CHAPTER 11
Managing Health Care
Professionals
Sharon B. Buchbinder and Dale Buchbinder
LEARNING OBJECTIVES
By the end of this chapter, the student will be able to:
Distinguish among the education, training, and credentialing of
physicians, nurses, nurse aides, midlevel practitioners, and allied health
professionals;
Deconstruct factors affecting the supply of and demand for health
care professionals;
Analyze reasons for health care professional turnover and costs of
turnover;
Propose strategies for increasing retention and preventing turnover of
health care professionals;
Create a plan to prevent conflict of interest in a health care setting;
Examine issues associated with the management of the work life of
physicians, nurses, nurses’ aides, midlevel practitioners, and allied
health professionals; and
Investigate sources of data for health workforce issues.
INTRODUCTION
Health care organizations employ a wide array of clinical, administrative, and
support professionals to deliver services to their patients. The Bureau of
,Labor Statistics (BLS) indicated that there were close to 16 million jobs in
hospitals, offices of health practitioners, nursing and residential care
facilities, home health care services, and outpatient settings (Torpey, 2014).
The largest employment setting in health care is hospitals and the largest
category of health care workers is registered nurses, with 2.7 million jobs,
61% of which are in hospitals (BLS, 2014h). According to the BLS, there were
691,400 physicians and surgeons who held jobs in 2012 (BLS, 2014e).
Increasingly, physicians are choosing to practice in large groups or to be
employed by hospitals, rather than in solo or small practices. In 2013,
Jackson Healthcare re-conducted a survey of physicians and found 26% were
employed by hospitals, an increase of 6% over the previous year.
Ownership stakes in practices, solo practices, and independent contractor
statuses all declined in the same period (Vaidya, 2013). Employment offers
physicians a safe haven in a volatile health care environment. Under the
umbrella of a hospital or other large health care organization, they have
better work hours, benefits, and time off, which they could not always afford
in small or solo practice. It is expected the proportion of employed physicians
will continue to grow in the coming decade. In 2012, physician assistants
held 86,700 jobs, over 55% of which were in ambulatory health care
services, including physician practices, about 20% were in hospitals, and
the rest in nursing care facilities and government settings (BLS, 2014f).
Allied health professionals constitute a broad array of 28 health science
professions, including, but not limited to, anesthesiologist assistants,
medical assistants, respiratory therapists, and surgical technologists
(Commission on Accreditation of Allied Health Education Programs, 2015).
These statistics mean that, as a health care manager, in many instances
you will be working with a mix of people with either more or less education
than you have. It also means you will not have the clinical competencies that
these health care providers have—an intimidating scenario, to say the least.
Instead of clinical expertise, however, you will bring a background that
enables you to enhance the environment in which these highly specialized
personnel deliver health care services. You will be the person responsible for
making sure nurses, doctors, and other health care professionals have the
resources to provide safe and effective patient care. Your role will be to
provide and monitor the infrastructure and processes to make the health
care organization responsive to the needs of the patients and the employees.
The more you understand clinical health care professionals, the better
prepared you will be to do your job as a health care manager. The purpose of
this chapter is to provide you with an overview of who your future colleagues
are, how they were trained, and ways to manage the quality of their work
environment.
PHYSICIANS
,Physicians begin their preparation for medical school as undergraduates in
premedical programs. Premedical students can obtain a degree in any
subject; however, the Association of American Medical Colleges (AAMC)
(2015) indicates that the expectation is that they will graduate with a strong
foundation in mathematics, biology, chemistry, and physics. Entry into
medical school is competitive; applicants must have high grade point
averages and high scores on the Medical College Admission Test (MCAT).
There are some shorter, combined Bachelor of Science/Medical Doctor
(BS/MD) programs; however, the majority of medical school graduates will
have 8 years of post–high school education before they go through the
National Residency Matching Program (NRMP), a matching process whereby
medical students interview and rank their choices for graduate medical
education (GME), also known as residencies, and the residency training
programs do the same (NRMP, 2015). Once matched with a residency
training program, physicians are prepared in specialty areas of medicine.
Depending on the specialty, the length of the residency training program can
be as short as 3 years (for family practice) or as long as 10 years (for cardio-
thoracic surgery or neurosurgery). According to the Accreditation Council for
Graduate Medical Education (ACGME), “When physicians graduate from a
residency program, they are eligible to take their board certification
examinations and begin practicing independently. Residency training
programs are sponsored by teaching hospitals, academic medical centers,
health care systems and other institutions” (ACGME, 2015, para. 4–5). Due to
recent GME legislation working on the physician shortage, there will be a
gradual increase of residency training positions over the coming years with a
priority on primary care physician residency spots (AMA Wire, 2015a). Some
authors have begun to question the need for lengthy training programs,
given the presence of shorter pre-medical programs, competency based
education, the looming shortage of physicians, and levels of debt incurred by
medical students (Duvivier, Stull, & Brockman, 2012; Emanuel & Fuchs,
2012). Regardless of the specialty, length of physician training programs, or
number of trainees, depending on the type of health care organization where
you are employed, you may be working with residents-in-training and
medical students, as well as physicians who have been in independent
practice for decades.
In addition to having a long time before they can practice independently,
residents work extensive hours as part of their training programs. At one
time, it was not uncommon for residents to be on call continuously for 48
hours, because ceilings on hours of work for residents varied by residency
training program. However, that all changed due to the death of Libby Zion,
an 18-year-old college student, who was seen at the Cornell Medical Center
in 1984 and allegedly died due to resident overwork (AMA, Medical Student
Section, n.d.). Although the hospital and resident were exonerated in court,
the battle over resident work hours had begun. New York was the first state
to institute limits on resident work hours in 1987. Over the past two decades,
, various specialty societies, medical associations, and legislators fought over
the definition of “reasonable” work hours for physicians in training. The
battle has continued, and new rules have been updated from those published
in 2003. Per these new rules, hospitals and residency training program
directors will be required to limit resident work hours to no more than “80
hours per week, averaged over a four-week period, inclusive of in-house call
activities and all moonlighting” (i.e., side jobs in addition to the 80 hours per
week) (ACGME, 2014, p. 4). First-year residents (PGY-1) are not permitted to
moonlight (ACGME, 2011).
“Sponsoring institutions and programs must ensure and monitor effective,
structured hand-over processes to facilitate both continuity of care and
patient safety” (ACGME, 2014, p. 13). This mandate means when the
resident goes home, the next person taking care of the patient must be
briefed to ensure that the patient care team has all relevant information.
Despite the restrictions on work hours, residents are not permitted to walk
out the door without communicating this important patient care information.
At times, this means a delicate balancing act to ensure compliance with all
standards, which also emphasize the need for interpersonal and
communication skills, professionalism, systems-based practice as
components in a culture of safety and patient-centric care.
When the work-hour rules first went into effect, physicians who trained
under the “work until you drop” mentality protested that professionalism
would decline and residents would miss out on learning opportunities
associated with continuity of the care from patient admission to discharge.
Surgeons, in particular, protested, fearing walk-outs in the middle of long
cases, a reflection of a time-clock-punching and a shift-work mentality.
Ethnographic research conducted among medical and surgical residents in
two hospitals did not find evidence for those fears. Over the course of three
months, Szymczak, Brooks, Volpp, and Bosk (2010) followed residents,
observed behaviors, and conducted in-depth face to face interviews. These
researchers found that rather than leave at a critical juncture, the residents
were, on occasion, more inclined to stay—off the clock. Interviews elucidated
thoughtful, analytical rationales for the non-compliant behaviors, as well as a
respect for the work-hour rules. Residents were mindful of the implications of
their behaviors and the implications of non-compliance and were conflicted
about under-reporting their hours, i.e., lying about their time on duty. These
work-hour rules and patient handoff protocols underscore the fact that
residents are in the hospital for education, not to provide service to the
hospital, a major departure from the way graduate medical education was
conducted a few decades ago. More time is needed to see if the pendulum
will swing back to longer duty-hours in light of actual behaviors.
The implications of limits on resident work hours are multifold. While
residency training program directors are responsible for monitoring resident
work hours, they must be in compliance with the health care institution’s
policies as well. You may be responsible for ensuring compliance by
Managing Health Care
Professionals
Sharon B. Buchbinder and Dale Buchbinder
LEARNING OBJECTIVES
By the end of this chapter, the student will be able to:
Distinguish among the education, training, and credentialing of
physicians, nurses, nurse aides, midlevel practitioners, and allied health
professionals;
Deconstruct factors affecting the supply of and demand for health
care professionals;
Analyze reasons for health care professional turnover and costs of
turnover;
Propose strategies for increasing retention and preventing turnover of
health care professionals;
Create a plan to prevent conflict of interest in a health care setting;
Examine issues associated with the management of the work life of
physicians, nurses, nurses’ aides, midlevel practitioners, and allied
health professionals; and
Investigate sources of data for health workforce issues.
INTRODUCTION
Health care organizations employ a wide array of clinical, administrative, and
support professionals to deliver services to their patients. The Bureau of
,Labor Statistics (BLS) indicated that there were close to 16 million jobs in
hospitals, offices of health practitioners, nursing and residential care
facilities, home health care services, and outpatient settings (Torpey, 2014).
The largest employment setting in health care is hospitals and the largest
category of health care workers is registered nurses, with 2.7 million jobs,
61% of which are in hospitals (BLS, 2014h). According to the BLS, there were
691,400 physicians and surgeons who held jobs in 2012 (BLS, 2014e).
Increasingly, physicians are choosing to practice in large groups or to be
employed by hospitals, rather than in solo or small practices. In 2013,
Jackson Healthcare re-conducted a survey of physicians and found 26% were
employed by hospitals, an increase of 6% over the previous year.
Ownership stakes in practices, solo practices, and independent contractor
statuses all declined in the same period (Vaidya, 2013). Employment offers
physicians a safe haven in a volatile health care environment. Under the
umbrella of a hospital or other large health care organization, they have
better work hours, benefits, and time off, which they could not always afford
in small or solo practice. It is expected the proportion of employed physicians
will continue to grow in the coming decade. In 2012, physician assistants
held 86,700 jobs, over 55% of which were in ambulatory health care
services, including physician practices, about 20% were in hospitals, and
the rest in nursing care facilities and government settings (BLS, 2014f).
Allied health professionals constitute a broad array of 28 health science
professions, including, but not limited to, anesthesiologist assistants,
medical assistants, respiratory therapists, and surgical technologists
(Commission on Accreditation of Allied Health Education Programs, 2015).
These statistics mean that, as a health care manager, in many instances
you will be working with a mix of people with either more or less education
than you have. It also means you will not have the clinical competencies that
these health care providers have—an intimidating scenario, to say the least.
Instead of clinical expertise, however, you will bring a background that
enables you to enhance the environment in which these highly specialized
personnel deliver health care services. You will be the person responsible for
making sure nurses, doctors, and other health care professionals have the
resources to provide safe and effective patient care. Your role will be to
provide and monitor the infrastructure and processes to make the health
care organization responsive to the needs of the patients and the employees.
The more you understand clinical health care professionals, the better
prepared you will be to do your job as a health care manager. The purpose of
this chapter is to provide you with an overview of who your future colleagues
are, how they were trained, and ways to manage the quality of their work
environment.
PHYSICIANS
,Physicians begin their preparation for medical school as undergraduates in
premedical programs. Premedical students can obtain a degree in any
subject; however, the Association of American Medical Colleges (AAMC)
(2015) indicates that the expectation is that they will graduate with a strong
foundation in mathematics, biology, chemistry, and physics. Entry into
medical school is competitive; applicants must have high grade point
averages and high scores on the Medical College Admission Test (MCAT).
There are some shorter, combined Bachelor of Science/Medical Doctor
(BS/MD) programs; however, the majority of medical school graduates will
have 8 years of post–high school education before they go through the
National Residency Matching Program (NRMP), a matching process whereby
medical students interview and rank their choices for graduate medical
education (GME), also known as residencies, and the residency training
programs do the same (NRMP, 2015). Once matched with a residency
training program, physicians are prepared in specialty areas of medicine.
Depending on the specialty, the length of the residency training program can
be as short as 3 years (for family practice) or as long as 10 years (for cardio-
thoracic surgery or neurosurgery). According to the Accreditation Council for
Graduate Medical Education (ACGME), “When physicians graduate from a
residency program, they are eligible to take their board certification
examinations and begin practicing independently. Residency training
programs are sponsored by teaching hospitals, academic medical centers,
health care systems and other institutions” (ACGME, 2015, para. 4–5). Due to
recent GME legislation working on the physician shortage, there will be a
gradual increase of residency training positions over the coming years with a
priority on primary care physician residency spots (AMA Wire, 2015a). Some
authors have begun to question the need for lengthy training programs,
given the presence of shorter pre-medical programs, competency based
education, the looming shortage of physicians, and levels of debt incurred by
medical students (Duvivier, Stull, & Brockman, 2012; Emanuel & Fuchs,
2012). Regardless of the specialty, length of physician training programs, or
number of trainees, depending on the type of health care organization where
you are employed, you may be working with residents-in-training and
medical students, as well as physicians who have been in independent
practice for decades.
In addition to having a long time before they can practice independently,
residents work extensive hours as part of their training programs. At one
time, it was not uncommon for residents to be on call continuously for 48
hours, because ceilings on hours of work for residents varied by residency
training program. However, that all changed due to the death of Libby Zion,
an 18-year-old college student, who was seen at the Cornell Medical Center
in 1984 and allegedly died due to resident overwork (AMA, Medical Student
Section, n.d.). Although the hospital and resident were exonerated in court,
the battle over resident work hours had begun. New York was the first state
to institute limits on resident work hours in 1987. Over the past two decades,
, various specialty societies, medical associations, and legislators fought over
the definition of “reasonable” work hours for physicians in training. The
battle has continued, and new rules have been updated from those published
in 2003. Per these new rules, hospitals and residency training program
directors will be required to limit resident work hours to no more than “80
hours per week, averaged over a four-week period, inclusive of in-house call
activities and all moonlighting” (i.e., side jobs in addition to the 80 hours per
week) (ACGME, 2014, p. 4). First-year residents (PGY-1) are not permitted to
moonlight (ACGME, 2011).
“Sponsoring institutions and programs must ensure and monitor effective,
structured hand-over processes to facilitate both continuity of care and
patient safety” (ACGME, 2014, p. 13). This mandate means when the
resident goes home, the next person taking care of the patient must be
briefed to ensure that the patient care team has all relevant information.
Despite the restrictions on work hours, residents are not permitted to walk
out the door without communicating this important patient care information.
At times, this means a delicate balancing act to ensure compliance with all
standards, which also emphasize the need for interpersonal and
communication skills, professionalism, systems-based practice as
components in a culture of safety and patient-centric care.
When the work-hour rules first went into effect, physicians who trained
under the “work until you drop” mentality protested that professionalism
would decline and residents would miss out on learning opportunities
associated with continuity of the care from patient admission to discharge.
Surgeons, in particular, protested, fearing walk-outs in the middle of long
cases, a reflection of a time-clock-punching and a shift-work mentality.
Ethnographic research conducted among medical and surgical residents in
two hospitals did not find evidence for those fears. Over the course of three
months, Szymczak, Brooks, Volpp, and Bosk (2010) followed residents,
observed behaviors, and conducted in-depth face to face interviews. These
researchers found that rather than leave at a critical juncture, the residents
were, on occasion, more inclined to stay—off the clock. Interviews elucidated
thoughtful, analytical rationales for the non-compliant behaviors, as well as a
respect for the work-hour rules. Residents were mindful of the implications of
their behaviors and the implications of non-compliance and were conflicted
about under-reporting their hours, i.e., lying about their time on duty. These
work-hour rules and patient handoff protocols underscore the fact that
residents are in the hospital for education, not to provide service to the
hospital, a major departure from the way graduate medical education was
conducted a few decades ago. More time is needed to see if the pendulum
will swing back to longer duty-hours in light of actual behaviors.
The implications of limits on resident work hours are multifold. While
residency training program directors are responsible for monitoring resident
work hours, they must be in compliance with the health care institution’s
policies as well. You may be responsible for ensuring compliance by
