While putting together this column for the PLJ, I found myself trying to answer the K.I.S.S. challenge: Keep It Super Simple. Our industry is arguably the most complicated of all sectors. Looking after the complex biology, physiology, and pathology of people is difficult enough. Layer on the complexities of working in a set of systems that have evolved to carry 25–30% waste and inefficiency, coupled with the 10–15% major error rates, while also spending the most from the Gross Domestic Product (GDP), it makes being excited and satisfied about the medical profession a challenge.
This is especially true considering the American healthcare system rankings compared to other developed countries in the Organization for Economic Cooperation and Development (Figures 1 and 2).
Figure 1. Health Expenditure and Financing by Country (Source: OECD)
Figure 2. Life Expectancy at Birth by Country (Source: OECD)
It is a profession we chose, however. As physician leaders, we are best suited to provide the optimal (not the only) insights on evolving the industry to improve care for people by using more cost-effective, safer, higher-quality, and efficient strategies. But the healthcare industry playing field makes it complicated, and as physician leaders, we must keep an eye on its shifting sets of issues and influences.
What follows are a couple of those issues and some simple related thoughts.
Demographics
The Federation of State Medical Boards (FSMB) compiles demographic information on the populations of licensed U.S. physicians on a bi-annual basis (Table 1). According to data from 2020 found in the most recent FSMB report, there are 1,018,776 licensed physicians in the United States and the District of Columbia, representing a physician workforce that is 20% larger than it was a decade ago.
Most physicians (90%) have a Doctor of Medicine (MD) degree, while 10% have a Doctor of Osteopathic Medicine (DO) degree. In 2020, 83% of licensed physicians were board-certified by either the ABMS or the AOA, up from 77% in 2010. The mean age of licensed physicians is 51.7 years, a year older than in 2010.
The percentage of licensed female physicians continues to increase, although men still comprise the majority of physicians in the workforce. In 2020, 36% of licensed physicians were women, compared to 30% of the physician population in 2010. Over the last decade, the licensed female physician population has increased by 46%, compared to only 10% for male physicians. Overall, in many medical schools today, slightly more than half the students are female, indicating a continuous shift toward gender equity in numbers.
Medical school enrollment increased by 20% for MD-granting schools and 63% for DO-granting schools between 2010 and 2020. More than three-quarters (77%) of licensed physicians are U.S. or Canadian medical graduates (referred to as USMGs), and 23% are international medical graduates (IMGs). Physicians in the United States have graduated from 2,200 medical schools representing 169 countries worldwide.
Simple Thought: As physician leaders, we need to recognize how the workforce continues to change with the increase in women (an excellent thing) but a potentially shrinking overall workforce following the pandemic. IMGs’ interest in working in America remains high, and interest in entering medicine through an osteopathic route is rapidly increasing. We need to follow closely the workplace locations and specialty choices of USMGs (MDs and DOs) and IMGs to understand how best to look after almost 350 million Americans.
Career Choices
The Association of American Medical Colleges (AAMC) publishes an annual report on physician specialty data. This publication provides detailed statistics about active physicians and physicians in training in the specialties with the largest numbers of active physicians in the United States (i.e., specialties with more than 2,500 active physicians).
In 2019, the specialties with the most significant numbers of active physicians were the primary care specialties of internal medicine (120,171 physicians), family medicine/general practice (118,198), and pediatrics (60,618). While 45.8% of the residents and fellows in ACGME-accredited programs were female, percentages of females in the 47 largest specialties ranged from a high of 83.8% in obstetrics and gynecology residencies to a low of 12.9% in sports medicine (orthopedic surgery) residencies.
The rationale for choices is multi-faceted, but there are clear preferences toward employment models, earlier retirement ages, and so-called controllable lifestyle specialties. The ongoing shifts created by the increasing number of women in medicine are noticeable.
The U.S.-licensed physicians serve a national population of 331 million people, reflecting a physician-to-population ratio of 307 licensed physicians per 100,000 people, an increase from 277 in 2010. The licensed physician population has grown in numbers relative to the total population, but concerns about a doctor shortage are real as both the general and physician populations age.
Simple Thought: The complexities surrounding how best to train physicians, and the amount of time required to do so effectively, are rich with academic considerations and ongoing studies. The challenge for physician leaders is maintaining the pace of evolving medical education and specialty training while simultaneously keeping up with the pace of change in healthcare delivery systems and the growing expectations of patients or families for shared decision-making.
Compensation
A recent analysis calculates, after accounting for specialty, hours, location, and years of experience, a persistent 25% pay gap between female and male physicians that adds up to $2 million over a medical career. Similarly, there remain significant differences in compensation levels between specialties, with cognitive specialties usually receiving significantly less pay than procedural specialties.
Simple Thought: As in general society, gender-based compensation inequities persist in healthcare. It remains unclear why this should occur in a predominantly fee-for-service reimbursement payment model. So, for physician leaders, clearly more work is needed to understand the reasons behind the inequity and, more importantly, determine how best to rectify the disparities as quickly as possible.
Differences in cognitive versus procedural specialty compensation are likely to persist for some time. They are predominantly related to perceived risks, procedural complexities, and liability issues, but inequities are profound across specialties (Figure 3).
Figure 3. Mean Annual Salaries of Professions (Source: U.S. Bureau of Labor Statistics)
Violence in The Workplace
The National Quality Forum (NQF) convenes a Leadership Consortium that brings together experts and recognized leaders from the private and public sectors committed to improving the safety and quality of healthcare. I was privileged to be co-chair of an initiative focused on violence in the healthcare workplace.
I raise this issue because the multitude of complexities and stressors in healthcare, coupled with the trends presented in the other topics covered earlier, provide a potentially ripe environment for poor behaviors to manifest — especially as our workforce and the public continue to navigate the complexities of a pandemic.
An NQF issue brief shows that “nearly 75% of workplace assaults occur in healthcare settings. Healthcare workplace violence — both physical and emotional — jeopardizes the health and well-being of staff and patients. Healthcare workplace violence can stem from encounters between staff and patients and/or their families, aggression or harassment from co-workers, or the intrusion of community violence into the workplace. Healthcare workers are at an increased risk of workplace violence, with incidents of serious violence occurring four times more often in healthcare than in the private industry. However, violence in the healthcare workplace is vastly underreported, masking the true magnitude of this issue.
“In addition to the physical and emotional toll caused by workplace violence, workplace violence also has high costs to a healthcare organization, including costs associated with medical treatment, lost productivity, and workers’ compensation. After an episode of workplace violence, staff often experience missed work, burnout, job dissatisfaction, decreased productivity, and a diminished feeling of safety. As healthcare workers increasingly face physical and emotional threats, healthcare organizations must protect them from the sources of harm that infringe upon the stability and sustainability of this critical workforce.”
Simple Thought: Most of us have witnessed or experienced a workplace violence situation. The propensity for these situations to escalate in frequency is high, given the significant rates of burnout and dissatisfaction within the workforce.
As physician leaders, we and our peers or co-workers often are in the direct path of workplace violence. Preventive actions and safety are the predominant needs overall, but as leaders, there are many opportunities to ensure appropriate policies, procedures, reporting, and evaluations are also in place. Looking for ways to collaborate on this issue within organizations and different care environments can also provide a methodology for building team culture and collegiality.
Time To K.I.S.S.
Many other factors contribute to why healthcare is such a complex industry. In fact, when viewed across all sectors of the industry, there are almost too many to cover beyond the added few below:
Diversity and inclusion
Generational differences
Technology and telehealth
Social media approaches
Burnout and wellness
Patient-centered care and shared decision-making
Social determinants of health and community care
Ours truly is a special profession, and it is a privilege to be involved, but it is indeed a complex industry in which we practice our craft. As physician leaders, we must embrace the complexities of our industry. We must embrace the reality we chose to enter this profession, and we can choose to embrace the opportunities in which our individual and collective energies can help create the change needed for our industry as we all emerge through the pandemic’s impacts.
Together, perhaps, we can simplify and help make it a better industry that embraces the positive aspects of caring for people.
Remember, leading and creating significant change in healthcare is our overall intent as physicians. AAPL focuses on maximizing the potential of physician-led, interprofessional leadership to create personal and organizational transformation that benefits patient outcomes, improves workforce wellness, and refines the delivery of healthcare internationally.
We must all continue to seek deeper levels of professional and personal development and recognize ways we can each generate constructive influence for one another at all levels. As physician leaders, let us become more engaged, stay engaged, and help others become involved. Exploring and creating the opportunities for broader levels of positive transformation in healthcare is within our reach – individually and collectively.