Dr Steve Schoenbaum's commentary is a timely analysis of the problem of dealing with the physician work force. Many of the issues faced on the American scene find their parallels in Israel, and they are no less "complex, controversial and politically sensitive". But, as might be expected, there are local unique aspects resulting from the differences in organization of health services, as well as cultural, economic, and political differences. As one who has spent considerable periods of my career both in the USA and in Israel, I have followed both scenes with great interest for several decades.
In both countries there have frequently been almost abrupt swings from periods in which the prevailing threat was a surplus of physicians to one of a shortage, and vice versa. Whereas everyone in Israel is worried about the impending physician shortage, only a few years ago there was pressure in the Knesset to close one or two of Israel's four medical schools! It seems that the experts often seem to err, and are required to reverse their earlier predictions. Dr Jim Pittman, the long term dean of the University of Alabama School of Medicine, explained one of the basic roots of the problem by coining a new word, "pedisolane", which to the best of my knowledge appeared only once or twice in the medical literature (1), and only in articles by him. Pedisolane means "pipeline", and Pittman pointed out that the medical educational pipeline, from admission of a medical student until he/she enters the workforce, is over a decade. Thus actions stimulated by a given manpower assessment, by the time they are effective are often rendered inappropriate and counterproductive by rapidly changing situations.
In contrast to the United States where the organization of health care , like most everything else "is not known for central planning or management", Israel might have been expected to be able to apply a much greater degree of planning and management. The country is smaller, the organizations involved are fewer, there is national health insurance, virtually all health care personnel are salaried, and all the universities are government sponsored. Yet serious health manpower planning has been singularly deficient. It is embarrassing to note that the data upon which even to begin serious analysis and planning are lacking. In Israel granting of a medical license is for life, with no need for renewal. In contrast to most other advanced countries where periodic renewal of licensure permits at least some semblance of analysis of the health manpower, in terms of number, location, specialty and professional activity, all the data here are scattered and fragmentary, making planning extremely difficult. It is suspected by some, that organized medicine in Israel sees relicensing as a first step to compulsory recertification and therefore opposes it. If there is no current reliable data base on the number of physicians, their ages, specialties, practice activities and plans it is hard to plan the future.
As in the USA the younger physicians are much more demanding of what has been called a "controllable life style", and their decisions as to specialty and location of practice, in Israel, as in the USA, are strongly influenced by such factors. I can still remember in my childhood the shock in our community when we heard that the local general practitioner took a vacation! As house officers we worked every other night, unthinkable nowadays. The world has changed, with dramatic implications for management of physician manpower, and we must learn to cope with these changes.
It may seem surprising to an American to learn that in a small country like Israel there is such a preference to location in the central part of the country, which is so short a distance from the "periphery". But a major part of this preference is based on the much greater opportunity for treating private patients beyond the usual hours of the physician's salaried position. Since there is significant dissatisfaction with the compensation of physicians, these opportunities for private practice potential in the large cities are alluring. For the first time in Israeli history the latest wage agreements specifically provided additional salary benefits for the "periphery". These agreements aroused considerable antagonism among physicians in centrally located hospitals, yet were regarded as insufficient by those in the periphery. Nevertheless the agreements represented a first step towards trying to attract physicians to outlying institutions.
As one who has been interviewing medical school applicants in Israel for close to forty years I have found that fewer and fewer applicants now mention primary care as possible future career options, and this when they know they are being interviewed for a medical school with a clear mandate for educating towards primary care. Years ago many applicants averred interest in primary care, although I sometimes doubted their sincerity. Now few even mention primary care. The image of medicine that is projected in the media in Israel is one of brilliant technological advances. Israel is indeed a world power in technology and each achievement gets much publicity. The image of a family physician treating an elderly patient with dozens of chronic problems is not projected, and the youth sees the cardiac catheterizer or the ophthalmological surgeon as the attractive model. So that both the money and the prestige are on the side of the super specialist-particularly in those specialties in which private practice is readily available. Neonatology and nephrology for example suffer because there is limited opportunity for private practice in these specialties.
Internal medicine, once the field that attracted the top students in each class, has fallen on bad times. Unfortunately in Israel, virtually all of the residency training is inpatient, exposing the residents to older patients, desperately ill, during extremely short hospital stays (mean less than four days). Subspecialties have cut drastically into the variety of patients. The subsequent prospects for financial rewards in general internal medicine are much less promising than in the subspecialties. I projected a crisis in internal medicine residency programs several decades ago (2), and unfortunately my prophecies came true. Most tragically with the aging population there is more than ever a growing need for general internists and geriatricians at a time when these specialties have out of favor.
Several other factors need to be considered in the physician manpower problem. With the number of women physician graduates now equaling the number of men (a most positive phenomenon, in my opinion) one needs to take into account that the average woman works fewer hours per week than her male counterpart. In addition the clear trend for men to decrease their number of weekly work hours one must count not just the absolute number of physicians, but must take into account the number of working hours per physician.
In discussing physician manpower most of the discussion relates to overall manpower needs. One needs also to review specifically house staff numbers and training. Clearly no programs will go back to the 36 hours on 12 hours off of my days, and the trend is moving inexorably to fewer and fewer hours per week. Unfortunately the legislators, labor negotiators and regulators have in many cases not provided the increase in job lines to compensate for the reduction in physician work hours. This failure manifests itself in two areas. The first is patient safety, because while the less exhausted physician may indeed make fewer errors, many more occur during repeated transfers of responsibility, In addition some of the rules insisting on time off after night call often leave the departments with grossly inadequate staffing. It has been suggested (3) that greater use of "physician extenders" to relieve residents of some of their less critical duties may be one solution. Another problem is the major reduction in training time during the residency. A chairman of orthopedics recently calculated (4) that today's residents in his department have 40% fewer patient contact hours during their residencies than he had. Insufficient attention has been paid thus far to the full implication of shortened residency hours to the quality of the training.
In attempting to deal with the range of issues involved in improving the health manpower situation there are several additional difficulties that face Israel in coping with these issues. Because of strong unions, both of physicians and of nurses, necessary changes in outdated staffing patterns and of job descriptions to meet changing needs are more difficult than in the USA. For example physician assistants have not been recognized in Israel, whereas in the USA they provide valuable service. Extension of nurse responsibilities is also more problematic, not only because of union problems, but also because of a serious nursing shortage as well.
Another difficulty facing health care administrators in Israel is the lack of local flexibility in providing individual contract benefits in order to attract specific personnel to outlying areas. All physicians and nurses countrywide have similar salaries and fringe benefits.
On the positive side, Israel has had amazing success in absorbing an unprecedented number of physicians into the health care system over a short period of time, retraining many of them and finding useful employment for them. I do not believe that any country in the world has had the experience of doubling the number of practicing physicians in its system just a few years
It is clear to me that both in the USA and in Israel there is critical need for an ongoing careful and comprehensive examination of health manpower in order to try to provide reasonable care for the population. The problems are multifactorial; we are dealing with a "moving target"; even with the best of all intentions we will make serious miscalculations, and many of our proposed solutions may not be feasible. But try we must, and in spite of differences between our countries, we may well learn from each other's experiences.
Shimon M. Glick MD
Professor (emeritus)
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva, Israel
1 Pittman JA Campbell JH. Tomorrow is already here:physician manpower in Alabama-the medical pedisolane in action. Alabama Journal of Medical Sciences 1979;16:239-258
2.Glick SM the impending crisis in internal medicine training programs. Am J Med 1988;84:929-932
3.McLean TR the 80-hour work week: why safer patient care will mean more health care is provided by physician extenders. J. Legal Medicine 2005;26:339-384.
4.Pellegrini VD Jr Perspective:ten thousand hours to patient safety, sooner or later. Academic Medicine 2012;87:164-167
Competing interests
I have no competing interests
Further thoughts related to the physician workforce and its training
Stephen Schoenbaum, Josiah Macy Jr. Foundation
8 May 2012
I first met Prof. Shimon Glick about 25 years ago when at the invitation of Prof. Carmi Margolis I first visited the medical school, now the Joyce and Irving Goldman Medical School, at Ben Gurion University of the Negev. Prof. Glick was then the medical school¿s dean. Over the years, I have learned much from him, and always find his comments thoughtful and provocative. Given our many years of friendship, I know that he will not be surprised that I have several additional comments related to the thoughtful comments he has shared here.
1. A personal view of primary care vs. specialty practice:
In my own clinical lives, I was first a specialist in infectious diseases and then a primary care physician. In full disclosure, I should note that I never did either full-time: I was a specialist when I was in academia, at which time I was doing a lot of teaching and epidemiologic research; and I was a primary care internist after I joined a staff-model HMO, Harvard Community Health Plan, where I spent the majority of my time as a manager. I enjoyed both types of practice; but I found primary care much more interesting, challenging, and rewarding than practice as a specialist. Despite the fact that primary care physicians do see many people with minor, 'routine' illnesses, I believe that primary care practice is much less routinized than specialty practice. I felt I could master the specialty with its relatively limited, albeit detailed, knowledge and skill base; whereas I never felt that I could master primary care when so much depends upon the nuances of individual relationships and so much depends upon being alert to clues that unfold over time. In primary care I was always energized, never bored.
A major issue in primary care is knowing when someone might have a true positive finding: I hope all readers with a scientific background are aware that the predictive value of a positive test is lower when the prevalence of a condition is lower; and in primary care, the prevalence of disease is lower than in specialty care. Thus, patients in primary care settings who have a positive finding may well not have a major problem; and determining efficiently which ones do have something that must be pursued is an interesting and important challenge. In contrast, specialists see a patient population with a much higher prevalence of positive findings, and it is usually less of a challenge to hone in on a condition, even a seemingly rare one, and manage it. Of course, I fully agree with Prof. Glick¿s observation that 'the money and the prestige are on the side of the super specialist.' That is true not only in Israel but in the United States. At least in the U.S., technical skills are valued more highly than cognitive ones. If policy-makers understand, however, that there is nothing so special about specialists, it ought to be possible for them to be creative in their policy-making and change the status quo. Lest any readers who are specialists, or any readers who harbor that illusion that all specialists are special, think I¿m 'anti-specialist,' let me hasten to point out that I believe that both generalists and specialists are very important to having a high performance health care system. I¿m simply trying to address the imbalance in money and prestige that Prof. Glick has highlighted.
2. The Danish health system and primary care:
This being a journal that seeks international input, I think is worth considering some other countries, in particular Denmark, a country of about 5.4 million people which like Israel spends considerably less of its GDP on health care. In Denmark, super specialists do not enjoy the money and prestige in relation to primary care; and as I¿ve suggested above, both types of practice are valued. That situation has been facilitated greatly by the Danes approach to health policy. General practitioners (GPs) are the cornerstone of the Danish health system. Their patients, like those of family physicians in other countries or GPs in the U.K., include adults and children. Danish GPs receive payment differently from specialists ¿ the former are paid partly by capitation (about 30 percent) and partly fee-for-service while the latter are salaried through hospitals. But the total compensation for generalist physicians and specialist physicians in Denmark is about the same. GPs are highly respected by the Danish people who look to their GPs to help them navigate the health system and coordinate their care. The Danish GP is the gatekeeper for specialty consultations; but the public also know that their GP has all pertinent information about their condition no matter whether they have seen several specialists, been hospitalized or received urgent care in the evening or on a weekend. The GP and all other parts of the health care system are supported by services such as the nationally mandated, regionally organized out-of-hours service that provides care to patients when physicians¿ offices are not open, e.g., nights, weekends, and a highly effective national health information system infrastructure that supports both clinical and administrative functions. (1,2)
3. Relicensure, revalidation, recertification, and professionalism:
I was unaware until reading Prof. Glick¿s comments that 'It is suspected by some, that organized medicine in Israel sees relicensing as a first step to compulsory recertification and therefore opposes it.' I hope that is not the case. The first responsibility of a professional is to be competent. There is little to no evidence that our competence as clinicians simply maintains itself or is maintained, let alone greatly enhanced, by routine 'clinical experience.' The literature supports the fact that there is a need for practicing physicians to update their knowledge and skills continually. One article by Choudhry reviewed 62 evaluations and found that 32, or half, 'deported decreasing performance with increasing years in practice for all outcomes assessed.
This sort of information has been leading to recertification in specialties and to meaningful processes of relicensure or revalidation in some countries. Evidence is just beginning to be accumulated to indicate that recertification is associated with higher performance. The U.K. is currently in the midst of an effort to institute revalidation of all physicians. It will consist of a five year process of appraisal and development of 'a portfolio of evidence to show that they meet the standards.' Not surprisingly, the British Medical Association, which is the principal organization representing physicians in the U.K., has sought and had a lot of input into the development of the process to ensure that it is as fair as possible; but as the British Medical Association notes, 'Revalidation is the process for doctors to positively affirm to the General Medical Council (the British national licensing authority) that they are up to date and fit to practice.' It seems to me that that is the responsible position for organized medicine to take in any country.
4. Handoffs, communication, and education:
Prof. Glick raises several very important issues in relation to resident work hours and staffing. I agree with his concern that 'the legislators, labor negotiators and regulators have in many cases not provided the increase in job lines to compensate for the reduction in physician work hours.' It is obviously important for policy-makers to understand how many resident work hours, used efficiently both for service to patients and education, are necessary in each discipline to ensure adequate coverage of current patient needs and adequate development of the future physician workforce.
I also agree with Prof. Glick that transfers in responsibility, 'handoffs,' or 'handovers,' have a potential to lead to error. Yet, it is possible to design more effective ways of structuring communication during the handover and support it with systems. (4) At Children¿s Hospital (Boston), a process of team training, coupled with computerized patient summaries, and structured oral handoffs led in a pilot study to a 40 percent decrease in medical errors and is now being evaluated in a multi-hospital randomized controlled clinical trial.
I further agree with Prof. Glick¿s assertion that 'Insufficient attention has been paid thus far to the full implication of shortened residency hours to the quality of the training'. I know that is the case in the U.S. I would not, however, suggest that shorter residency hours must be associated with a lower quality of training. Less exhausted residents are more capable of functioning effectively and learning, in the time that they are awake and on duty. Furthermore, both undergraduate and graduate medical training could undoubtedly be more effective and efficient. Much time is wasted on rounds; relatively little thought has gone into consideration of how to take basic clinical processes such as test-ordering and turn them into educational exercises; and there continues to be relatively little use of modern technologies to assist the educational process. This situation is beginning to change with the introduction of simulation, checklists, interprofessional education, etc; but there is an opportunity for much more to be done to improve educational effectiveness and efficiency.
References:
1. Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in Western countries: assessment of different organizational models. BMC Health Serv Res. 2009;9:105. Available at: http://www.biomedcentral.com/1472-6963/9/105 (accessed May 3, 2012)
2. Protti D, Johansen I. Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study, The Commonwealth Fund, March 2010. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Mar/1379_Protti_widespread_adoption_IT_primary_care_Denmark_intl_ib.pdf (accessed May 3, 2012)
3. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Annals of Internal Medicine 2005;142(4):260-273.
4. Kripilani S. What have we learned about safe inpatient handovers? perspective. AHRQ webM-M March 2011. Available at: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=100 (accessed May 4, 2012)
5. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012 Feb;129(2):201-4. Epub 2012 Jan 9; and see: http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?pagewanted=all
Israel Journal of Health Policy Research
Health manpower planning - America and Israel
26 April 2012
Dr Steve Schoenbaum's commentary is a timely analysis of the problem of dealing with the physician work force. Many of the issues faced on the American scene find their parallels in Israel, and they are no less "complex, controversial and politically sensitive". But, as might be expected, there are local unique aspects resulting from the differences in organization of health services, as well as cultural, economic, and political differences. As one who has spent considerable periods of my career both in the USA and in Israel, I have followed both scenes with great interest for several decades.
In both countries there have frequently been almost abrupt swings from periods in which the prevailing threat was a surplus of physicians to one of a shortage, and vice versa. Whereas everyone in Israel is worried about the impending physician shortage, only a few years ago there was pressure in the Knesset to close one or two of Israel's four medical schools! It seems that the experts often seem to err, and are required to reverse their earlier predictions. Dr Jim Pittman, the long term dean of the University of Alabama School of Medicine, explained one of the basic roots of the problem by coining a new word, "pedisolane", which to the best of my knowledge appeared only once or twice in the medical literature (1), and only in articles by him. Pedisolane means "pipeline", and Pittman pointed out that the medical educational pipeline, from admission of a medical student until he/she enters the workforce, is over a decade. Thus actions stimulated by a given manpower assessment, by the time they are effective are often rendered inappropriate and counterproductive by rapidly changing situations.
In contrast to the United States where the organization of health care , like most everything else "is not known for central planning or management", Israel might have been expected to be able to apply a much greater degree of planning and management. The country is smaller, the organizations involved are fewer, there is national health insurance, virtually all health care personnel are salaried, and all the universities are government sponsored. Yet serious health manpower planning has been singularly deficient. It is embarrassing to note that the data upon which even to begin serious analysis and planning are lacking. In Israel granting of a medical license is for life, with no need for renewal. In contrast to most other advanced countries where periodic renewal of licensure permits at least some semblance of analysis of the health manpower, in terms of number, location, specialty and professional activity, all the data here are scattered and fragmentary, making planning extremely difficult. It is suspected by some, that organized medicine in Israel sees relicensing as a first step to compulsory recertification and therefore opposes it. If there is no current reliable data base on the number of physicians, their ages, specialties, practice activities and plans it is hard to plan the future.
As in the USA the younger physicians are much more demanding of what has been called a "controllable life style", and their decisions as to specialty and location of practice, in Israel, as in the USA, are strongly influenced by such factors. I can still remember in my childhood the shock in our community when we heard that the local general practitioner took a vacation! As house officers we worked every other night, unthinkable nowadays. The world has changed, with dramatic implications for management of physician manpower, and we must learn to cope with these changes.
It may seem surprising to an American to learn that in a small country like Israel there is such a preference to location in the central part of the country, which is so short a distance from the "periphery". But a major part of this preference is based on the much greater opportunity for treating private patients beyond the usual hours of the physician's salaried position. Since there is significant dissatisfaction with the compensation of physicians, these opportunities for private practice potential in the large cities are alluring. For the first time in Israeli history the latest wage agreements specifically provided additional salary benefits for the "periphery". These agreements aroused considerable antagonism among physicians in centrally located hospitals, yet were regarded as insufficient by those in the periphery. Nevertheless the agreements represented a first step towards trying to attract physicians to outlying institutions.
As one who has been interviewing medical school applicants in Israel for close to forty years I have found that fewer and fewer applicants now mention primary care as possible future career options, and this when they know they are being interviewed for a medical school with a clear mandate for educating towards primary care. Years ago many applicants averred interest in primary care, although I sometimes doubted their sincerity. Now few even mention primary care. The image of medicine that is projected in the media in Israel is one of brilliant technological advances. Israel is indeed a world power in technology and each achievement gets much publicity. The image of a family physician treating an elderly patient with dozens of chronic problems is not projected, and the youth sees the cardiac catheterizer or the ophthalmological surgeon as the attractive model. So that both the money and the prestige are on the side of the super specialist-particularly in those specialties in which private practice is readily available. Neonatology and nephrology for example suffer because there is limited opportunity for private practice in these specialties.
Internal medicine, once the field that attracted the top students in each class, has fallen on bad times. Unfortunately in Israel, virtually all of the residency training is inpatient, exposing the residents to older patients, desperately ill, during extremely short hospital stays (mean less than four days). Subspecialties have cut drastically into the variety of patients. The subsequent prospects for financial rewards in general internal medicine are much less promising than in the subspecialties. I projected a crisis in internal medicine residency programs several decades ago (2), and unfortunately my prophecies came true. Most tragically with the aging population there is more than ever a growing need for general internists and geriatricians at a time when these specialties have out of favor.
Several other factors need to be considered in the physician manpower problem. With the number of women physician graduates now equaling the number of men (a most positive phenomenon, in my opinion) one needs to take into account that the average woman works fewer hours per week than her male counterpart. In addition the clear trend for men to decrease their number of weekly work hours one must count not just the absolute number of physicians, but must take into account the number of working hours per physician.
In discussing physician manpower most of the discussion relates to overall manpower needs. One needs also to review specifically house staff numbers and training. Clearly no programs will go back to the 36 hours on 12 hours off of my days, and the trend is moving inexorably to fewer and fewer hours per week. Unfortunately the legislators, labor negotiators and regulators have in many cases not provided the increase in job lines to compensate for the reduction in physician work hours. This failure manifests itself in two areas. The first is patient safety, because while the less exhausted physician may indeed make fewer errors, many more occur during repeated transfers of responsibility, In addition some of the rules insisting on time off after night call often leave the departments with grossly inadequate staffing. It has been suggested (3) that greater use of "physician extenders" to relieve residents of some of their less critical duties may be one solution. Another problem is the major reduction in training time during the residency. A chairman of orthopedics recently calculated (4) that today's residents in his department have 40% fewer patient contact hours during their residencies than he had. Insufficient attention has been paid thus far to the full implication of shortened residency hours to the quality of the training.
In attempting to deal with the range of issues involved in improving the health manpower situation there are several additional difficulties that face Israel in coping with these issues. Because of strong unions, both of physicians and of nurses, necessary changes in outdated staffing patterns and of job descriptions to meet changing needs are more difficult than in the USA. For example physician assistants have not been recognized in Israel, whereas in the USA they provide valuable service. Extension of nurse responsibilities is also more problematic, not only because of union problems, but also because of a serious nursing shortage as well.
Another difficulty facing health care administrators in Israel is the lack of local flexibility in providing individual contract benefits in order to attract specific personnel to outlying areas. All physicians and nurses countrywide have similar salaries and fringe benefits.
On the positive side, Israel has had amazing success in absorbing an unprecedented number of physicians into the health care system over a short period of time, retraining many of them and finding useful employment for them. I do not believe that any country in the world has had the experience of doubling the number of practicing physicians in its system just a few years
It is clear to me that both in the USA and in Israel there is critical need for an ongoing careful and comprehensive examination of health manpower in order to try to provide reasonable care for the population. The problems are multifactorial; we are dealing with a "moving target"; even with the best of all intentions we will make serious miscalculations, and many of our proposed solutions may not be feasible. But try we must, and in spite of differences between our countries, we may well learn from each other's experiences.
Shimon M. Glick MD
Professor (emeritus)
Faculty of Health Sciences
Ben Gurion University of the Negev
Beer Sheva, Israel
1 Pittman JA Campbell JH. Tomorrow is already here:physician manpower in Alabama-the medical pedisolane in action. Alabama Journal of Medical Sciences 1979;16:239-258
2.Glick SM the impending crisis in internal medicine training programs. Am J Med 1988;84:929-932
3.McLean TR the 80-hour work week: why safer patient care will mean more health care is provided by physician extenders. J. Legal Medicine 2005;26:339-384.
4.Pellegrini VD Jr Perspective:ten thousand hours to patient safety, sooner or later. Academic Medicine 2012;87:164-167
Competing interests
I have no competing interests
Further thoughts related to the physician workforce and its training
8 May 2012
I first met Prof. Shimon Glick about 25 years ago when at the invitation of Prof. Carmi Margolis I first visited the medical school, now the Joyce and Irving Goldman Medical School, at Ben Gurion University of the Negev. Prof. Glick was then the medical school¿s dean. Over the years, I have learned much from him, and always find his comments thoughtful and provocative. Given our many years of friendship, I know that he will not be surprised that I have several additional comments related to the thoughtful comments he has shared here.
1. A personal view of primary care vs. specialty practice:
In my own clinical lives, I was first a specialist in infectious diseases and then a primary care physician. In full disclosure, I should note that I never did either full-time: I was a specialist when I was in academia, at which time I was doing a lot of teaching and epidemiologic research; and I was a primary care internist after I joined a staff-model HMO, Harvard Community Health Plan, where I spent the majority of my time as a manager. I enjoyed both types of practice; but I found primary care much more interesting, challenging, and rewarding than practice as a specialist. Despite the fact that primary care physicians do see many people with minor, 'routine' illnesses, I believe that primary care practice is much less routinized than specialty practice. I felt I could master the specialty with its relatively limited, albeit detailed, knowledge and skill base; whereas I never felt that I could master primary care when so much depends upon the nuances of individual relationships and so much depends upon being alert to clues that unfold over time. In primary care I was always energized, never bored.
A major issue in primary care is knowing when someone might have a true positive finding: I hope all readers with a scientific background are aware that the predictive value of a positive test is lower when the prevalence of a condition is lower; and in primary care, the prevalence of disease is lower than in specialty care. Thus, patients in primary care settings who have a positive finding may well not have a major problem; and determining efficiently which ones do have something that must be pursued is an interesting and important challenge. In contrast, specialists see a patient population with a much higher prevalence of positive findings, and it is usually less of a challenge to hone in on a condition, even a seemingly rare one, and manage it. Of course, I fully agree with Prof. Glick¿s observation that 'the money and the prestige are on the side of the super specialist.' That is true not only in Israel but in the United States. At least in the U.S., technical skills are valued more highly than cognitive ones. If policy-makers understand, however, that there is nothing so special about specialists, it ought to be possible for them to be creative in their policy-making and change the status quo. Lest any readers who are specialists, or any readers who harbor that illusion that all specialists are special, think I¿m 'anti-specialist,' let me hasten to point out that I believe that both generalists and specialists are very important to having a high performance health care system. I¿m simply trying to address the imbalance in money and prestige that Prof. Glick has highlighted.
2. The Danish health system and primary care:
This being a journal that seeks international input, I think is worth considering some other countries, in particular Denmark, a country of about 5.4 million people which like Israel spends considerably less of its GDP on health care. In Denmark, super specialists do not enjoy the money and prestige in relation to primary care; and as I¿ve suggested above, both types of practice are valued. That situation has been facilitated greatly by the Danes approach to health policy. General practitioners (GPs) are the cornerstone of the Danish health system. Their patients, like those of family physicians in other countries or GPs in the U.K., include adults and children. Danish GPs receive payment differently from specialists ¿ the former are paid partly by capitation (about 30 percent) and partly fee-for-service while the latter are salaried through hospitals. But the total compensation for generalist physicians and specialist physicians in Denmark is about the same. GPs are highly respected by the Danish people who look to their GPs to help them navigate the health system and coordinate their care. The Danish GP is the gatekeeper for specialty consultations; but the public also know that their GP has all pertinent information about their condition no matter whether they have seen several specialists, been hospitalized or received urgent care in the evening or on a weekend. The GP and all other parts of the health care system are supported by services such as the nationally mandated, regionally organized out-of-hours service that provides care to patients when physicians¿ offices are not open, e.g., nights, weekends, and a highly effective national health information system infrastructure that supports both clinical and administrative functions. (1,2)
3. Relicensure, revalidation, recertification, and professionalism:
I was unaware until reading Prof. Glick¿s comments that 'It is suspected by some, that organized medicine in Israel sees relicensing as a first step to compulsory recertification and therefore opposes it.' I hope that is not the case. The first responsibility of a professional is to be competent. There is little to no evidence that our competence as clinicians simply maintains itself or is maintained, let alone greatly enhanced, by routine 'clinical experience.' The literature supports the fact that there is a need for practicing physicians to update their knowledge and skills continually. One article by Choudhry reviewed 62 evaluations and found that 32, or half, 'deported decreasing performance with increasing years in practice for all outcomes assessed.
This sort of information has been leading to recertification in specialties and to meaningful processes of relicensure or revalidation in some countries. Evidence is just beginning to be accumulated to indicate that recertification is associated with higher performance. The U.K. is currently in the midst of an effort to institute revalidation of all physicians. It will consist of a five year process of appraisal and development of 'a portfolio of evidence to show that they meet the standards.' Not surprisingly, the British Medical Association, which is the principal organization representing physicians in the U.K., has sought and had a lot of input into the development of the process to ensure that it is as fair as possible; but as the British Medical Association notes, 'Revalidation is the process for doctors to positively affirm to the General Medical Council (the British national licensing authority) that they are up to date and fit to practice.' It seems to me that that is the responsible position for organized medicine to take in any country.
4. Handoffs, communication, and education:
Prof. Glick raises several very important issues in relation to resident work hours and staffing. I agree with his concern that 'the legislators, labor negotiators and regulators have in many cases not provided the increase in job lines to compensate for the reduction in physician work hours.' It is obviously important for policy-makers to understand how many resident work hours, used efficiently both for service to patients and education, are necessary in each discipline to ensure adequate coverage of current patient needs and adequate development of the future physician workforce.
I also agree with Prof. Glick that transfers in responsibility, 'handoffs,' or 'handovers,' have a potential to lead to error. Yet, it is possible to design more effective ways of structuring communication during the handover and support it with systems. (4) At Children¿s Hospital (Boston), a process of team training, coupled with computerized patient summaries, and structured oral handoffs led in a pilot study to a 40 percent decrease in medical errors and is now being evaluated in a multi-hospital randomized controlled clinical trial.
I further agree with Prof. Glick¿s assertion that 'Insufficient attention has been paid thus far to the full implication of shortened residency hours to the quality of the training'. I know that is the case in the U.S. I would not, however, suggest that shorter residency hours must be associated with a lower quality of training. Less exhausted residents are more capable of functioning effectively and learning, in the time that they are awake and on duty. Furthermore, both undergraduate and graduate medical training could undoubtedly be more effective and efficient. Much time is wasted on rounds; relatively little thought has gone into consideration of how to take basic clinical processes such as test-ordering and turn them into educational exercises; and there continues to be relatively little use of modern technologies to assist the educational process. This situation is beginning to change with the introduction of simulation, checklists, interprofessional education, etc; but there is an opportunity for much more to be done to improve educational effectiveness and efficiency.
References:
1. Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in Western countries: assessment of different organizational models. BMC Health Serv Res. 2009;9:105. Available at: http://www.biomedcentral.com/1472-6963/9/105 (accessed May 3, 2012)
2. Protti D, Johansen I. Widespread Adoption of Information Technology in Primary Care Physician Offices in Denmark: A Case Study, The Commonwealth Fund, March 2010. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2010/Mar/1379_Protti_widespread_adoption_IT_primary_care_Denmark_intl_ib.pdf (accessed May 3, 2012)
3. Choudhry NK, Fletcher RH, Soumerai SB. Systematic review: The relationship between clinical experience and quality of health care. Annals of Internal Medicine 2005;142(4):260-273.
4. Kripilani S. What have we learned about safe inpatient handovers? perspective. AHRQ webM-M March 2011. Available at: http://webmm.ahrq.gov/perspective.aspx?perspectiveID=100 (accessed May 4, 2012)
5. Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC; I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012 Feb;129(2):201-4. Epub 2012 Jan 9; and see: http://www.nytimes.com/2011/08/07/magazine/the-phantom-menace-of-sleep-deprived-doctors.html?pagewanted=all
Competing interests
None
Competing interests
None declared