Taylor Walsh on Health Affairs-AAMC & Primary Care: Licensed Integrative Disciplines Absent from Workforce Plans

Numerous whole person, integrative medicine and health professions view themselves as primary care. This ranges from acupuncture and Oriental medicine practitioners who work as general practitioners to chiropractic doctors who view themselves as "primary spine care," direct-entry midwives positioned as "primary maternity care" and naturopathic doctors who are running medical homes in Oregon, Washington and Vermont.  

Special focus on primary care

November 2013 witnessed a series of organized activities from major healthcare players relative to the nation's primary care workforce. Health Affairs, the most significant policy journal for members of Congress and their staffs devoted their issue to the topic. The American Association of Medical Colleges similarly focused Volume 88, No 12, December 2013 to the topic. The two joined for a Redesigning the Healthcare Workforce Briefing in Washington, DC.

Integrator columnist Taylor Walsh attended

A Perspective on the "Redesigning the Workforce" Briefing
and the (Non) Inclusion of Integrative health and Medicine

Taylor Walsh

Consultant, Entrepreneur and Writer on Digital Media & Integrative Health
Washington, D.C.
Integrative Health & Wellness

Twitter: @taylorw

The reconfiguration of the American healthcare workforce is a topic of intense examination, but if a national conference in Washington last week is any indication, the role for integrative health disciplines will remain "a hidden dimension," as described by the Academic Consortium for Complementary and Alternative Health Care in its 2013 white paper, "Meeting the Nation's Primary Care Needs."

Taylor Walsh

Many of the nation's leaders in workforce academic and health policy gathered in Washington Nov. 14 to discuss the state of the workforce in light of the Affordable Care Act and the continuation of dispiriting trends that have left the nation's healthcare professions mismatched with the needs of many communities and patients.

The briefing was sponsored by the magazines Health Affairs and Academic Medicine, the journal of the American Association of Medical Colleges, both of whose current issues are devoted to the workforce issues addressed at the briefing.

The primary take away from this half-day session is that medical education and policy actions have been lagging well behind and are not responding to the reality in the marketplace. Several speakers noted that this is likely to become more pronounced as millions of previously uninsured citizens arrive to be served by the care system.  Sheldon Retchin, MD, CEO of the Virginia Commonwealth University Health System, reporting on VCU research on the care needs of the uninsured said the most dominant need in this population is for mental health, which "we are unprepared for."

While the topic of non-physician leadership in primary care and in other points of delivery was thoroughly discussed, any role for integrative disciplines as contributors to such a solution was oblique, at best.   But it is also clear that sharing any physician-assigned responsibility even with nurse practitioners or physician assistants will be a tremendous culture pull that will not quickly come to pass.

The two presenters who offered the most potent visions for adjusting the prevailing medical education culture were Edward Salsberg, director of the National Center for Health Workforce Analysis at HRSA, and George Thibault, president of the Josiah Macy Jr. Foundation, which has take a leading role in funding workforce development innovations.

Salsberg said that at HHS the starting points for any workforce analysis and any resultant prescription is driven by the growth of the aging population and the system's unsustainable costs.  HRSA's role, he said, was to be a "supply stimulator;" one that reflects what he called the "disruptive innovations" occurring in the market:

• Non-physician clinician care
• Retail clinics outside physician-directed or owned premises
• Attention to primary care and to prevention
• New models that will affect delivery and demand: medical homes, ACOs
• Interprofessional education (IPE)
• "Full use of all health workers" (the elusive term "all" being undefined)
• Teams and collaborative practices

HRSA is creating an institutional infrastructure in an attempt to reflect these trends, such as a National Health Services Corps and a National Center for Interprofessional Practice and Education.  He also said that workforce planning is a "Federal-state shared responsibility."  

Salsberg did not mention it, but HRSA has already been active in "supply stimulation," by funding in 2012 the formation of the National Coordinating Center for Integrative Medicine (NccIM, also called IMPriME), which is now coordinating 12 HRSA grants that support integrative education in a dozen preventive medicine residency programs.

Thibault was unambiguous in his remarks about the "cultural change" that is needed in medical education:  "Collaborative, non-hierarchical.  Delivery and education have to work together.  Listen to patients, the community and families."

He laid out the actions needed to bring about such a change.  "First and most important," he said, "is interprofessional education.  Education processes don't reflect the team future."  "Team competencies," he said, "become core."  Other factors:

• Expanding beyond the primarily hospital-based clinical education model; develop relationships with patients and families
• Integrate with even non-medical disciplines: "bio-science is not sufficient"
• Move to competency-based advancement, rather than time-based, to reflect individual attainment
• Use technology that simulates the world that practitioners will work within: a team environment, collaboration, and education delivered in a distributed model
• Invest in faculty from diverse disciplines

Meanwhile, the imminence of the Affordable Care Act (assuming it is not laid to rest next to HillaryCare), brings its own considerable uncertainty, according to many of the speakers.  Atul Grover, chief public policy officer of AAMC said, "The ACA will accelerate shortages."  An audience member from the College of American Pathologists stood to say that the likely adoption of labor saving genomic and other technology-driven advances is causing serious concern among her peers. 

CEO Retchin of the VCU Health System said that "the workforce won't be sufficient ...  We have to look at unmet needs of the newly insured."  Michael Hoge, PhD, director of Yale Behavioral Health and a founding member of the Annapolis Coalition on Behavioral Health Workforce reinforced Retchin's admonition.  Noting the shortages expected for child and geriatric psychiatrists, he basically made a plea "to broaden the concept of the workforce and enhance the skills" needed in mental health and addiction.

CODA:

It's true that the account above constitutes a real stretch to find some linkage between the thoroughly described problems confronting the US health care workforce - as articulated by these policy and academic leaders -- and the vast cohort of integrative practitioners whose presence, even though literally right around the corner, remains to be acknowledged.

In an article in the issue of Academic Medicine published concurrently with the briefing, George Thibault wrote that the Macy Foundation's purpose is based on "promoting innovations in health professions education that better align education with the needs of the public..." But what does the phrase "needs of the public" mean today?  And what will it mean five years from how?  And who determines these needs? 

Perhaps "preferences" of the public is more apt; or "expectations."  Or perhaps "...better aligning education with all the health services valued by the public..."