Public Health

CHAPTER 9

Health Professionals and the Health Workforce

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LEARNING OBJECTIVES

By the end of this chapter, the student will be able to:

•   describe roles that education and credentialing play in the development of health professions, such as medicine and nursing.

•   describe the continuum of public health education and identify educational pathways for becoming a public health professional.

•   identify recent changes in the education of physicians.

•   describe the educational options in nursing.

•   identify components of prevention and public health that are recommended for inclusion in clinical education.

•   explain the concept of primary care and differentiate it from secondary and tertiary care.

•   identify a range of mechanisms used to compensate clinical health professionals and explain their advantages and disadvantages.

Upon your arrival at the hospital, the nurse specialist examines you and consults with the radiologists, the gastroenterologist, and the general surgeon. Your medication is reviewed by the pharmacist and your meals by the clinical nutritionist. Throughout the hospitalization, you are followed by a hospitalist. Once you get back home, the home care team comes to see you regularly for the first two weeks, and the certified physician assistant and the doctor of nursing practice (DNP) see you in the office. You realize that health care is no longer just about doctors and nurses. You ask yourself: What roles do all of these health professionals play in the healthcare system?

Jenna decides that after college, she wants to become a doctor and practice medicine. “I thought there was only one kind of doctor who could diagnose disease and prescribe medicine,” she mentions at a career counseling meeting. “Not so, anymore,” says her advisor. “There are allopathic and osteopathic physicians. In addition, there are nurse practitioners who are authorized to diagnose and prescribe medications, and there are physician assistants who do the same under a physician’s supervision. The universe of ‘doctors’ now includes doctors of nursing practice, as well as other doctoral degree professionals, such as pharmacists, occupational therapists, and physical therapists.” Understanding careers in health care can be as difficult for students as it is for patients, Jenna thinks to herself. Now she understands why her advisor asked: “What do you mean by ‘practice’? What do you mean by ‘doctor’?”

Sarah was about to begin medical school and was expecting two years of “preclinical” classroom lectures focusing on the basic sciences, followed by the study of clinical diseases. Then, as she had heard from her physician father, she expected two years of clinical hospital “rotations” and electives investigating specialties. She is surprised to find that medical school has changed. There are small-group, problem-based learning sessions where she needs to be able to locate and read the research literature. There is contact with patients and their problems right from the beginning. There is increasingly a four-year approach instead of a preclinical and clinical approach to medical education. She wonders: Are these changes for the better? What else needs to be done to improve medical education?

You are interested in clinical care, as well as public health. I need to make a choice, you think to yourself. “Not necessarily,” your advisor says. “There are many ways to combine clinical care with public health.” After a little investigation, you find out that undergraduate public health education is increasingly seen as preparation for clinical education, and clinical prevention and population health are increasingly becoming part of clinical care. In addition, many careers, from health administration, to health policy, to health education, to clinical research, combine the individual orientation of clinical care with the population perspective of public health. So what is the best pathway to a public health career for you?

 

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WHAT DO WE MEAN BY A “HEALTH PROFESSIONAL”?

Until the early years of the 1900s, education and practice for the health professions in the United States were an informal process, often without standardized admissions requirements, curricula, or even formal recognition of a profession. Throughout the 1900s and into the 2000s, there has been an ongoing movement to formalize and standardize the education process for health professionals. These formal requirements have come to define what we mean by a “health professional” and include admission prerequisites, coursework requirements, examinations of competency, official recognition of educational achievements, and granting of permission to practice. Today, the list of formal health professions is very long. Clinical health professions include physicians, nurses, dentists, pharmacists, optometrists, psychologists, podiatrists, and chiropractors. They also include nurse practitioners, physician assistants, health services administrators, and allied health practitioners. 1 “Allied health practitioner” is a broad category in its own right, ranging from graduate degree–trained professionals, such as physical therapists, occupational therapists, and medical social workers, to technical specialists often with an associate’s degree, such as dental assistants, sonographers, and laboratory technicians.

Education and training are central to the development and definition of most health professions. Education implies that a student is pursuing a degree or certificate from an accredited educational institution. Training is often organized and directed outside of educational institutions. Hospitals, health departments, and large group practices often have the responsibility of training new health professionals.

Before we take a look at specific health professions, let us step back and ask the more general question: How do education and training serve to define health professions?

HOW DO EDUCATION AND TRAINING SERVE TO DEFINE HEALTH PROFESSIONS?

Defining and enforcing educational requirements is central to creating and maintaining a profession. This can be accomplished using two basic approaches: accreditation and credentialing.

Accreditation implies a process of setting standards for educational and training institutions and enforcing these standards using a regularly scheduled institutional self-study and an outside review. Accreditation is used by most health professions to define and enforce educational expectations. At times, these expectations may be laid out in detail down to the level of square footage per student for laboratory space and the number of hours devoted to specific subjects. In other health professions, educational subject areas may be outlined and institutions left to judge how to best implement the curriculum.

Credentialing implies that the individual, rather than the institution, is evaluated. “Credentialing” is a generic term indicating a process of verifying that an individual has the desirable or required qualifications to practice a profession. Credentialing often takes the form of certification. Certification is generally a profession-led process in which applicants who have completed the required educational process take an examination. Successful completion of formal examinations leads to recognition in the form of certification.

Certification also has come to define specialties and even subspecialties within a profession. Successful completion of a specialty or subspecialty examination may entitle a health professional to call him- or herself “board-certified.” Certification is often a prerequisite for licensure, which is a state governmental function and usually requires more than certification. It may include residency requirements, a legal background check, continuing education requirements, etc. Licensure, when applicable, is usually required for practice of a health profession.

Thus, in order to understand what is meant by a particular health profession, it is important to understand the credentials that are expected or required. Let us take a look at the education required for public health, as well as for physicians and nurses.

WHAT ARE THE EDUCATIONAL OPTIONS WITHIN PUBLIC HEALTH?

Within public health, there is a growing array of health specialties. Some specialties require bachelor’s degrees, such as environmental health specialists and health educators. However, many public health roles require graduate degrees that focus on disciplines including epidemiology, biostatistics, environmental sciences, health administration and policy, and social and behavioral sciences. Box 9-1 discusses the development of what is being called the continuum of public health education.

BOX 9-1 Development of the Continuum of Public Health Education 2

The history of public health education as a formal academic activity in the United States dates back approximately 100 years to the 1915 Welch-Rose Report. Funded by the Rockefeller Foundation, this report set the stage for development of separate schools of public health focused on graduate education designed for those with previous professional education, particularly as physicians, nurses, and engineers.

The focus on graduate-level education of those with previous professional education remained the norm for half a century after the publication of the Welch-Rose Report. This began to change in the 1970s and 1980s with the growth of schools of public health as well as programs in public health, often located in medical schools. By the 1980s, a substantial portion of the students entering graduate training in public health had a bachelor’s degree but no prior professional training.

In addition, graduate training in public health increasingly became specialized, with master of public health (MPH) degrees often focusing not only on a generalist core but also on a specialty area, such as epidemiology, biostatistics, environmental health, health administration, health policy, health education, health communications, etc. This was accompanied by the growth of doctoral programs, including both PhDs and doctor of public health (DrPH) degrees.

Undergraduate public health education began as specialty areas, such as health education, environmental health, and health services administration, during the last half of the 1900s. For instance, health education developed its own undergraduate degree programs, competencies, and certifying examination, the certified health education specialist (CHES).

A major change in public health education began in 2003 with the Institute of Medicine’s recommendation that “all undergraduates should have access to education in public health.” 3 This recommendation launched what came to be known as the Educated Citizen and Public Health movement, a collaborative effort of undergraduate education associations and public health education associations. The Educated Citizen and Public Health movement led to a series of recommendations, including the Critical Component Elements of an Undergraduate Major in Public Health. These recommendations are now being used by the Council on Education for Public Health (CEPH) as part of the accreditation process for undergraduate majors in public health, including those providing generalist education and specialty education, as well as those in institutions with and without graduate public health education.

As the 100th anniversary of the Welch-Rose Report neared, public health educators and practitioners joined with undergraduate educators and health profession leaders to form the Framing the Future Task Force: The Second Hundred Years of Education for Public Health. At the heart of the task force’s deliberation was how to create a continuum of public health education. Key to the continuum was undergraduate public health education, including public health education as part of the curriculum of community colleges. The task force created the Community College and Public Health project, which is developing prototype curriculum models that encourage articulation of community college associate degrees and bachelor’s degrees in both specialty areas as well as generalist degrees. In addition, community colleges are beginning to look at how to integrate public health into their own areas of strength and interest, including programs such as public health preparedness/disaster planning, health information systems, and health navigator/community health worker.

Thus, today, formal public health education includes degree programs at community colleges and four-year colleges as well as at the master’s and doctoral level. The process of articulating these degrees and ensuring the development of career ladders is well underway. The continuum of public health education has been established as a goal and is rapidly becoming a reality.

In addition to the educational options that lead to becoming a public health professional, a large and growing number of options are available to combine public health education with other professions. Combined or joint degrees with medicine, nursing, and physician assistants are widely offered. Combinations with law, social work, international affairs, and a range of other fields are also being offered. Combined or joint degrees often allow students to reduce the total number of credit hours required to satisfy the requirement for the two degrees.

Public health professionals today include those who specialize in a wide range of disciplines and work in a variety of settings, from governmental public health to not-for-profit and for-profit institutions, as well as in educational and healthcare institutions. There are approximately 500,000 public health professionals in the United States, and it is estimated that in coming years, there will be a substantial shortage. 4

Public health is one of the last health fields to formalize educational and professional requirements. Today, many public health professionals are trained exclusively in public health, and the process of formal credentialing is underway. The recognition of public health as a distinct professional field with its own educational process has been formalized through accreditation of public health schools and programs by the Council on Education for Public Health (CEPH). CEPH requires five areas of knowledge basic to public health: biostatistics, epidemiology, environmental health sciences, social and behavioral sciences, and health services management. Specific disciplines within public health, such as epidemiology and social and behavioral sciences, have provided recognition for specialized training through advanced degrees, such as the academically oriented doctor of philosophy (PhD) degree and the practice-oriented doctor of public health (DrPH) degree.

Specific technical areas have existed within public health for many years and have included competency examinations, especially in fields such as occupational and environmental health. Health educators in recent decades have formalized and standardized their education and increasingly taken on the structure of a profession, including examinations, certifications, and continuing education requirements.

Formal certification as a public health specialist has only been available since 2008, when the first certifying examination was given. The examination covers the five areas expected for a professional master’s degree, such as a master’s of public health (MPH). These are biostatistics, epidemiology, environmental health sciences, social and behavioral sciences, and health policy and management. In addition, new cross-cutting competencies have been defined and are being incorporated into the examination. These include communications and informatics, diversity and culture, leadership, professionalism, program planning, systems thinking, and public health biology.

The certifying examination tests core competencies, rather than more specialized competencies that students also frequently achieve as part of an MPH degree. Certification is a voluntary process, though it is expected that many employers will look for certification as an important credential in the future. 5 Licensure of public health professionals is not yet an issue. Thus, public health, along with health care, has increasingly formalized its educational requirements, formal credentialing, and competencies. This process is likely to continue.

WHAT IS THE EDUCATION AND TRAINING PROCESS FOR PHYSICIANS?

Physicians are a central part of what is called the practice of medicine. They can be categorized as allopathic or osteopathic physicians. Allopathic physicians graduate with an MD degree, while osteopathic physicians graduate from osteopathic medical schools and receive a DO degree. Graduates of both allopathic and osteopathic medical schools are eligible to apply for the same residency and fellowship programs for their postgraduate medical education. The number of osteopathic medical schools has grown rapidly in recent years and now totals approximately 30 nationwide. Allopathic medical schools number approximately 130 and have only recently begun to again grow in size and number. a

Within medicine, specialties and subspecialties continue to emerge. For instance, hospice and palliative medicine has recently been added to the list of specialties, and others, such as hospitalists, may be moving in that direction. Table 9-1 outlines many of the current specialties and subspecialties within the field of medicine. 6 Box 9-2 discusses the process of medical education and the changes that have occurred in recent years and continue to evolve. 7

TABLE 9-1 Selected Specialties and Subspecialties of Medicine

Example of specialty area	Example of subspecialty area
Anesthesiology	Critical care medicine Hospice and palliative medicine Pain medicine
Emergency medicine	Hospice and palliative medicine Medical toxicology Pediatric emergency medicine Sports medicine Undersea and hyperbaric medicine
Family medicine	Adolescent medicine Geriatric medicine Hospice and palliative medicine Sleep medicine Sports medicine
Internal medicine	Adolescent medicine Cardiovascular disease Clinical cardiac electrophysiology Critical care medicine Endocrinology, diabetes, and metabolism Gastroenterology Geriatric medicine Hematology Hospice and palliative medicine Infectious disease Interventional cardiology Medical oncology Nephrology Pulmonary disease Rheumatology Sleep medicine Sports medicine Transplant hepatology
Obstetrics and gynecology	Critical care medicine Gynecologic oncology Hospice and palliative medicine Maternal and fetal medicine Reproductive endocrinology/infertility
Orthopaedic surgery	Orthopaedic sports medicine Surgery of the hand
Otolaryngology	Neurotology Pediatric otolaryngology Plastic surgery within the head and neck Sleep medicine
PATHOLOGY Anatomic pathology and clinical pathology Pathology—anatomic Pathology—clinical	Blood banking/transfusion medicine Chemical pathology Cytopathology Dermatopathology Forensic pathology Hematology Medical microbiology Molecular genetic pathology Neuropathology Pediatric pathology
Pediatrics	Adolescent medicine Child abuse pediatrics Developmental-behavioral pediatrics Hospice and palliative medicine Medical toxicology Neonatal-perinatal medicine Neurodevelopmental disabilities Pediatric cardiology Pediatric critical care medicine Pediatric emergency medicine Pediatric endocrinology Pediatric gastroenterology Pediatric hematology-oncology Pediatric infectious diseases Pediatric nephrology Pediatric pulmonology Pediatric rheumatology Pediatric transplant hepatology Sleep medicine Sports medicine
Physical medicine and rehabilitation	Hospice and palliative medicine Neuromuscular medicine Pain medicine Pediatric rehabilitation medicine Spinal cord injury medicine Sports medicine
Plastic surgery	Plastic surgery within the head and neck Surgery of the hand
PREVENTIVE MEDICINE Aerospace medicine Occupational medicine Public health and general preventive medicine	Medical toxicology Undersea and hyperbaric medicine
Psychiatry Neurology Neurology with special qualifications in child neurology	Addiction psychiatry Child and adolescent psychiatry Clinical neurophysiology Forensic psychiatry Geriatric psychiatry Hospice and palliative medicine Neurodevelopmental disabilities Neuromuscular medicine Pain medicine Psychosomatic medicine Sleep medicine Vascular neurology
RADIOLOGY Diagnostic radiology Radiation oncology Radiologic physics	Diagnostic radiological physics Hospice and palliative medicine Medical nuclear physics Neuroradiology Nuclear radiology Pediatric radiology Therapeutic radiological physics Vascular and interventional radiology
Surgery Vascular surgery	Hospice and palliative medicine Pediatric surgery Surgery of the hand Surgical critical care
Urology	Pediatric urology

Data from American Board of Medical Specialties. Available at: http://www.abms.org/ . Accessed July 24, 2013.

BOX 9-2 Medical Education

Medical education in 19th and early 20th century America was built upon the apprentice system. Future physicians, nearly all men, worked under and learned from practicing physicians. Medical schools were often moneymaking enterprises and primarily used lectures without patient contact or laboratory experiences. That changed with the introduction of the European model of science-based medical education, hospital-based clinical rotations, and a four-year education model. The 1910 Flexner Report formalized these standards, which soon became universal for medical education in the United States, in what came to be called the Flexner era of U.S. medicine. This era extended into the 1980s, and at some institutions, into the 2000s. It led to the growth and dominance of specialties and specialists within particular medical fields.

Hospital-based residency programs and fellowships leading to specialty and subspecialty training became the dominant form of clinical training. Emphasizing this trend, medical school education came to be called undergraduate medical education. Medical school was traditionally formally or informally divided into two years of basic science or preclinical training, followed by two years of hospital-based clinical rotations in specialty areas including surgery, internal medicine, obstetrics and gynecology, and psychiatry. This division of medical education is reflected in the examinations of the National Board of Medical Examiners, which traditionally included part 1 after the second year of medical school, part 2 prior to graduation, and part 3 after the first-year residency, which is often called the “internship.” Additional specialty and subspecialty board examinations were linked to completion of training that occurs after medical school.

Change began to accelerate in medical education during the mid-1980s with the increasing movement of health care outside of hospitals, the increased medical school enrollment of women and minorities, a broader view of what should be included in medical education, and a better understanding of how learning takes place. Specific changes have occurred in the last two decades at all stages of medical education, and new proposals for change continue to be formally reviewed and implemented. These can be outlined as follows, starting with the premed college years and continuing through residency and fellowship training:

•   Premedical training in the Flexner era was largely restricted to majors in the physical and biological sciences, plus specific social sciences such as psychology. Beginning in the early 1990s, medical schools encouraged a wider range of majors, while usually retaining biology, chemistry, and physics courses as prerequisites. Medical schools are increasingly receptive to a wide range of preparation for medical education, encouraging completion of courses in behavioral and social sciences, including public health and epidemiology.

•   The comprehensive review of the Medical College Admission Test (MCAT) has resulted in changes to the MCAT. The changes include a new section emphasizing the behavioral and social sciences to parallel the sections emphasizing the physical and biological sciences. A framework known as scientific inquiry and reasoning skills (SIRS) will incorporate basic research methods and statistics into each of the content examinations.

•   Admission to medical school was dominated by white males throughout the Flexner era. In the last 20–30 years, the percentage of women applicants has increased steadily. Today, the majority of medical students at many institutions are females. Likewise, the increase in minority applicants has paralleled the changes occurring in other aspects of U.S. education and society.

•   The first two years of medical school in the Flexner era were dominated by lectures and laboratories. Basic sciences were the focus, with little or no patient contact. An important change in the last two decades includes widespread use of problem-based learning (PBL). PBL is characterized by small-group, student-initiated learning centered on “cases,” or patient-oriented problems. New curricula in medical education, including evidence-based medicine, interviewing skills, and ethics, have become a standard part of coursework. A new simulated patient interview and physical examination are now part of the certifying examination process.

•   Changes in the third and fourth years of medical school began in the 1960s, the era of student activism. Since then, the fourth year of medical school has been dominated by electives. Fourth-year students may choose formal courses, elective clinical experiences, or a wide array of other options. These usually include options for laboratory or clinical research; international experiences; and clinical rotations at other institutions, often called “audition” rotations, designed to increase a graduate’s potential for selection as a resident.

•   The growing trend of patient treatment outside of the traditional hospital setting has increased the range of types and locations of clinical experiences available. Most medical schools now require primary care experiences, along with traditional specialty rotations.

•   Residency training has paralleled the changes in medical school, with greater outpatient and less inpatient, or hospital-based, education. Fellowship training beyond residency is now a routine part of the process of specialization. The general move toward more and more specialization has led to longer postgraduate training. The rigors of residency training remain, but limits have now been placed on it by the Residency Review Committees (RRCs), which govern graduate medical education. An average of 80 hours per week is now the maximum standard for residents.

Further changes in medical education and residency programs can be expected in the near future. The increasing recognition that health care is a group, and not an individual, enterprise is leading to a focus on interprofessional education and practice. An appreciation that evidence is central to improving quality and controlling costs should continue to encourage the critical reading of clinical research as part of evidence-based medicine in medical school and in journal clubs as part of postgraduate education. The use of computer-based information systems should increase the sharing and coordination of information, the ability to monitor and control health care, and the ways that physicians communicate with colleagues and patients. Technology is also likely to have continued unexpected impacts on the ways that medicine is taught, learned, and practiced.

Now let us take a brief look at the largest of the health professions—nursing. 8

WHAT IS THE EDUCATION AND TRAINING PROCESS FOR NURSING?

Nursing as a profession dates from the middle of the 1800s, when it began to be organized as a profession in England. Florence Nightingale is often associated with the founding of nursing as a profession. In the United States, the nursing profession grew out of the Civil War and the essential role played by women in this conflict, who performed what we would today call nursing functions. Nursing has long been organized as a distinct profession and is governed by its own set of laws, often referred to as the “nursing practice acts.”

Today, there are a wide range of health professionals that fall under the legal definition of nursing. Licensed practical nurses (LPNs) provide a range of services often under the direction of registered nurses (RN). An LPN’s educational requirements vary widely from state to state, ranging from one year of education after high school to a two-year associate’s degree. Certified nursing assistants (CNAs) or nursing aides have usually completed a short-term certification program and are allowed to perform only the basic care of patients.

Registered nurses are considered central to the nursing profession and they are usually responsible for hospital-based services. Each state defines its own requirements for RN licensure. Traditionally, many nurses graduated with a diploma that was offered through hospital-based programs. The move toward integrating nursing into the formal degree system has resulted in nurses with associate’s degrees, bachelor of science in nursing (BSN) degrees, as well as graduate degrees. Being a registered nurse requires a state license that, depending on the state, may or may not require a BSN degree.

Advanced nursing degrees have been offered as a master’s of science in nursing, or as an academic research-based degree, the PhD. Recently, a clinical doctorate, the doctor in nursing practice (DNP) is becoming central to graduate nursing education. The DNP is increasingly becoming the standard graduate degree for nursing, often replacing master’s degrees.

Until recent years, there was little formal specialization within nursing, at least compared to physicians and other health professions. Nurse midwives and nurse anesthetists, however, are two traditional specializations within nursing. Graduate-level education and training of nurses has expanded rapidly in recent years. Nursing has added a series of advanced practice degrees, including nurse practitioners, as well as specialists such as pediatric, geriatric, and intensive care nurses. The DNP degree is becoming standard for a range of specialty areas within nursing. Recent changes in nursing have opened up the option to pursue a bachelor’s degree in a range of fields followed by a shorter degree program leading to a BSN or a nurse practitioner degree.

WHAT ROLES DO PHYSICIANS, NURSES, AND OTHER CLINICAL HEALTH PROFESSIONS PLAY IN PUBLIC HEALTH?

As we have seen, the aim of the initial schools of public health was to train physicians, nurses, and other professionals who sought to play lead roles in local and state health departments. Thus, for many years, public health education was often combined with other professions. Box 9-3 discusses the roles that clinicians still play in public health.

Remember that we have only touched on three basic types of health professionals: physicians, nurses, and public health professionals. There are several hundred other types of professions in the healthcare realm. As you think about a career in health, you should take a look at a range of health professions, using the concepts of education, training, and certification that we have discussed.

To understand the connections between the large number of diverse health professions, we need to look at how clinical care is organized into primary, secondary, and tertiary care.

WHAT IS MEANT BY “PRIMARY, SECONDARY, AND TERTIARY CARE”?

Primary, secondary, and tertiary care are traditional ways to categorize services delivered within the healthcare system. 9 Primary care traditionally refers to the first contact providers of care who are prepared to handle the great majority of common problems for which patients seek care. Secondary care often refers to specialty care provided by clinicians who focus on one or a small number of organ systems or on a specific type of service, such as obstetrics and gynecology or anesthesiology. Tertiary care, or subspecialty care, is usually defined in terms of the type of institution in which it is delivered, often academic or specialized health centers. Tertiary care may also be defined in terms of the type of problem that is addressed, such as trauma centers, burn centers, or neonatal intensive care units.

BOX 9-3 Roles of Clinicians in Public Health

Public health is often distinguished from the clinical health profession by its focus on populations rather than individuals, public service rather than individual service, and disease prevention and health promotion rather than disease diagnosis and treatment, and its broad perspective on the determinants of disease. However, at the professional level, individuals have commonly combined the two approaches or moved from one to the other.

Clinicians have always played key roles in public health. From the early years of formal public health training nearly a century ago, until the 1960s and 1970s, the master of public health (MPH) degree was aimed primarily at physicians and nurses who were expected to take up leadership roles in health departments. Today, public health professionals come from much more diverse backgrounds, many entering master’s programs directly after receiving a bachelor’s degree. The role of clinicians in public health is also far more varied. For instance, today’s pharmacists—now educated as doctors of pharmacy or PharmDs—play an increasingly important public health role in providing education about drugs for patients and practitioners and controlling prescription drug abuse. Prevention of dental and gum disease and early detection of oral cancers have significantly improved due to the careful attention of dentists and dental assistants. The dental profession has been a long-standing advocate of fluoridation of public water systems and other population health interventions.

Primary care specialists, including allopathic and osteopathic physicians, nurse practitioners, and physician assistants, are on the front lines of clinical prevention. Their involvement in screening, behavioral counseling, immunization, and the use of preventive medication is key to the success of these efforts. Primary care clinicians, as well as specialty care clinicians, also have important roles to play in being alert to new diseases or changes in well-known diseases; reporting adverse effects of drugs, vaccines, and medical devices; and coordinating case-finding efforts with public health agencies.

Within medicine, the field of preventive medicine has a long history. Formal specializations exist in public health and general preventive medicine, occupational medicine, as well as aerospace medicine.

Finally, all clinicians have the right and often the responsibility to advocate for improvements in patient care and of the health system as a whole. A few clinical specialties, such as pediatrics, regard advocacy as a core responsibility of the profession. Their work has had major impacts on child health policies, ranging from the use of child car restraints, to advocacy for pediatric HIV/AIDS care, to universal coverage of childhood vaccinations, as well as the provision of comprehensive insurance coverage for children.

The roles of clinicians in public health are likely to become ever more varied in coming years as public health and healthcare systems and institutions become more closely coordinated.

Primary care is widely seen as the foundation of a healthcare system, and a strong primary care system is viewed as a prerequisite for maximizing the potential benefits of health care. Traditionally, primary care was considered the domain of physicians. Today, a range of health professionals are involved in primary, as well as secondary and tertiary, care. In fact, the term “medical home” is becoming widely used, suggesting that primary care is increasingly viewed as a team effort.

Today, only about one third of physicians in the United States practice primary care. Increasingly, primary care is being delivered by physician assistants (PAs) and nurse practitioners (NPs), who in most states have authority to diagnose disease and prescribe medication either under the supervision of a physician (in the case of PAs) or under a nursing practice act (as in the case of NPs). A team approach to primary care is becoming standard practice. The Affordable Care Act (ACA) has encouraged the use of nurse practitioners as part of primary care by providing greater ability for them to bill directly for services without going through a physician.

It is important to understand the ideals of primary care, as well as today’s realities. 7 Primary care is key to the healthcare system because it is where most care is delivered and it is often the entry point for subsequent specialty care. In addition, primary care is critical to the delivery of clinical preventive services and to the connections between health care and public health. Ideal primary care has been described using 6 Cs: contact, comprehensive, coordinated, continuity, caring, and community.

•   “Contact” implies first contact with patients as they present for health care.

•   “Comprehensive” refers to the ability of primary care practitioners or primary care teams to completely or at least initially address most health issues.

•   “Coordinated” relates to the concept that primary care teams should have the responsibility to ensure that the parts of the healthcare system work together for the good of patients.

•   “Continuity” is the role that primary care teams see themselves playing to hold together the components of the system.

•   “Caring” implies a personalized relationship with each patient.

•   “Community” implies that primary care provides the link with the broader community, including with public health institutions and services.

Despite the fact that many primary care practitioners continue to see this model of primary care as a highly desirable way to deliver clinical care, the realities of today’s healthcare system deviate substantially from this model. Table 9-2 outlines the 6 Cs and indicates ways that the current healthcare system differs from this primary care ideal. 9 , b

Thus, there is a large gulf between the ideals of primary care and their execution in practice. Part of the reason for this and other realities of health care can be better understood by looking at how health professionals are rewarded and compensated.

HOW ARE CLINICAL HEALTH PROFESIONALS REWARDED AND COMPENSATED FOR THEIR SERVICES?

Physicians—and, increasingly, other health professionals—are compensated through a variety of mechanisms. Compensation levels depend on the site where care is delivered, the nature of the patient’s insurance, and the type of institution in which the professional works or is employed.

Complicating the issues of coordination of services and continuity of care is the fact that patients can and are often encouraged to change insurance coverage on a yearly basis. Thus, clinicians now live in a complex, changing, and often confusing world in which issues of compensation can get in the way of quality care. Despite the best of intentions, many clinicians find themselves having to address compensation as another “C.” Table 9-3 outlines a number of methods of financial compensation to providers of health services and examines some of their advantages and disadvantages.

In addition to the mechanism of payment for services, another key factor that affects health professionals is the number of people in the profession. Let us look at how the right number makes a difference.

TABLE 9-2 Ideals and Realities of Primary Care—the 6 Cs

	Primary care ideals	Realities
Contact	The point of first contact with the healthcare system—the entry point	Patients enter the healthcare system through many disconnected points, including ER, specialists, urgent care centers, nontraditional practitioners, etc.
Comprehensive	Primary care intends to be able to diagnose and treat the great majority of problems	Rapid increase in possible treatments and high-volume practices increase proportion of patient problems that are referred to specialists
Coordinated	Primary care intends to be the focal point for diagnosis and treatment, with coordination through referral to specialists for consultation and feedback	Primary care physicians increasingly being replaced by “hospitalists,” who are full time in the hospital, provide care for inpatients, and direct patient access to specialists
Continuity	Patient followed over many years—continuous care provision	Patients increasingly required or encouraged to change physicians/providers for insurance purposes
Caring	Individualized care based on individual relationships	Primary care increasingly becoming an administrative entity without long-term individual relationships
Community	Primary care designed to connect the individual patient with community resources and community requirements (required examinations, reportable diseases, vaccinations, driver’s licenses, etc.)	Healthcare professionals and public health have a long history of distant and—at times—contentious relationships

Data from Institute of Medicine. Defining Primary Care: An Interim Report. Washington DC: National Academies Press; 1994.

TABLE 9-3 Method of Financial Compensation to Providers of Health Services

HOW CAN WE ENSURE THE SYSTEM HAS THE RIGHT NUMBER OF HEALTHCARE PROFESSIONALS?

Financial compensation is the fundamental market mechanism for regulating the supply of most professionals. This mechanism has not generally worked well in the health professions. The demand for positions in medical schools, for instance, far exceeds the supply. Thus, much of the control over the number of professionals who are trained has been made by the profession itself through policies that control the number and size of accredited degree-granting institutions. This control has had limited success. For instance, in the 1980s, dentists determined that there was an oversupply of dentists. A number of dental schools were closed and new dental schools were limited. Today, there is an undersupply of dentists. Balancing the supply and demand for health professionals is a complex undertaking, as illustrated by the current shortage of nurses. 10 The nursing shortage is discussed in Box 9-4.

We have now taken a look at the complex world of health care and public health professions, including the creation of health professions through education, training, and credentialing. We have also looked at issues of compensation and how we can try to ensure the right numbers of health professionals. Now, let us turn our attention to examining the institutions in which health care is delivered.

BOX 9-4 The Nursing Shortage and What Is Being Done About It

Nursing is the largest of the health professions, with almost 3 million registered nurses. The number of U.S.-trained registered nurses (RNs), however, has not kept up with demand. The shortage of nurses, especially those who work in the increasingly technical hospital environment, continues to grow. The projected size of the shortage is controversial, but estimates of a shortage of 200,000 or more RNs in the coming years are commonly quoted. Everyone agrees that nursing is one of the most (if not the most) rapidly growing professions in terms of available job positions. The shortage is made worse by the fact that the average age of nurses is increasing, because until very recently, there was a decline in the number of newly trained nurses. Why is there such a large and growing shortage? A number of factors contribute to this problem, reflecting changes in nursing and the U.S. society. There is both a greater demand for nursing services and a supply that is not growing fast enough. Among the factors are:

•   Technology—The increased availability and use of technology has increased the need for skilled nurses. Most of those who qualify for these technologically oriented jobs are recent graduates, and the number of recent graduates is very small compared to the demand.

•   More patients—The aging baby boomer generation is expected to have a major impact on the need for nursing services. The large number of baby boomers born between 1946 and 1964 will need and expect increased nursing services.

•   Reduced supply—Nursing has been viewed as a woman’s profession, which has historically limited its attractiveness to men. In addition, many women leave the profession or practice part time, which may be accelerated by the increasingly stressful nature of the work.

•   Restrictions on entry—Until recently, nursing education was self-contained—to become a nurse, you needed to complete an undergraduate nursing degree, and the only way to pursue a graduate nursing degree was to already have a bachelor’s degree in nursing.

•   Shortage of nursing faculty—A shortage of nursing faculty and teaching facilities has also contributed to the shortage of nurses and the ability to rapidly expand the size of colleges of nursing.

A national effort is now underway to increase the number of nurses in training. The approaches being used include:

•   Better compensation—higher salaries and more flexible work schedules

•   Increased educational opportunities—scholarships to encourage admissions to nursing schools and more flexibility in entering nursing after bachelor’s degree training in other fields

•   Increasing the applicant pool—encouraging male and underrepresented minority group enrollment

•   Raising status of nursing—greater independence and recognition

Enrollment in colleges of nursing is now increasing. However, it is not likely that the supply of U.S.-trained nurses will meet the rapidly increasing demand in the foreseeable future.