratification in the profession. 352
Because the economic utilities of particular professions are most easily identified, it is not surprising that as each manpower category has gained credibility, it also has strived for greater financial reward using the physician as a standard. It is also not surprising that each category has established its prestige by the proportion of services it has assumed that had been traditionally provided by the physician. While this phenomenon is understandable, its occurrence has negative implications on health care delivery both in our ability to efficiently deliver services and upon the costs of those services. If each health manpower category were to strive to assume an ever increasing number of tasks traditionally controlled by the physician and with that striving greater financial reward, the future would merely be a reflection of the past, particularly in the delivery of ambulatory care services. The existence of this drive is partly encouraged by the failure of our training programs to provide flexible linkages. As long as medical education remains a separate tract favoring the premedical student who has been in full-time college attendance and who probably comes from a middle or upper-income family, the new professional will not realize easy progression, if indeed he should want to enter medicine. In the future, we must address more innovative links between allied health professional training and medical education. Minimally, there must be collaborative teaching by medical, nursing, and allied health faculties. More importantly, a continuum of training must be delineated that allows entrance into different categories of health manpower inclusive of medicine. As long as medical education only minimally recognizes the experience and ability of many health professional categories, our system of health will remain a dual and conflicting one - the physician vs all others. Secondly, the contrast between training programs for physicians associates and nurse practitioners and those currently existing in medical schools is another argument for more collaboration. Dr. Charles Lewis compares them as "Frankenstein" (madeto-order) curricula and "Topsy" (itj ust-grew) curricula, respectively.1 Medical school courses, in fact, are designed to meet faculty needs and are
incredibly allergic to input from educators concerned with behavioral objectives, testing, etc. In contrast, new practitioner programs were designed to meet specific needs, and most courses were designed de novo to achieve these goals. In the future, it is advisable that medical education adopt the principles and techniques fostered by these new professional programs. Utilization studies of health manpower have been conducted both by economists and operations researchers. Both types of approaches address themselves to increasing the productivity and efficiency of a particular category of health manpower or of several categories. Productivity is achieved when a larger volume of output than before can be obtained fromn a given magnitude of resources, holding quality constant, or when the same volume of output, with improved quality, can be produced. There are several types of changes in utilization of health manpower which can alter the production function for health services: 1. The application of more and different facilities, equipment, and materials which increase the productivity of manpower; 2. The transfer of tasks or functions from more to lesser skilled categories of health personnel in order to increase productivity of the most highly skilled health professionals; 3. Increasing the scale of production of health services with the objective of increasing productivity of health manpower. Many investigations in the late 1960s and early 1970s have documented the effect of each of these approaches on productivity. Jeffrey Weiss has shown that dentists in recent decades have achieved productivity growth with the use of better equipment as well as with the employment of auxiliary personnel. Donald Yett investigated the existence of economies of scale in the provision of physician services.2 To date, however, there has been little developed to indicate the magnitude of productivity differentials between solo and group practice. For this reason, emphasis on utilization has been directed toward productivity expansion in the medical profession by way of substitution. In order to derive maximum impact from new staffing procedures which have been developed, it is necessary that:
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
1. An adequate amount of effort be expended on longer term evaluation of the effects on personnel utilization once the new procedures have been applied; 2. The methodologies and their effect must be widely disseminated whenever improved utilization can be conclusively established. Additional investigation is also required to define limits of substitutability of lower for higher skilled personnel, ie, determining the minimum amount of a given skill necessary in the production of medical care without impairment of quality. Since the health care industry is a service industry and since service industries are my nature labor intensive, it would also be useful to develop some approximate notions regarding the scope for further substitution of capital for manpower. Finally, more knowledge is needed on the way in which economies of scale in the production of health services affect manpower productivity and how optimal scale of production may be identified for different types of health care facilities. Any discussion about the distribution of manpower must recognize four types of distribution: (1) locational distribution, (2) occupational distribution, (3) specialty distribution within a given profession, and (4) socioeconomic (demographic) distribution within a given profession. All four of these are interrelated - a policy which attempts to impact on one necessarily impacts to a varying degree on each of the others. Unfortunately, the state of our knowledge about these interrelationships is in its infancy. Manpower policies have aimed at each of these distributional problems with a scattered approach, hoping that one will be eliminated. On one hand Affirmative Action among health manpower categories (ie, inclusion of minorities, women, and the poor) has been a rule of thumb, the impact of these inclusions on locational distribution and occupational and specialty distribution has been rarely considered. While critics of medical education often underscore the maldistribution among those entering medical school, few look at what impact such a maldistribution may have on specialty distribution. The average medical student and faculty member is a white male whose family
is an upper middle to upper-income family. Realizing this, we must be cautious in analyzing the current locational distribution and to a lesser degree the specialty distribution. While Rimlinger and Steel found that high income areas have substantially larger numbers of physicians in relation to population than low income areas, their reasons for this maldistribution, ie, patients visiting physicians more often for more expensive visits and physicians being able to charge higher fees all neglect the biased sample of the physician population.3 The current increased competition for entry into medical school with greater than 40,000 applicants for 14,000 medical school places, associated with decreased financial assistance for the poor, ensures a maintenance of this m aldistribution. Given the socioeconomic status of the applicant pool and the size of that pool, medical schools could charge tuitions of $10,000 to $15,000 per annum and continue to fill their places. Unfortunately, this would heighten the crisis of medical maldistribution. A pilot study by Mark Plovnick at the Massachusetts Institute of Technology attempted to correlate medical school learning styles with career choice. His study suggested that those students whose learning styles are associated with primary care careers are also those who are dissatisfied with traditional basic science curriculum and are influenced more than the average student by concrete work experiences as well as identification with role models in making career decisions.4 Although based on a small sample, this type of investigation suggests a need to reassess our medical school admissions criteria, if indeed we are to increase primary care in this country. The imposition of costly primary care medical school programs given the preselection that occurs both in faculty and students may prove expensive folly. No discussion about health manpower would be complete without a view on policy and legislation. Throughout my presentation I have stressed the interrelationships that exist among categorical types and utilizational and distributional issues. I have noted our failure to define or even seek the extent of these interrelationships. I have alluded to the fragmentation that has been inherent
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
in manpower planning. Most of us would agree that health care and health education systems are complex and interrelated, public policy has not acted as if these interrelationships are critical. Lacking a conceptual model for a health care system, and facing a legislative process that involves a division of labor among Congressional committees, public policy has been simplistic.5 We can expect no solution to our manpower crises until it is recognized that present legislative approaches, the present division of responsibilities, and our methodology for developing policy may create programs that are at cross purposes. Many have found themselves unable to implement a particular education or service or program change because a totally extraneous policy, legislated for another purpose has overlapping and constraining impact. The cost of this partial approach has been high: A wastage of funds, a lack of progress, and the invalidation of approaches which under certain conditions would prove helpful but have failed because they have not been part of a more comprehensive program. If we approach health manpower development in the future without a conceptual model, without a mechanism to develop public policy with an overall perspective, and without a comprehensive mode of integrating diverse actions and associated budgets, we will fall on our proverbial faces. American public policy is deeply ingrained in the free-market system. Health care represents another market to the policy maker. The characteristics of the health care market are substantially different from any other market. In health care we find a singular lack of competition, a large nonprofit sector, and a lack of knowledge among consumers. It is sophistry to believe that market forces will yield desirable solutions. If the market has failed, and I feel it has, no hands-off policy nor marginal intervention is likely to correct those failures. Any attempt to redirect health services solely through incentives will prove both costly and frustrating. Our health manpower requirements in the future are very much wedded to the need for primary care services. To change primary care to really do the task is to change American medicine as it is practiced and where it is practiced. This can not be done by yet 353
another add-on program that rewards those who are interested in primary care and that threatens no one. To develop effective primary care services and the associated manpower is to involve public policy and the policy maker in controversy. It is a departure from broad aggregate policies and involvement in the "nitty gritty." Health care policy will be strongly influenced in the future by the state of the economy. It will also be affected by what legislators view as a depressing history of uncontrollable expenditures. Our manpower planning has reflected overall health planning fragmentation. With this fragmentation has developed a suboptimalization of goals that can no longer be justified. The preservation of one manpower category because it exists, can no more be justified than the relative lack of firm intervention in professional education and its objectives. Conversely, we must be cautious in accepting a rigid cost-benefit analysis of these programs. There are nonmonetary returns that must be emphasized. Unfortunately, little attention has been placed on educating policymakers about a benefit that acknowledges monetary as well as nonmonetary factors. If there is a benefit in utilizing new professionals and expanded professionals, as I believe there is, such benefit can only be documented by an associated increase in services over what currently exists, or an improvement in quality. Once again, we must be cautious in justifying a new program solely on quality. Too often we delude ourselves on issues of quality. Often an efficient system with appropriate procedural guidelines will indirectly ensure quality. There is not a single hemodialysis unit, open heart surgery suite, intensive care unit, or EM Scanner that has not been justified by quality, yet we know that many are inefficient, underutilized, and manifest associated poor quality. Health manpower must get its house in order. Manpower strategies must now be focused on specific service objectives. Our goal must be to increase the production and availability of certain priority services. Once these priorities have been established, one may ask: (1) What are the functional roles required to deliver those services? (2) What are the rates of su bstitution among personnel types? (3) What are the complementar354
ities? Although basic functional relationships can be established, further sophistication is required based on rural/urban differences and organizational differences. Once these utilization considerations have been established one must focus first on occupational and specialty distribution among existing health categories. If, for example, the delivery of primary care does not require the current rate of training of neurosurgeons, we must look at how we will change the ratio of career choices among training program graduates. It is at this point that we must look at, other things remaining constant, who, if trained appropriately, is most likely to perform those functions that will meet our objectives? If, indeed, Plovnick's "diverger learning-style group," or women, or minorities, or the poor, or people with particular life experiences manifest a higher probability of satisfying our goals, then these groups must be selectively admitted into our training programs. Secondly, we must define a training course which, with appropriate role models, will prepare the required types of personnel to perform well. Simultaneously, we must develop appropriate interrelationships among personnel types during training and encourage effective crossovers along the training ladder both of which promote more effective working relationships and prevent frustrations of perceived career "deadends" from dissipating the service output. Lastly, given our selection and training developments, we can then address locational distribution. Locational distribution, given this sequence of questions and solutions, reflects a puristic problem. Unfortunately, one can not analyze locational distribution when it is superimposed on occupational, specialty, and socioeconomic distributional issues. Once these have been addressed, one can deal with achieving the proper locational distribution based on our service objective. Although correction of personnel and specialty maldistribution may partially correct locational maldistribution, one must then look at organizational and financing incentives that both encourage the consumer to seek our objective services and also encourage the health professional's involvement in those services by locus. One can not articulate catastrophic national health insurance and simul-
taneously encourage primary care services. Primary care services require increased access to and availability of care for noncatastrophic illness. A financing mechanism that through large deductibles and coinsurance encourages both the use of and the delivery of secondary and tertiary levels of care discourage primary care except among the more affluent. In summary, we must view our manpower needs in light of service objectives, locus variables, and organizational requirements. Associated with this view must be a financing mechanism that stimulates our objective both in its delivery and in its consumption. The failure of our nation to set priorities in its service needs has resulted in a wastage of funds, energies, and personnel. Until our policy reflects the complexity of interrelationships among service objectives, manpower needs, organizational requirements, and the financing mechanism, our nation will remain in health care crisis - the cost of which we all must bear.
Literature Cited 1. Lewis CE: The training of new health manpower. Perspectives in primary care education. J Med Educ 50:75-83, 1975 2. Yett DE: An evaluation of methods of estimating physicians' expenses relative to output. Inquiry 4:3-28, 1967 3. Rimlinger GV, Steele HB: An economic interpretation of the spatial distributions of physicians in the US. South Econ J 30:1-12, 1963 4. Plovnick MS: Primary care career choices and medical student learning styles. J Med Educ 50:849-855, 1975 5. Fein R: Issues in primary care: The policy perspective. Perspectives in primary care education. J Med Educ 50:15-22, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
Health manpower developments of the past decade have resulted in an absolute increase in the number of health personnel, the expansion of the roles of some traditional categories of personnel, and the introduction of new professional categories. Inherent in these developments has been the acceptance of the principal that the relative and absolute increase in manpower would result in an increased availability of health services. Unfortunately, in the last decade, the correlation between increased numbers and increased services is not a strong one. The failure to link manpower needs to specific service objectives and to identify appropriate rates of substitution among professional types has resulted in a wastage of funds and energies. A framework for future planning must now be developed which (1) defines service priorities, (2) delineates the functions required to deliver those services, and (3) defines appropriate manpower categories with their rates of substitution to perform those functions. Training programs must be coordinated to allow appropriate linkages among categorical types of personnel. The maldistribution of health care service must be viewed as a result of the demographic maldistribution among the health professions as well as the maldistribution of organizational and financial incentives for provision of priority services as well as utilization of priority services. As we view health manpower needs in the future, it is essential that we develop an analytical framework so that programs and demonstrations fall into a rational scheme. Such an approach can allow the planner and the policymaker to realize appropriate utilities and thereby effect substitutions and complementarities in personnel. Although past manpower development has acknowledged a shortage, this realization has been dissipated
Presented at the Conference on Health Manpower Development for U nderserved Areas of New England, Harvard University School of Public Health, March 30, 1976. Requests for reprints should be addressed to Dr. Stanford A. Roman, Jr., Director, Ambulatory Care, Boston City Hospital, 818 Harrison Avenue, Boston, Mass 02118.
into arguments between that school which recognizes an absolute shortage, ie, inadequate numbers, and that school which acknowledges a relative shortage, ie, adequate numbers of personnel but either inappropriate utilization or distribution. My hypothesis is that although such discussions may be cogent in the development of shortterm solutions, they are not relevant in long-term health manpower planning. Inherent in the provision for and planning of a supply to meet an expressed medical care demand are both quantity issues and productivity issues. Isolation of these variables has no meaning. Long-term manpower development must address two basic issues, namely the utilization and distribution of personnel - it is only after these factors
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
have been adequately addressed that a quantity can be specified. Unfortunately, initial health manpower efforts were in the direction of quantity definition. Such indices as personnel-to-population ratios were heralded as an index of supply. Unfortunately, these indices conveniently assume a homogeneity of productivity and utilization that is not inherent in health care delivery. Also, utilization of such measures for forecasting ignores underlying factors in future demand for manpower such as rising incomes, rising educational attainment, increased urbanization, and advances in medical sciences - all of which variously impact on medical care demand and manpower utilization. Current manpower developments have occurred in the absence of overall objectives except that of increasing the numbers of personnel. While demonstration projects have stimulated innovative programming, such programming in the absence of an overall framework has led to further fragmentation. The training of nonphysician providers has mushroomed into a myriad of categories, often distinguishable only by title. Each category has developed a form of chauvinism that prohibits analysis of substitutability or complementarities. The few studies that do exist, while occasionally documenting the impact of a categorical manpower type on physician care, rarely document crosscategorical comparisons. Is the physician associate more, less, or equally as effective as the nurse practitioner? Is the Emergency Room technician more effective than one receiving a more general training? Given current economic constraints, these are questions which must be addressed in the imminent future. 351
The original reliance on numbers rather than on utilization and distribution has resulted in a failure to relate manpower to services except as an afterthought. Although the demand for primary care services has provided a type of framework for most recent manpower planning, the lack of consensus as to what is primary care, and as to what organizational requirements facilitate such services does not lend clarity to the argument. Three directions of improvement in supply and demand estimates of personnel in health occupations becomes apparent: (1) Supply and demand estimates should first be made in terms of manpower services rather than mere quantitative categories; (2) There is an important need to develop estimates of productivity change and of the rate of substitution between different types of personnel and between manpower and non-labor inputs; and (3) health manpower supply and demand estimates must take into account relationships of complementarity and substitutability among different health occupations rather than focusing on one profession at a time. Although the provision of subsidies and economic assistance is a recognized mainstay in stimulating a given manpower category, this is but one determinant of the number of entrants into a given profession. Others which must be considered are: 1. The non-monetary attraction of entering a given profession relative to other professions, such as pleasantness or challenge of work, opportunity to help others or to be of service to society, prestige attached to the profession, etc. 2. The relative economic status of the profession as reflected in lifetime earnings relative to training costs, ie, by rates of return or by present value of lifetime earnings. 3. The availability and dispersion of accurate information on cost and length of training associated with entry into a profession, the probability of admission into the profession, and on economic and psychic gratification in the profession. 352
Because the economic utilities of particular professions are most easily identified, it is not surprising that as each manpower category has gained credibility, it also has strived for greater financial reward using the physician as a standard. It is also not surprising that each category has established its prestige by the proportion of services it has assumed that had been traditionally provided by the physician. While this phenomenon is understandable, its occurrence has negative implications on health care delivery both in our ability to efficiently deliver services and upon the costs of those services. If each health manpower category were to strive to assume an ever increasing number of tasks traditionally controlled by the physician and with that striving greater financial reward, the future would merely be a reflection of the past, particularly in the delivery of ambulatory care services. The existence of this drive is partly encouraged by the failure of our training programs to provide flexible linkages. As long as medical education remains a separate tract favoring the premedical student who has been in full-time college attendance and who probably comes from a middle or upper-income family, the new professional will not realize easy progression, if indeed he should want to enter medicine. In the future, we must address more innovative links between allied health professional training and medical education. Minimally, there must be collaborative teaching by medical, nursing, and allied health faculties. More importantly, a continuum of training must be delineated that allows entrance into different categories of health manpower inclusive of medicine. As long as medical education only minimally recognizes the experience and ability of many health professional categories, our system of health will remain a dual and conflicting one - the physician vs all others. Secondly, the contrast between training programs for physicians associates and nurse practitioners and those currently existing in medical schools is another argument for more collaboration. Dr. Charles Lewis compares them as "Frankenstein" (madeto-order) curricula and "Topsy" (itj ust-grew) curricula, respectively.1 Medical school courses, in fact, are designed to meet faculty needs and are
incredibly allergic to input from educators concerned with behavioral objectives, testing, etc. In contrast, new practitioner programs were designed to meet specific needs, and most courses were designed de novo to achieve these goals. In the future, it is advisable that medical education adopt the principles and techniques fostered by these new professional programs. Utilization studies of health manpower have been conducted both by economists and operations researchers. Both types of approaches address themselves to increasing the productivity and efficiency of a particular category of health manpower or of several categories. Productivity is achieved when a larger volume of output than before can be obtained fromn a given magnitude of resources, holding quality constant, or when the same volume of output, with improved quality, can be produced. There are several types of changes in utilization of health manpower which can alter the production function for health services: 1. The application of more and different facilities, equipment, and materials which increase the productivity of manpower; 2. The transfer of tasks or functions from more to lesser skilled categories of health personnel in order to increase productivity of the most highly skilled health professionals; 3. Increasing the scale of production of health services with the objective of increasing productivity of health manpower. Many investigations in the late 1960s and early 1970s have documented the effect of each of these approaches on productivity. Jeffrey Weiss has shown that dentists in recent decades have achieved productivity growth with the use of better equipment as well as with the employment of auxiliary personnel. Donald Yett investigated the existence of economies of scale in the provision of physician services.2 To date, however, there has been little developed to indicate the magnitude of productivity differentials between solo and group practice. For this reason, emphasis on utilization has been directed toward productivity expansion in the medical profession by way of substitution. In order to derive maximum impact from new staffing procedures which have been developed, it is necessary that:
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
1. An adequate amount of effort be expended on longer term evaluation of the effects on personnel utilization once the new procedures have been applied; 2. The methodologies and their effect must be widely disseminated whenever improved utilization can be conclusively established. Additional investigation is also required to define limits of substitutability of lower for higher skilled personnel, ie, determining the minimum amount of a given skill necessary in the production of medical care without impairment of quality. Since the health care industry is a service industry and since service industries are my nature labor intensive, it would also be useful to develop some approximate notions regarding the scope for further substitution of capital for manpower. Finally, more knowledge is needed on the way in which economies of scale in the production of health services affect manpower productivity and how optimal scale of production may be identified for different types of health care facilities. Any discussion about the distribution of manpower must recognize four types of distribution: (1) locational distribution, (2) occupational distribution, (3) specialty distribution within a given profession, and (4) socioeconomic (demographic) distribution within a given profession. All four of these are interrelated - a policy which attempts to impact on one necessarily impacts to a varying degree on each of the others. Unfortunately, the state of our knowledge about these interrelationships is in its infancy. Manpower policies have aimed at each of these distributional problems with a scattered approach, hoping that one will be eliminated. On one hand Affirmative Action among health manpower categories (ie, inclusion of minorities, women, and the poor) has been a rule of thumb, the impact of these inclusions on locational distribution and occupational and specialty distribution has been rarely considered. While critics of medical education often underscore the maldistribution among those entering medical school, few look at what impact such a maldistribution may have on specialty distribution. The average medical student and faculty member is a white male whose family
is an upper middle to upper-income family. Realizing this, we must be cautious in analyzing the current locational distribution and to a lesser degree the specialty distribution. While Rimlinger and Steel found that high income areas have substantially larger numbers of physicians in relation to population than low income areas, their reasons for this maldistribution, ie, patients visiting physicians more often for more expensive visits and physicians being able to charge higher fees all neglect the biased sample of the physician population.3 The current increased competition for entry into medical school with greater than 40,000 applicants for 14,000 medical school places, associated with decreased financial assistance for the poor, ensures a maintenance of this m aldistribution. Given the socioeconomic status of the applicant pool and the size of that pool, medical schools could charge tuitions of $10,000 to $15,000 per annum and continue to fill their places. Unfortunately, this would heighten the crisis of medical maldistribution. A pilot study by Mark Plovnick at the Massachusetts Institute of Technology attempted to correlate medical school learning styles with career choice. His study suggested that those students whose learning styles are associated with primary care careers are also those who are dissatisfied with traditional basic science curriculum and are influenced more than the average student by concrete work experiences as well as identification with role models in making career decisions.4 Although based on a small sample, this type of investigation suggests a need to reassess our medical school admissions criteria, if indeed we are to increase primary care in this country. The imposition of costly primary care medical school programs given the preselection that occurs both in faculty and students may prove expensive folly. No discussion about health manpower would be complete without a view on policy and legislation. Throughout my presentation I have stressed the interrelationships that exist among categorical types and utilizational and distributional issues. I have noted our failure to define or even seek the extent of these interrelationships. I have alluded to the fragmentation that has been inherent
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 69, NO. 5, 1977
in manpower planning. Most of us would agree that health care and health education systems are complex and interrelated, public policy has not acted as if these interrelationships are critical. Lacking a conceptual model for a health care system, and facing a legislative process that involves a division of labor among Congressional committees, public policy has been simplistic.5 We can expect no solution to our manpower crises until it is recognized that present legislative approaches, the present division of responsibilities, and our methodology for developing policy may create programs that are at cross purposes. Many have found themselves unable to implement a particular education or service or program change because a totally extraneous policy, legislated for another purpose has overlapping and constraining impact. The cost of this partial approach has been high: A wastage of funds, a lack of progress, and the invalidation of approaches which under certain conditions would prove helpful but have failed because they have not been part of a more comprehensive program. If we approach health manpower development in the future without a conceptual model, without a mechanism to develop public policy with an overall perspective, and without a comprehensive mode of integrating diverse actions and associated budgets, we will fall on our proverbial faces. American public policy is deeply ingrained in the free-market system. Health care represents another market to the policy maker. The characteristics of the health care market are substantially different from any other market. In health care we find a singular lack of competition, a large nonprofit sector, and a lack of knowledge among consumers. It is sophistry to believe that market forces will yield desirable solutions. If the market has failed, and I feel it has, no hands-off policy nor marginal intervention is likely to correct those failures. Any attempt to redirect health services solely through incentives will prove both costly and frustrating. Our health manpower requirements in the future are very much wedded to the need for primary care services. To change primary care to really do the task is to change American medicine as it is practiced and where it is practiced. This can not be done by yet 353
another add-on program that rewards those who are interested in primary care and that threatens no one. To develop effective primary care services and the associated manpower is to involve public policy and the policy maker in controversy. It is a departure from broad aggregate policies and involvement in the "nitty gritty." Health care policy will be strongly influenced in the future by the state of the economy. It will also be affected by what legislators view as a depressing history of uncontrollable expenditures. Our manpower planning has reflected overall health planning fragmentation. With this fragmentation has developed a suboptimalization of goals that can no longer be justified. The preservation of one manpower category because it exists, can no more be justified than the relative lack of firm intervention in professional education and its objectives. Conversely, we must be cautious in accepting a rigid cost-benefit analysis of these programs. There are nonmonetary returns that must be emphasized. Unfortunately, little attention has been placed on educating policymakers about a benefit that acknowledges monetary as well as nonmonetary factors. If there is a benefit in utilizing new professionals and expanded professionals, as I believe there is, such benefit can only be documented by an associated increase in services over what currently exists, or an improvement in quality. Once again, we must be cautious in justifying a new program solely on quality. Too often we delude ourselves on issues of quality. Often an efficient system with appropriate procedural guidelines will indirectly ensure quality. There is not a single hemodialysis unit, open heart surgery suite, intensive care unit, or EM Scanner that has not been justified by quality, yet we know that many are inefficient, underutilized, and manifest associated poor quality. Health manpower must get its house in order. Manpower strategies must now be focused on specific service objectives. Our goal must be to increase the production and availability of certain priority services. Once these priorities have been established, one may ask: (1) What are the functional roles required to deliver those services? (2) What are the rates of su bstitution among personnel types? (3) What are the complementar354
ities? Although basic functional relationships can be established, further sophistication is required based on rural/urban differences and organizational differences. Once these utilization considerations have been established one must focus first on occupational and specialty distribution among existing health categories. If, for example, the delivery of primary care does not require the current rate of training of neurosurgeons, we must look at how we will change the ratio of career choices among training program graduates. It is at this point that we must look at, other things remaining constant, who, if trained appropriately, is most likely to perform those functions that will meet our objectives? If, indeed, Plovnick's "diverger learning-style group," or women, or minorities, or the poor, or people with particular life experiences manifest a higher probability of satisfying our goals, then these groups must be selectively admitted into our training programs. Secondly, we must define a training course which, with appropriate role models, will prepare the required types of personnel to perform well. Simultaneously, we must develop appropriate interrelationships among personnel types during training and encourage effective crossovers along the training ladder both of which promote more effective working relationships and prevent frustrations of perceived career "deadends" from dissipating the service output. Lastly, given our selection and training developments, we can then address locational distribution. Locational distribution, given this sequence of questions and solutions, reflects a puristic problem. Unfortunately, one can not analyze locational distribution when it is superimposed on occupational, specialty, and socioeconomic distributional issues. Once these have been addressed, one can deal with achieving the proper locational distribution based on our service objective. Although correction of personnel and specialty maldistribution may partially correct locational maldistribution, one must then look at organizational and financing incentives that both encourage the consumer to seek our objective services and also encourage the health professional's involvement in those services by locus. One can not articulate catastrophic national health insurance and simul-
taneously encourage primary care services. Primary care services require increased access to and availability of care for noncatastrophic illness. A financing mechanism that through large deductibles and coinsurance encourages both the use of and the delivery of secondary and tertiary levels of care discourage primary care except among the more affluent. In summary, we must view our manpower needs in light of service objectives, locus variables, and organizational requirements. Associated with this view must be a financing mechanism that stimulates our objective both in its delivery and in its consumption. The failure of our nation to set priorities in its service needs has resulted in a wastage of funds, energies, and personnel. Until our policy reflects the complexity of interrelationships among service objectives, manpower needs, organizational requirements, and the financing mechanism, our nation will remain in health care crisis - the cost of which we all must bear.
Literature Cited 1. Lewis CE: The training of new health manpower. Perspectives in primary care education. J Med Educ 50:75-83, 1975 2. Yett DE: An evaluation of methods of estimating physicians' expenses relative to output. Inquiry 4:3-28, 1967 3. Rimlinger GV, Steele HB: An economic interpretation of the spatial distributions of physicians in the US. South Econ J 30:1-12, 1963 4. Plovnick MS: Primary care career choices and medical student learning styles. J Med Educ 50:849-855, 1975 5. Fein R: Issues in primary care: The policy perspective. Perspectives in primary care education. J Med Educ 50:15-22, 1975
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