partners

European Observatory on Health Systems and Policies

United States Of America


Health Systems in Transition (HiT) profile of United States Of America

4.2 Human resources

4.2.1 The United States health-care workforce

Due to the fact that health care is a complex set of services provided in a variety of settings, it is not surprising that the human resources needed to provide these services are also varied and complex. The United States Bureau of Labor Statistics (BLS) categorizes health-care personnel into three main categories: “healthcare diagnosing and treating practitioners”, “healthcare technologists and technicians” and “healthcare support occupations” (BLS, 2011a, 2011b). The first category includes practitioners with both diagnostic and treatment capabilities, such as chiropractors, dentists, optometrists, physicians, podiatrists, pharmacists, registered nurses (RNs) and PAs. It also includes a large grouping of therapists with diagnostic and treatment roles: occupational, physical, respiratory, speech-language and other therapists. In providing their specialized care these therapists consult and practise with other health professionals. The second category is comprised of a large number of technologists and technicians, such as clinical laboratory technologists and technicians, dental hygienists, licensed practical (vocational) nurses (LPNs) and medical record technicians. The distinction between technologist and technician involves the level of education, which is longer for technologists, and work roles, which are more complex and analytical for technologists. In addition, technologists may supervise the work of technicians. The last category is the health-care support occupations, some examples of which are several types of aide (nursing, psychiatric and home health) and dental assistants.

Box4.1 lists some of the important occupations under each of the three BLS categories and provides a brief summary of the BLS descriptions of a selection of these occupations at the time of publication. The box includes a description of one type of health-care worker that is not currently tracked by the BLS – the community health worker (CHW), also called community health advisers, lay health advocates, community health representatives, peer health promoters and other titles.

4.2.2 Trends in the United States health-care workforce and international comparisons

Table4.5 presents the numbers of workers employed in the United States in the occupations described above (with the exception of CHWs) from 1990 to 2010. Unless stated otherwise, data are at the national level and it must be remembered that trends may be different at the state level. Increases in employment occurred with physicians, chiropractors, optometrists, pharmacists, RNs, PAs, all the therapist occupations, most of the technologist and technician occupations, and all the support occupations. The increases in PAs, and several types of therapists were significant – greater than 70%. Decreases in employment occurred with dentists, podiatrists, and clinical laboratory technologists and technicians. What is noteworthy about these trends is that most decreases occurred in the higher paid professional occupations. In some of these occupations (such as dentist), one can see a decrease in the number of professionals but an increase in the corresponding technical (dental hygienist) and support (dental assistant) occupations, indicating substitution of the professional workforce by technical and non-professional workers. The moderate increases in physicians and RNs, and the large increases in PAs and therapists do not seem to be due to a per capita increase in utilization of services, since hospital admissions and days of care decreased and outpatient visits to physicians and for screenings (such as mammograms) increased only slightly in this time period (National Center for Health Statistics, 2011). The increase in RNs and PAs may indicate increasing reliance on these professionals for primary health care (Hooker & McCaig, 2001; Naylor & Kurtzman, 2010).

Changes in BLS classification may be responsible for some of the changes. The large increase in the “other” category of therapists may be due to changes in BLS inclusion criteria for that occupation. The decrease in podiatrists may also reflect changes in the BLS occupational classification system since the values changed significantly in 2000, and the trend since 2000 shows an increase in numbers.

Since there is no BLS occupational code for reporting numbers of CHWs, there are no official estimates of the number of CHWs in the United States. A recent survey by the Health Resources and Services Administration (HRSA) estimated their numbers by approximating the percentage of workers in occupations in which CHWs were likely to have been included in BLS reports. HRSA reported that in 2000 there were approximately 86 000 CHWs (HRSA, 2007). California and New York had the most (8000–9000 each).

Fig4.8–Fig4.11 provide a seven-country international comparison of trends in doctors, nurses, pharmacists and dentists respectively. Comparisons must be made with caution due to differences in the data collected from country to country and over time. Most of the data are of head counts of the professionals while some report full-time equivalents (FTEs). Countries may also differ in whether they report all licensed professionals, only those who are professionally active or only those who are practising in direct care. Definitions of these categories are in the tables.

Fig4.8 demonstrates that three of seven OECD countries – France, Germany and the Netherlands – tend to utilize a greater number of physicians per population than the remaining four. Of those three, the Netherlands’ physician to population ratio grew the most, making it the country with the highest ratio from 2004 to 2008 (note that the Netherlands reported the number of licensed physicians, which will be higher than the number of professionally active or practising physicians). Of the four countries with lower physician to population ratios, the United Kingdom’s ratio started at the bottom in 1990 and increased to be the highest of the four by 2010. The United States was just below the United Kingdom in 2010. Canada had very little change in physician to population ratio in these years.

Fig4.9 plots the trends in nurses from 2000 to 2010. (Data were not available for international comparisons prior to 2000.) The United States had the highest nurse to population ratios of all seven countries in all years except 2010, though the ratio has increased the least. It may be that the numbers are higher because the United States includes LPNs in the count while other countries may not include a comparable category of nurse. Ratios in Germany, the Netherlands and the United Kingdom are also high and grew moderately over the eight years. Ratios in Canada actually fell from 2000 to 2004. France had the lowest ratio through all years, and even though the ratio increased significantly it was still much lower in 2010 than in any other country. This result could be partially due to the fact that the ratio reflected FTEs instead of head counts.

Fig4.10 shows the trends in pharmacists in seven OECD countries from 2000 to 2010. The United States follows the median trend, along with Canada. Japan has the highest ratios, and the Netherlands (a densely populated country) has the lowest by a significant amount. In all countries ratios increased steadily but only slightly over the eight years.

Fig4.11 presents the trends in dentists in seven OECD countries from 1990 to 2010. The United States occupies a median position. In France, the United States and the Netherlands the ratio did not change from 2000 to 2008 (note that BLS statistics in Table4.5 indicate a decline in dentists in the United States). Germany has had the most dentists per population, and along with Japan had the biggest increase. The Netherlands had the fewest dentists per population.

4.2.3 International mobility of the health-care workforce

Included in the numbers of United States health-care professionals in the previous section are international immigrants, who add to the number of practising health-care professionals. In contrast, health-care professionals also emigrate from the United States, which reduces their United States number. Whether the total numbers of health-care professionals are higher or lower depends on the net migration. For physicians, WHO has found that the high-income countries, including the United States, have experienced a positive net migration (Arah, Ogbu & Okeke, 2008). Between 23% and 28% of physicians in the United States, Canada, the United Kingdom and Australia received their medical degrees outside the host countries (Mullen, 2005). In 2004, 25.6% of physicians in the United States were international medical graduates (IMGs) (Akl et al., 2007). Immigration of nurses to the United States has tripled since 1994, and in 2005 the United States had more nurse immigrants than any other country in the world (Aiken, 2007). Around 8% of the United States nursing workforce in 2000 consisted of international nursing graduates (INGs) (Aiken, 2007).

Forty to seventy-five per cent of the source countries for IMGs in the United States were low to middle-income countries (Mullen, 2005; Starfield & Fryer, 2007). Eighty per cent of foreign nurses in the United States are from lower income countries (Aiken, 2007). India, the Philippines, the Middle East and North Africa have been key source countries for physician and nurse immigration to the United States (Cooper, 2005; Aiken, 2007). The Philippines accounts for 30% of nursing immigrants (Aiken, 2007). High-income countries contribute only a small percentage to the United States physician and nurse workforce.

These source countries can least afford to lose health-care personnel. Firstly, they have fewer economic resources to put into training health-care professionals (Mullen, 2005; Starfield & Fryer, 2007). Secondly, they tend to have lower physician and nurse to population ratios than other countries (Starfield & Fryer, 2007). One study found that the countries that contribute primary care physicians to the United States have higher infant mortality rates, lower life expectancies and lower immunization rates than countries that contribute specialists (Starfield & Fryer, 2007). However, another study found that the source countries with more resources and better health outcomes contributed more physicians to the United States, Canada, Australia and the United Kingdom than the poorest countries with the worst health outcomes (Arah, Ogbu & Okeke, 2008).

These international migration patterns have a number of causes. Although countries of all income levels have faced health-care workforce shortages, the higher income countries have had the advantage of being attractive migration destinations and have actively recruited medical and nursing graduates from low and middle income countries. These graduates are attracted to the United States for the prospects of higher income and greater freedom (Hussey, 2007).

There have been few studies of the impact of IMGs and INGs on the United States health-care system. Obviously, immigrants add to the health-care workforce supply but there is no evidence that they improve distributional issues, such as primary care specialty or geographical maldistributions (addressed in the following section). There is no evidence, for example, that nurse immigrants locate in areas of health-care need, such as rural areas, in any greater proportion than native-born nurses (Aiken, 2007). It also appears that IMGs do not work in areas of need any more than native-born physicians (Akl et al., 2007). Furthermore, a reliance on health-care professional immigration reduces the incentive to expand educational capacity, increase matriculates, raise wages, improve working conditions or create incentives to work in high need areas in the United States. As a consequence, future workforce shortages and maldistributions could be exacerbated (Flynn & Aiken, 2002). On the positive side, international graduates are ethnically more diverse than native-born graduates. However, relatively small proportions of international graduates are Black or Hispanic, which are the predominant racial and ethnic groups in the United States (Aiken, 2007).

United States physician and nursing workforce experts have called for greater accountability by the United States so that the country is not responsible for a “brain drain” from other countries. It is generally recognized that supplementing the United States health-care workforce with foreign graduates is only a short-term solution and that factors contributing to underlying shortages in the United States need to be addressed. Experts encourage adherence to the WHO recommendations for recipient countries to: (1) promote temporary stays; (2) assist lower income countries to develop measures that will motivate their graduates to stay; (3) commit to ethical practices that consider the effects of migration on developing countries; and (4) engage in agreements with developing countries that will maintain immigration within acceptable limits (Cooper, 2005; Aiken, 2007).

4.2.4 Distribution of the health-care workforce

In addition to the net migration of the health-care workforce, the distribution of workers must be considered when assessing workforce adequacy. This section addresses three types of distributional issues with the health-care workforce. The first involves the type of practice and setting. The second is geographical. The third is racial and ethnic representation in the workforce.

Practice and setting distribution

The United States has had a disproportionate number of specialist physicians compared to primary care physicians for many years. According to Bodenheimer & Pham (2010), the 65% increase in physicians between 1965 and 1992 was almost entirely in specialist areas. For reasons discussed in section 4.2.7, the growth of specialists slowed in the 1990s but picked back up again in 2000. In 2005, even though 56% of visits to doctors’ offices were for primary care, only 37% of physicians (both medical doctors and osteopaths) were in that field (BHPr, 2008). In 2006, less than 45% of primary care residencies were filled and 56% of these were filled with IMGs (Friedman, 2008). A 2007 survey of fourth-year students at several United States medical schools found that only 7% planned careers in adult primary care (Bodenheimer & Pham, 2010). NPs and PAs have been filling in some of the gaps. In 2005 they constituted around 22% and 6% of the primary care workforce respectively (Steinwald, 2008).

There is evidence that the primary–specialty physician imbalance is affecting access to primary care. In 2008, 28% of Medicare beneficiaries without a primary care physician had problems getting a physician appointment, a 17% increase from 2006, whereas only 11% had problems finding a specialist, a 54% decrease from 2006 (MedPAC, 2009). Bodenheimer & Pham (2010) cite other facts: in 2008, 22% of Medicare beneficiaries and 31% of privately insured beneficiaries had unwanted delays in appointments for routine care; only 27% of adults with a usual doctor or source of care could easily contact their physician over the phone, receive medical advice after hours or obtain a timely office visit.

In nursing, the biggest distributional issue with regard to area of practice is the low number of RNs in nursing education. In 2008, the percentage of RNs employed in nursing education was 3.8%, essentially the same as it was in 1980 (BHPr, 2006, 2010). This low number of RN faculties creates bottlenecks in the educational process and contributes to nursing shortages. Seventy-one per cent of schools of nursing attribute faculty shortages as a reason for not accepting all qualified applicants into entry-level nursing programmes (AACN, 2008).

Another distribution issue in nursing involves the practice setting. Institutional settings, such as hospitals and nursing homes, appear to have more nurse staffing issues than ambulatory settings such as doctors’ offices, home care and school health. Until recently, hospitals had reported double or high single-digit vacancy rates for many years (Buerhaus, Auerbach & Staiger, 2007). The percentage of RNs working in hospitals (in direct patient care, supervisory, and advanced practice roles) peaked at 68% of RN supply in 1984, declined to 56% by 2004 (BHPr, 2006), then rose to 62% in 2008 (BHPr, 2010). Community health settings are also understaffed. Federally funded CHCs have had RN vacancy rates similar to those of hospitals (WWAMI, 2006).

Geographical distribution

Physician supply varies by region and urban or rural locations. Physician to population ratios vary between United States hospital-referral regions by more than 50%, and the variation does not appear to be related to health-care needs (Goodman & Fischer, 2008). Urban areas tend to have higher physician to population ratios than rural areas, and wealthy urban areas higher ratios than poor urban areas. In a 2008 survey, physician shortages were reported in rural areas by 75.4% of the hospital CEOs in those areas (MacDowell et al., 2010).

Primary care physicians are especially affected by uneven geographical distribution. States with the highest levels of primary care physicians are in the Mid-Atlantic and Northeast, while states with the lowest are in the South and Mountain West (Cunningham, 2011). In urban areas the ratio of primary care physicians to population is 100 per 100 000 population, while in rural areas it is less than half (46 per 100 000) (Bodenheimer & Pham, 2010). Poorer urban areas also have fewer primary care physicians than wealthier urban areas. Some areas have such a shortage of primary care professionals that they have been designated as Primary Care Health Professional Shortage Areas (areas with ratios of population to primary care practitioners greater than 2000 to 1).

The regional density of RNs varies two-fold across the country (BHPr, 2010). The District of Colombia, New England states, and West North Central states (e.g. Iowa, Nebraska, Kansas and Minnesota) have the highest employed RN to population ratios. The West South Central (Arkansas, Louisiana, Oklahoma and Texas), Mountain and Pacific states have the lowest. Geographical variation in employment also occurs by employment setting (BHPr, 2010). The New England states employ a smaller percentage of RNs in hospitals (57.1%) and ambulatory care settings than other regions, but a higher percentage in nursing homes than other regions. In the Pacific region RNs are more likely to be employed in ambulatory care settings (13.2%) than in other regions. In the West South Central states a higher percentage of RNs are employed in home care than in other regions.

There is not much information on whether there are differences in RN supply between urban and rural areas. A 2007 study found that RN shortages tend to be more acute in rural areas compared to urban areas (Zigmond, 2007). In another study of RN supply in Nebraska, hospital shortages were much more severe in rural areas (Cramer et al., 2006). The CHC RN shortages noted in the section above were highest in isolated small rural areas and urban areas, and lowest in large and less isolated rural areas (WWAMI, 2006).

Ethnic and racial disparities

Compared to their proportion in the general population, African Americans, Latinos and American Indians are underrepresented in the health professions (Grumbach & Mendoza, 2008). The only setting in which population proportions of minorities exist in the health workforce is in public health. Educational programmes are attempting to change this situation but progress is slow. Between 1990 and 2005, baccalaureate nursing programmes increased underrepresented minorities from 12% to 18%, but allopathic and osteopathic medicine and pharmacy programmes have made no improvement (Grumbach & Mendoza, 2008). Dentistry programmes have shown a slight improvement in this period.

4.2.5 Adequacy of the health-care workforce

Adequacy of physicians

As evidenced by difficulties in obtaining access to physician care in certain areas, and by the reliance on IMGs for a significant proportion of physician services, some stakeholders such as state medical societies, hospital associations and researchers believe that there is currently a physician shortage in the United States (Igelhart, 2008). Furthermore, projections of the future adequacy of physicians using several forecasting models indicate a future shortage of physicians of 5–20% of the workforce by 2020 (Blumenthal, 2004; COGME, 2005; BHPr, 2008). Key to these forecasts of future shortages are assumptions of continued growth in population and GNP and the ageing of the population – all of which will stimulate greater demand for health care – and an ageing physician workforce, in which supply will grow at too slow a rate. Health-care reform, with its expansion of Medicaid and health insurance, will also add to demand. However, provisions under the ACA help build physician and nurse supply by funding training in the health professions, and scholarships and loan repayment for those who agree to serve in designated Health Professional Shortage Areas for two to five years (Iglehardt, 2010).

Other analysts believe that while a small increase in physicians may be needed to meet population growth and to decrease reliance on IMGs, many more allopathic physicians are not needed since the growth in non-physician providers and osteopathic doctors can supplement this supply (Wilson, 2005; Weiner, 2007). Still others contend that perceptions of a shortage of physicians may be partially due to primary care shortages and geographical imbalances of physicians (Wilson, 2005; Forrest, 2006; Scheffler, 2008). Better workforce distribution, such as increasing the number of primary care physicians and rural physician practices, could avoid the need for large increases in physicians overall (Goodman & Grumbach, 2008).

There is also no consensus regarding the supply of primary care and specialty physicians. While it appears that the supply of primary care practitioners for the care of children will be adequate for the next two decades, growth of the aged population will increase needs for adult primary care practitioners above expected supply (Bodenheimer & Pham, 2010). One projection of primary care supply states that even when NPs and PAs are included in the primary care professional workforce, primary care supply is expected to fall 9% from 2005 to 2020 (Bodenheimer & Pham, 2010). However, the BHPr (2008) has a different projection. Since the supply of primary care physicians is currently growing faster than demand, says the agency, the shortage of primary care physicians should be relieved somewhat. Instead, the BHPr projects a growing shortage of specialists. Surgical specialists especially will be in short supply. It appears that one reason why the BHPr projects an adequate supply of primary care but a shortage of specialists is because it assumes that demand for primary care will not grow at the same pace as the demand for specialty care.

Adequacy of nurses

The history of nursing workforce adequacy in the United States is one of cyclical but deepening shortages in the past few decades. The most recent shortage lasted from the late 1990s to 2008. The shortage began to ease when the economic downturn began in 2008. Part-time and unemployed nurses returned to full-time employment if their spouses became unemployed, while hospital demand dropped as the number of admissions fell (Buerhaus et al., 2006; Unruh, 2010). In general, hospital demand has been a key factor in the shortages, as hospitals are the chief employer of nurses (62% of all nurses). Hospital demand for nurses is observed to vary given population demand and reimbursement for care (Unruh, 2010). During periods of low demand and reimbursement, such as the managed care period during the 1980s and early 1990s, hospital demand fell and shortages disappeared. During periods of higher demand and reimbursement, such as the one initiated in the late 1990s by the relaxing of managed care pressures, hospital demand for nurses rose and shortages re-emerged. Nursing supply appears to respond to the ebbs and flows in hospital demand as well as to economic factors (Unruh, 2010). Due to educational periods of 2–4 years for an RN, there are lags in supply meeting new upturns or downturns in demand.

Nursing workforce forecasters predict a large shortage of RNs in the future. BHPr models for RNs predict that from 2000 to 2020 RN demand per United States resident will grow 18%, while supply per resident will fall 11% (BHPr, 2002; Unruh & Fottler, 2005).17 Using informal methods, Buerhaus and colleagues project that due to past growth in demand for RNs of around 2–3% per year, along with a much slower projected growth for RN supply, the deficit of RNs will grow to 16% by 2025 (Buerhaus, Staiger & Auerbach, 2008). Factors taken into consideration in these analyses are similar to those of physicians: growth and ageing of the population, which will increase demand, and an ageing nursing workforce, which will slow the growth of supply. Another factor with nursing supply is stressful work environments, which contribute to nurses leaving bedside nursing at younger than retirement ages (Unruh & Fottler, 2005; Buerhaus et al., 2006). A final factor for nursing supply is the educator shortage, which creates bottlenecks in increasing supply (AACN, 2008). In the past, shortages have been ameliorated somewhat with international immigration. Workforce analysts caution against dependency on these nursing graduates, however, as they are a “brain drain” on the donor country and can delay needed measures to improve supply in the host country (Aiken, 2007). In summary, there is little debate among forecasters that without an increase in new graduates and better retention of younger RNs, there will be a severe RN shortage in the future.


17 These projections are quite outdated. The last BHPr forecast for RNs was in 2002 and was based on 1996 demand and 2000 supply data from the quadrennial National Sample Survey of RNs, Area Resource Files, Bureau of Labor Statistics, Occupational Employment Statistics, American Hospital Association (AHA) Annual Survey, National Home and Hospice Care Survey, and other sources. These numbers are calculations made by Unruh & Fottler (2005) based on results from the BHPr.

4.2.6 Education and training of the health-care workforce

Most health-care workers are licensed professionals who are college graduates, or who have formal educational training beyond high school. Entry to some of these professions, such as that of physician, advanced practice nursing, PA and the therapies requires advanced degrees and long educational periods. In contrast, unlicensed non-professionals usually have only a high school education and may or may not receive additional formal training and certificates.

This section focuses on the education and training of several of the professional occupations categorized as “health diagnosing and treating occupations” by the BLS: physicians, dentists, pharmacists, nurses and PAs. All of these professional occupations require several years of college, graduation from an accredited school in the specific occupation, and licensing or certification by the professional’s state of practice. Periods of residency training may also be required. All information is taken from the Occupational Outlook Handbook, 2010–2011 edition (BLS, 2011b) (see also section 2.8.2).

Physicians

To become a physician requires the greatest amount of formal education and training among all the health-care occupations. A physician typically completes four years of undergraduate school, four years of medical school, and three to eight years of internship and residency. An individual pursuing a career in medicine may either go for a medical doctorate (MD) or doctor of osteopathy (DO) degree. In 2008, there were 129 medical schools accredited for MD medical education programmes and 25 schools in 31 locations accredited for a DO degree. Following medical school, most MD graduates enter a residency in their specialty. Most DO graduates go into a 12-month internship before entering a two- to six-year residency.

All states, the District of Columbia and United States territories require that physicians be licensed in order to practise. To be eligible to take licensing exams, physicians must graduate from an accredited medical school. To be licensed, MD graduates must pass the United States Medical Licensing Examination (USMLE) and DO graduates must pass the Comprehensive Osteopathic Medical Licensing Exam (COMLEX). The exams and licences are given at the state level. Reciprocity is granted by most, but not all, states. IMGs can receive a licence after passing the exam and completing a United States residency.

MD graduates and DO graduates seeking board certification in a specialty may spend up to seven years in residency training. To be certified by the American Board of Medical Specialists (ABMS) or the American Osteopathic Association (AOA) they must take a certification exam. The ABMS covers 24 specialties and the AOA covers 18 specialties. To be certified in a subspecialty, another one to two years of residency is required.

A medical career, along with many of the health-care professions, requires that individuals continue their education and training throughout their lifetime in order to keep up with medical advances and changes in the occupation. The medical profession requires continuing education credits in order for physicians to keep their licence. In addition to “keeping up” with changes, physicians may advance their career by gaining expertise, developing a reputation for excellence among colleagues and patients, teaching medical students, residents and new physicians, and becoming supervisors or administrators.

Dentists

To become a dentist, an individual must graduate from an accredited dental school and pass written and practical licensing examinations. Dental school is usually four academic years. During the second half of their education, students begin to treat patients under the supervision of licensed dentists. On completion of studies and practicum, students will receive a degree of Doctor of Dental Surgery (DDS) or Doctor of Dental Medicine (DMD). In 2008 there were 57 accredited dental schools in the United States.

All 50 states and the District of Columbia require dentists to be licensed. In most states the licence is awarded to students who graduated from an accredited dental school and who passed the National Board Dental Examination and a practical exam administered by state or regional testing agencies. Specialty licences in nine different areas require 2–4 years of postgraduate education and may also require the completion of a residency and a special state examination. Most new dentists open their own practice immediately after dental school but some work for established dentists as associates for one or two years to gain experience and save money to equip an office of their own.

Pharmacists

To practise in the United States, a pharmacist must acquire a PharmD degree from an accredited college or school of pharmacy. These programmes usually take four years to complete. After graduating from a PharmD programme, some graduates go for further training in residency programmes or fellowships, especially if they plan to work in clinical settings, where a residency may be required. Pharmacists may obtain a master’s degree in business administration in order to help them run their own pharmacy.

Pharmacists must have a licence to practise. To obtain a licence, an individual must have graduated from an accredited PharmD programme and must pass several exams. All states require that pharmacists pass the North American Pharmacist Licensure Exam (NAPLEX), which tests pharmacy skills and knowledge. Other exams are required depending on the state. Hours of experience in a practice setting are also required. Often this can be accomplished while in the PharmD programme.

Registered nurses

The educational requirements for RNs are complex because there are three educational paths to becoming an RN: a diploma, an Associate Degree in Nursing (ADN) and a Bachelor of Science Degree in Nursing (BSN). In addition, to become an APRN – which includes clinical nurse specialist, nurse anaesthetist, nurse–midwife and NP – a Master of Science in Nursing (MSN) is required, and a Doctor of Nursing Practice (DNP) is becoming common (Cronenwet et al., 2011).

An ADN is the most common entry into the profession, followed by BSN. ADN programmes take two to three years to complete while BSN programmes take four years. Diploma programmes, which take three years to complete, do not result in a degree and are conducted by hospitals. They are a remnant of the old educational system, and few remain today. Of the three programmes, the BSN gives the student more training in areas such as communication, leadership and critical thinking, which are important in nursing practice today. It also provides more clinical experience in non-hospital settings. The BSN is usually required for administrative positions. For these reasons the BSN offers the graduate more employment and advancement opportunities. Since many RNs with ADN return for a BSN, special RN-to-BSN programmes have been designed by most schools of nursing. Accelerated programmes also exist that allow a college graduate in another field to complete their BSN in 12–18 months. Graduates of an accredited school of nursing must also pass the National Council Licensure Examination (NCLEX–RN) to practise. Licences are granted on a state-by-state basis with reciprocity in most states.

RNs engage in lifelong learning. Continuing education is required by many states. To demonstrate expertise in a specific area, RNs may choose, or their job may require them, to be credentialed through the American Nursing Credentialing Center, the National League for Nursing or other agencies. Specialty areas of credentialing include ambulatory care, gerontology, informatics, paediatrics and many others.

There are many opportunities for advancement in nursing. Most RNs begin as staff (bedside) nurses in hospitals but many move to other settings or are promoted to managerial, administrative or teaching positions within the hospital. With an advanced practice degree, RNs can work independently or in collaboration with physicians. Each state defines its requirements for advanced practice roles. For example, in some states APRNs may prescribe medicine but in other states they cannot. Some RNs go on to become educators in schools of nursing, which requires an MSN or PhD. Other RNs start their own businesses in ambulatory, home care or chronic care. Still others join insurance, managed care or pharmaceutical companies.

Physician assistant

To become a PA an individual must graduate from an accredited programme and pass a national certification exam. Many entering students are RNs, emergency medical technicians (EMTs) and paramedics. The programmes, offered at community colleges, academic medical centres, medical schools and colleges, take at least two years full-time. The PA programme combines classroom instruction with clinical experience. Students may have the opportunity of internships with physicians while in training, which may lead to employment after graduation. Upon completion of an accredited PA programme the graduate is eligible to sit for the PA certification exam and may in addition receive an associate, bachelor’s, or master’s degree.

To obtain a certificate to practise, graduates of accredited PA programmes must pass the Physician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants (NCCPA). PAs must engage in continuing education to remain certified. Every two years they must complete 100 hours of continuing education, and every six years they must pass a recertification examination or complete a programme that includes a take-home exam. PAs can pursue further education in medicine, rural primary care, emergency medicine, surgery, paediatrics, neonatology and occupational medicine.

4.2.7 Physician and RN career paths

This section investigates some of the factors involved in the career choices of these two professions. Major factors include levels of reimbursement, malpractice insurance costs and working conditions.

Factors in physician career paths

Career choices among physicians include choice of specialty (primary care versus one of several specialties), location of practice (regional and urban or rural), and whether to stay active in the profession. The choice of specialist over primary care careers among physicians has, for some time, led to an imbalance in the workforce in these areas. With new patients being brought into primary care due to health-care reform, the future imbalance is particularly problematic. Chief among the factors that contribute to these career choices is physician payment.

Despite improvements in primary care physician reimbursement in the 1990s, a primary care-specialty payment gap remains. Primary care payment improved relative to specialty care with the introduction of the RBRVS by the CMS in 1992, and with the managed care restructuring of the physician payment system to better reward primary care physicians in this same period. The improvement slowed when managed care mechanisms were loosened in the late 1990s. At that time primary care incomes declined and the income gap between primary and specialty care grew (Bodenheimer & Pham, 2010). The latest available official data for physician salaries indicates that in 2003 the average annual salary of a primary care physician was $146 405, compared to $235 820 for a specialist (Tu & Ginsburg, 2006). Among specialists, medical practitioners earned $211 299 on average while surgical specialists earned $271 652 in 2003. The hours-adjusted internal rate of return on the educational investment for primary care physicians was 16% in 1997, compared with 18% for procedure-based medicine (surgery, obstetrics, radiology, anaesthesiology and medical subspecialties) (Weeks & Wallace, 2002). Compared with 10 other OECD countries, the United States has the next to highest specialist to primary care physician salary ratio (the Netherlands had the highest) (Fujisawa & Lafortune, 2008).

Practice conditions and medical and societal devaluing of primary care also contribute to the primary care-specialty imbalance (Friedman, 2008; Bodenheimer & Pham, 2010). Primary care practice tends to involve more hours, on-call and night work, and rotating shifts compared to specialty practices. Specialty care is more prestigious and the medical educational system places a higher value on specialty practice. An example of the lower prestige of primary care is that it is much less likely that a primary care physician will become a medical school dean or achieve other positions of leadership (Friedman, 2008). The culture in some medical schools works against primary care by encouraging students to go into specialty practices (Brooks et al., 2002; Friedman, 2008).

Several factors contribute to a physician choosing not to practise in an underserved urban or rural area. As with primary care, rural practices involve longer hours, less specialty support and fewer opportunities for advancement (Brooks et al., 2002; Dussault & Francheschini, 2006). Rural locations have less social and cultural opportunities and are more professionally isolated, with fewer opportunities for career advancement (Dussault & Francheschini, 2006).

That being said, some medical schools are better than others at graduating physicians who go to underserved and rural areas. Physicians graduating from medical schools with rural curricula and rotations and a positive culture regarding rural practice are more likely to practise in rural areas (Brooks et al., 2002; Rabinowitz et al., 2008). Scholarships and loan-repayment programmes tied to rural practice on graduation are also good incentives (Friedman, 2008).

There are several factors that create dissatisfaction among physicians, which can lead to them leaving patient care practices. These factors include working with managed care plans, malpractice insurance costs, discrepancies between practice ideals and reality, administrative burdens and lack of time to complete necessary tasks (Landon, Reschovsky & Blumenthal, 2003; Mechanic, 2003; Zuger, 2004). Frustrations with managed care and insurance company billing, policies and requirements have been the focal point of many of these issues. Under managed care, physicians’ administrative tasks have grown over the years, giving them less time to perform clinical work. They have had less autonomy to refer patients to specialists, or to prescribe tests, treatments and medications. Additional governmental quality improvement requirements, such as P4P, have added to the administrative burden.

Factors in RN career paths

Career choices among RNs include the decision to become a nurse educator, whether to practise in a hospital or other health-care setting, and whether to stay in bedside nursing. Factors that are thought to contribute to the low number of RNs going into education include: low academic salaries; more attractive jobs in other careers for RNs with graduate degrees (partially a result of the first factor); long periods of clinical work prior to pursuing graduate education and an academic career; high educational costs (put that together with low salary and the returns to educational investment are low); and insufficient governmental funding of nursing education (Yordy, 2006). In addition, dissatisfaction among those who have gone into nursing education contributes to nurses leaving the field. Nursing faculties are dissatisfied with their heavy workloads and low remuneration (Yordy, 2006).

With regard to RNs’ decisions regarding work settings, studies have shown that the major issue with working in a hospital is the difficult working conditions for RNs. Staffing levels, workload, the degree of autonomy, shift work, scheduling, overtime and professional development are several of the factors leading to dissatisfaction with hospital bedside nursing (Buerhaus et al., 2006; Stone et al., 2006).

RNs’ intention to leave bedside nursing is also mainly related to working conditions. Chief among the work environment issues are: inadequate staffing, high workload, high work pressure, high job demands, lack of time to do adequate work, lack of supervisor support, lack of respect, disempowerment and poor relations with physicians (Geiger-Brown et al., 2004; Dunn, Wilson & Esterman, 2005; Khowaja, Merchant & Hirani, 2005). Salaries and benefits can also be an issue in hospitals, nursing homes and other settings (McHugh et al., 2011).

Influencing career path choices of physicians and nurses

Policies are needed to encourage physicians and nurses to take career paths that are optimum for the functioning of the United States health-care system. The difficulty is that the career choice must be an optimum one for the individual health-care professional as well. The issues discussed above provide information about some of the factors that need to be changed in order to accomplish this transformation: improvement in reimbursement to primary care, work in underserved areas and nursing education; medical and nursing education that encourages a proper distribution of those professionals; improvements in working conditions; and societal values that improve the prestige of currently undervalued careers. Until changes are made in these areas and others, these health-care professionals will continue to make personal career choices that result in a less than optimum workforce distribution in the United States.

Some recent initiatives will be of help. The 2009 American Recovery and Reinvestment Act (ARRA) invested $300 million in the National Health Service Corps, which recruits the primary care workforce in underserved areas (Kaiser Family Foundation, 2011h). Teaching health centres are receiving an additional $230 million to start primary care residency programmes. Under the ACA, the Medicare fee schedules provide 10% bonuses for primary care starting in 2011 (Kaiser Family Foundation, 2011h). By 2014, Medicaid primary care provider reimbursements must be at least as much as Medicare.