The shortage of health care workers in Maine, where I live and work, is a harbinger for the struggles the rest of the country will increasingly confront to hire and retain the individuals who make up the backbone of health care.
Maine’s population is the oldest in the nation and is tied with Vermont as being the most rural state. Maine’s health care workers are also among the oldest in the country, with many practitioners approaching or even exceeding retirement age. The challenges the state face are ahead of what other parts of the country will face as the nation ages and as urbanization creates pockets of underserved populations in cities as well as in vast remote rural areas.
As I explained on Thursday before the Senate Committee on Health, Education, Labor, and Pensions, higher education needs to partner productively with the government, business, and nonprofit sectors to move the needle in important ways on this critical problem. As the president of Maine-based University of New England, I see five ways forward, and offer examples from our university.
Increase the number of doctors, nurses, and other health care professionals being educated. That may sound simplistic, but it is not. The largest impediment to training more health care workers is the availability of clinical training experiences in hospitals and clinics. As financial margins have tightened and clinician workloads have increased over the past three decades, health care facilities and practicing clinicians have fewer resources and less time to devote to training students.
The single most important way to reverse that is to support and expand partnerships between universities and community health care settings to develop additional residencies for graduating medical students as well as clinical training opportunities for nurses, respiratory therapists, radiology technicians, and others. Doing this requires revising the antiquated funding policies of the Centers for Medicare and Medicaid Services, which make it very difficult to grow more medical residency placements.
Clinical training opportunities are not the only infrastructure limitation to training more health care workers. Cost, both to educational institutions and to students themselves, is also a factor. Standing up new educational facilities, or expanding existing ones, involves considerable startup costs; one-time governmental support is often needed to supplement institutional investments and philanthropy. And the costs to educate students have risen considerably — at the University of New England, for example, the cost of training third- and fourth-year medical students has increased fivefold since 2017.
As a consequence, the high tuition for many programs can be an impediment for many students. Scholarships and loan repayment programs can make health care education accessible to those who would otherwise find it out of reach.
Intentionally recruit and train more students who reflect communities. Individuals from underrepresented groups are more likely to seek out practitioners who share their identities and backgrounds. People of racial or ethnic groups who are treated by race/ethnic-concordant clinicians are more likely to use needed health services and are less likely to delay seeking care.
Maine has a growing immigrant population, especially people from Central and Eastern Africa. Not surprisingly, this community experiences significant health care discrepancies relative to Mainers in general. Addressing such discrepancies is important in every community. The University of New England has unilaterally increased recruitment efforts focused on students of color, and has expanded its advanced standing track in dentistry and pharmacy that are designed to accelerate the time it takes for foreign-trained professionals to achieve a U.S. degree and become eligible for licensure. The university has also developed partnerships with local community colleges to matriculate students from our immigrant communities into several health care programs.
Encourage newly minted health care workers to practice in underserved areas. The federal government has invested in programs that provide financial support in the form of loan repayment to graduates who serve in medical underserved areas, including rural, tribal, and some urban communities. Though these programs are essential, they are not enough. In the case of physicians, for example, the loan repayment subsidies do not compensate enough for the typical salary gap between rich urban and suburban communities and underserved urban and rural areas.
The paucity of health care professionals practicing in rural areas is particularly acute, fueled in part by the decline of students from rural backgrounds pursuing health care education. The University of New England has a successful strategy to encourage medical, dental, and nursing graduates to practice in rural areas. Students from rural areas, both from Maine and around the country, are intentionally recruited as they are more likely to return to such communities after graduation. And all students are placed in clinical training sites in underserved rural areas as part of their education.
Each year, many graduates exposed to these crucial settings during rotations return for employment. Over the past five years, up to 53% of our medical students who completed a rotation in a rural community hospital in Maine returned to those areas to practice, regardless of where they did their residency or where they were originally from.
Change state-level regulations that allow health professionals to practice at the top of their scope. “Scope of practice” defines what services or procedures a particular type of health professional is legally permitted to provide. Across the U.S., many states have scope of practice laws that prevent some health professionals from providing certain services even though they are trained and prepared to do so. During the early stages of the Covid-19 pandemic, many states made temporary changes to increase the flexibility of such regulatory practices to help address the pandemic-related workforce crisis. Continuing such flexibility should be seriously considered.
The focus of developing scope of practice regulation should be on what level of regulation results in the best outcomes in terms of health and safety of the population, not on guild-based political concerns.
Change the prevailing educational model in two ways. Accrediting bodies need to allow training programs to be more creative and flexible — without sacrificing educational quality — as a way to develop novel training models. This would include so-called career laddering opportunities that do not completely remove an individual from the workforce while they are pursuing an advanced degree, such as a physician assistant or nurse practitioner becoming a physician, a dental hygienist becoming a dentist, or a certified nursing assistant becoming a registered nurse. Accrediting bodies should also accept more high-quality clinical simulation hours in place of hours physically spent at clinical sites, thereby reducing the burden on clinical sites.
A second educational reform involves breaking down the traditional siloes that characterize health care training and practice. Anyone who’s recently been a patient in a hospital, or who has cared for a loved one who has been hospitalized, understands how siloed the practice of health care tends to be. In hospitals, people are often treated like a collection of disembodied organ systems. Various physicians and other providers come in, one-by-one, and look at one piece of the puzzle, often with very little coordination or even communication between them. This results in substandard care and increased medical errors.
An educational model has emerged in which students from diverse disciplines are explicitly trained to work together, across traditional boundaries, in multi-disciplinary teams. Known as interprofessional education, this model has been shown to improve clinical outcomes, reduce medical errors, increase patient satisfaction, and decrease provider burnout.
Successfully addressing America’s health care workforce crisis will require not merely acting on each of these five strategies in isolation but seamlessly integrating them. Although strategic investment of resources will be required, much of the work we confront reflects cultural changes that will require strong leadership, a willingness to innovate, and coordinated partnerships between academia, government, industry, and the nonprofit sector.
James Herbert, a clinical psychologist, is the president of the University of New England.
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