II. Special Report: Is Health Professions Education Part of the Solution?

Health care has become the focus of intense national debate. One approach to health care reform is to change providers' behavior at an early stage, during their education. Several activities are under way to test this approach, chiefly supported by foundations such as The Henry J. Kaiser Family Foundation, The Robert Wood Johnson Foundation, The Rockefeller Foundation, and W.K. Kellogg Foundation. To date, they have met with mixed success.

The Pew Charitable Trusts, through their Strengthening the Health Professions Initiative, have empaneled the Pew Health Professions Commission to stimulate reform in health professions education. ¹ The commission was founded on the belief that teaching providers different skills, while not sufficient by itself, is a necessary step for sustained, overall health care reform. The commission recognizes the central role of health professions schools in teaching new providers the skills, knowledge, values, and practice orientations needed in the future.

In its first report, Healthy America: Practitioners for 2005, released in October 1991, the Pew Health Professions Commission chronicled several major health system trends, including cost containment, consumer involvement, access to care, and shifts in demographics and disease burdens. ² The need to control costs has placed new emphasis on more cost-effective arrangements for care, optimal technology use, and changes in providers' behavior. Consumers' involvement in health care is redefining the doctor/patient relationship and leading to demands for increased accountability by providers. Finally, demographic changes and shifts in disease patterns are focusing interest on expanding access to care.

Projecting these trends to the year 2005, Healthy America identifies areas in which practitioners will have to demonstrate competence to meet the nation's health care needs. Viewed as the desired educational outcomes for all health professions schools, these areas of competency reflect the “emerging” skills, attitudes, and behavior patterns that the nation's health care providers must possess to function effectively. To test these proposed requirements and to stimulate reform of health professions education, the commission polled practicing health professionals about their training.

Survey Of Health Professionals

For each area of competency proposed by the commission, dentists, nurses, pharmacists, physicians, and veterinarians were asked to rate how well they were prepared by their professional education. Items were also constructed to collect information about demographic and practice characteristics.

The survey was conducted by Louis Harris and Associates for the Pew Health Professions Commission from February to March 1991. A total of 1,501 telephone interviews were conducted with national probability samples of the five health professions. The samples were limited to health professionals who met three criteria: graduated from professional school in 1960 or later; attended a professional school in the United States; and spent on average twenty hours or more per week on direct patient care or client care activities. ³ The adjusted response rates varied from a high of 82 percent for nurses to a low of 43 percent for physicians. We combined the excellent and good responses into a “positive” category here.

Most practicing professionals felt their schools did a good job in teaching “traditional” attitudes, knowledge, and skills such as diagnosing and treating disease, solving problems, pursuing continuing education, and practicing ethically. However, they perceived training as less adequate in such areas as communicating with patients, preventing disease, involving patients in their care, ensuring access to care, and working in health care teams. Within most or all professions, most respondents felt they received fair/poor preparation for factoring cost implications into their decision making, evaluating the appropriateness of complex and costly technology, responding to increased demands for accountability, practicing in a managed care system, understanding the needs of a culturally diverse society, and supporting the role of community agencies in meeting patients. health care needs ( Exhibit 1 ).

Policy Implications

From a policy standpoint, these results must be considered in the context of major health care trends. For instance, controlling health care spending requires providers and patients to assume active roles in addressing the problems. ⁴ Fewer than 40 percent of the respondents felt they received good or excellent preparation in factoring cost into treatment decisions, evaluating the appropriateness of costly technology, and involving patients in their health care. This suggests that existing training programs may not have given practitioners the skills needed to help reduce health care costs significantly. Similarly, working in health care teams has been advocated as a means of controlling health care costs and improving care. ⁵ Unfortunately, except for nurses, only four of ten practitioners surveyed gave positive ratings to their education in preparing them to work well with other health care professionals.

The organization and delivery of health services has changed significantly over the past twenty years and will continue to do so in the foreseeable future. Except for nurses and pharmacists, most providers indicated they had received fair or poor training for working in a managed care setting. At every level, health care providers are under scrutiny and expected to justify their actions. Practice guidelines, utilization review, consumer involvement in health care, and improved information systems are placing today's health care provider in a position of heightened accountability. Fewer than four out of ten practitioners surveyed felt they had been adequately prepared to meet these challenges. ⁶ Most notably, 86 percent of physicians rated their training in this critical area as fair or poor.

When one recognizes the importance of thorough and thoughtful communication between provider and patient, it is disturbing to find that only five out of ten dentists and seven out of ten physicians felt adequately trained to communicate. Only six out of ten dentists and five out of ten physicians felt they were adequately trained to involve patients in their own health care decisions and activities. While many of these skills may be learned on the job, a strong base should be established in pre- and postdoctoral professional training.

A large percentage of those surveyed did not feel adequately prepared to understand and respond to the diverse needs and values of different cultural or ethnic groups in their communities, or to understand and support the important role that service agencies in their communities play in meeting patients' health care needs. In addition, only half of the respondents in this study felt they had sufficient training in how to ensure access to good health care for all segments of the population, including the least advantaged. While it is naïve to expect that individual providers could ensure access to good health care for all segments of the population, it is reasonable for providers to expect their training to address this important issue.

This survey clearly shows that health care providers believe they did not receive adequate training for current and future demands. If health professions education is to be part of the solution to the problems facing health care in the United States, then policymakers, health providers, health professional organizations, and educational institutions should carefully reevaluate the adequacy of existing training programs. The Pew commission believes that by acting as an advocate for change at the multiple levels of the individual school, the university, the health professions, the government, and the public, it will greatly enhance the likelihood of achieving lasting change.

ACKNOWLEDGMENTS

This project was supported by a grant from The Pew Charitable Trusts. The opinions expressed in this report are those of the authors and do not necessarily reflect the views of The Pew Charitable Trusts. The authors gratefully acknowledge the assistance provided by Carolyn Setlow and Humphrey Taylor of Louis Harris and Associates.

NOTES

• 1. For more detailed information about the commission, contact Daniel A. Shugars, Pew Health Professions Programs, 3101 Petty Road, Suite 1106, Durham, NC 27707 . Google Scholar
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• 3. For complete survey methodology, contact Daniel A. Shugars at the above address . Google Scholar
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