Reform Must Address Workforce Issues

For lasting reform we must rethink workforce distribution across the specialty


In my continuing series on health care reform, let me just make simple statements. If ever asked if I would vote for health care reform, my answer would be, Of course! I’d love to vote for health care reform . . . if I ever saw it. No one is really reforming health care. What they’re talking about is the money. The money is only one-fifth of what needs to be reformed and so the current debate is like trying to squeeze a balloon with one hand. It always comes out in some other spot. You either do it all or you do none of it, and the current proposals border on the ridiculous.

An area that needs to be explored at great depth – and which has received absolutely no attention from the Obama administration or its opponents – is the question of workforce. Workforce, which in our old politically unreconstructed days was called manpower, is still what medicine is about. This is a service industry; services are given out from people, to people. If we don’t talk about who does what, we’re talking about nothing.


First, as regards our physician workforce, let me say that America is participating in an activity which is probably illegal, definitely immoral and, to quote W.C. Fields, also fattening. We are stealing physicians from the rest of the world. When I was the president of the American College of Emergency Physicians, I got to watch some of those discussions going on in Washington. Let’s just say that there are multiple countries on this planet that are not happy with us because of what we do with their physicians. Why on earth would the richest nation in the world staff one-quarter of its residency slots with foreign medical graduates? I’m sure there’s an excess of doctors in India. I’m sure the Nigerians don’t need doctors. I’m sure the Pakistanis have such good health that they don’t mind having to pay people to go to medical school only to have them escape to the United States. And don’t even begin to give me the weak argument that “they will go back and be such better doctors in their own country.” Total crap. The data confirms that less than two percent will be going back. I don’t blame them. The individual doctor is not the problem. If you came from Pakistan, you wouldn’t want to go back either. I understand the individual physician motivation. But we must also understand the frustration of the Pakistani people who have spent their money to send someone to the United States to do a residency only to have them settle in New Jersey and drive a Mercedes. There is no lack of people in the United States to go to medical school. Why do we continue to rob the rest of the world who need doctors desperately to fill our own needs?

Undoubtedly, people will cite the cost of educating more medical students. It should be noted that the cost of educating these additional medical students is less than the drug companies spend on physician advertising every year. I’ve got an idea. Let’s just cancel all physician advertising, and if the drug companies want to actually help out the citizens of the United States, let them pay for the remaining 25% of slots that we need to fill in this country. This question is not going away. It’s about time we lived up to our obligation on the planet and took care of this problem.

But workforce is about more than doctors. Throwing more doctors at the current situation will not solve the problem. If you’re going to talk about workforce, you need to talk about expanding the service capabilities of each person involved and deciding who should be doing what job. No physician should be making phone calls, sitting at the computer or filling out paperwork. It is estimated that we could double the physician output if physicians had scribes. Why wouldn’t you take a $12-to $17-per-hour position if you could double the output of a $125-per-hour person? No one who actually has a financial stake in running an emergency department would want to have their most expensive asset doing work that can be done by someone for one-tenth the cost. No other industry would be so wasteful. Why we’re doing it I have no idea.


I will posit that there are three reasons that real workforce examination has not taken place. The first one is “union mentality.” This applies to doctors, nurses and techs alike. Everyone is so jealously guarding their own turf that they will never step back – unless forced to do so – to look and see how things could be better staffed. If the emergency physicians actually owned the franchise of the emergency department and could actually hire and fire and staff with the correct personnel, I promise you they would not look like they do today. This is a holdover from probably two centuries ago and we need to rethink it. Who is doing the research on staffing solutions? I honestly think that the academic community has abandoned this area. When was the last time you saw a good paper on improving physician productivity, changing the role of nurses and techs in the department, and truly making health care more efficient? We have no lack of people who want to publish on negative outcome CPR research. Where are the people who want to publish on actually taking care of the live ones as opposed to beating the dead ones.

A second reason that workforce reform is going nowhere is we have a traditional model that we think is right. Why do we believe that people have to come to a window, get triaged, then go to a waiting room and touch all these various bases before they get their care? More and more emergency departments are realizing that too many stops before the patient gets to see the provider is a waste of time, does nothing to advance care, and basically leaves more cracks in the system for the patient to fall into.

The entire nursing question also needs to be studied. Nurses should do nursing. I want the nurses available for critically ill patients who need drugs, the adjustment of IV medications and need critical monitoring. You don’t need a nurse to take people back to their room, get them undressed and prepared to see a physician. This is tech work. I have seen no serious discussions or studies on turning out true emergency department technicians. I fully believe that with a 6-month on-the-job training program we could turn out an extremely valuable entity that would help move patients, provide excellent care and would alleviate the nursing shortage. EMTs age. It is very difficult to be a 60-year-old EMT. The logical progression for EMTs is to become emergency department techs as they mature their careers. Why there isn’t more discussion about how to move these people in an orderly and systematic fashion is beyond me.

Lastly, we need to review the relationship between work within and outside the department. There is no reason that radiologists shouldn’t read every film online 24-hours a day. There is no reason that there should be any delays in getting lab materials back. Until we look at work redistribution and training programs at all levels of health care workers, there will be no meaningful health reform in the United States.


Greg Henry, MD, is the founder and CEO of Medical Practice Risk Assessment, Inc. Dr. Henry is a past president of ACEP and directed an ED for 21 years.
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  1. Jerry Mothershead on

    While I have nothign but the highest respect for Dr. Henry, I think virtually everyone involved with this healthcare debate forgets perhaps the most critical part of healthcare – the patient. The only reason there are costs in healthcare are that people use (and abuse) the system, and physicians are willing aiders and abettors. Face it, what does someone hear when they call an ED or doctor’s office “if you think you hve an emergency, call 9-1-1 or go to your nearest ED.” How inane! This presumes that the caller has the knowledge and wherewithall to know whether their condition consitites and emergency. And so it goes with everything.
    1.We need to start educating the young about preventive healthy lifestyles (beyond condoms and STDs!), and appropriate use of the medical system

  2. Wow, nothing like a piece by Greg Henry to provoke thought and dicussion. He, of course, is addressing only one small part of TRUE healthcare reform (as opposed to the pseudoreform of the administration). Dr Mothershead hits another part of it, the use of the ED for primary care. But that’s nearly 40 years old (Medicaid, Medicare?), deeply rooted in our society, and will not change or go away.

    Improving ED efficiency will help in our present setting, but what to do with the Jurassic-era administrators who will not, will not, will not authorize more personnel in the ED, even low level, relatively inexpensive helpers?

    How about ED’s without PACs, EMRs that really contribute to good patient care instead of good administrative metrics, rapid admission schemes, and a dozens of other really good helps in improved the EDP’s efficiency? The reality is that most of us practice in primitive ED’s, surrounded by equipment that usually does not work or can’t be found, hampered by lack of skilled nursing staff, and ancient systems with outdated, outmoded procedures.

    How to change all of this, that is the question!

  3. What the world of (ED medicine) needs now is not love but good collaborative management. It would not be so hard to get the ED flowing smoothly if hospital administrators actually were competent. They are the ‘trained’ executives who should be instrumental at developing and over overseeing the front line processes needed for what we are all there for – taking care of patients while getting paid for our valuable services. Unfortunately this rarely gets done. They focus on myriad other issues and only care about the metrics that regulators make them care about. The many methods that could improve aspects of health (& ED) care need to be worked on from the front lines up – not the top (congress) down. Process improvements only happen now with the unusual manager (be they administrator, dept chief, nurse manager) who is willing to do the Herculean task of making small incremental changes while engaging the other participants in endless committee meetings. Instead they do the minimum required. So as Drs Henry and Childs points out most of us continue to work with antiquated processes in less than ideal ED’s surrounded by equipment that usually does not work or can’t be found, hampered by lack of skilled nursing staff, and ancient systems with outdated, outmoded procedures. We could do a lot better. What we need now is good collaborative management. Instead we get medicine by political fiat. Enjoy the ride.

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