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INTRODUCTION

THE HEALTH CARE WORKFORCE: A CHANGING INDUSTRY

Our nation's health care workforce represents both a major employment sector and a source of diverse employment opportunities for workers. As an industry, health care is one of the largest, providing more than 11 million jobs. Almost half of all health services jobs are in hospitals; another one-third are in either nursing and personal care facilities or physicians' offices. The nature and appearance of this large occupational industry are rapidly changing, most notably in two professions: medicine and nursing.

The supply of physicians has grown rapidly for several decades, and several reports within the past decade have concluded that the ratio of physicians to the general population is increasing. In recent years, growth in physician supply has moderated; in 1998, about 577,000 physicians were actively practicing medicine.

The growth of managed care and reductions in hospital inpatient care have helped to dramatically shift the volume of health services provided from inpatient institutions to ambulatory settings. Medical education has been slow, however, to adapt to these changes. Physician residents and students continue to receive most of their clinical training at teaching hospitals and academic medical centers that serve a disproportionate number of acute care patients. Although most primary care physicians practice in out-of-hospital community or managed care settings, generalist trainees may not receive adequate exposure to the conditions and treatment modalities that they eventually confront in practice. Efforts to train more residents in ambulatory settings has generally been thwarted by insufficient financial incentives and payment policies that continue to reward training in hospitals.

Once a male-dominated profession, the practice of medicine has seen a dramatic increase in women practioners during the past quarter century. In 1970, women represented just 8 percent of all physicians; by 2010, they are expected to comprise close to 30 percent of the total physician population.

As with women, minorities historically have been underrepresented in the medical profession but their representation in the field has increased significantly. In the 1950s, the percentage of minorities graduating from U.S. medical schools was less than 3 percent; by 1998, the proportion of minority graduates rose to just more than 33 percent. More specifically, African Americans, Hispanics and Native Americans-about 25 percent of the population-accounted for less than 15 percent of medical school graduates in 1998, while Asians-approximately 4 percent of the population-comprised more than 18 percent of graduates. Consequently, African American, Native American and Hispanic medical school graduates comprise just 6 percent of all U.S. practicing physicians. Although several efforts supported by public and private funds have been instituted to increase minority participation in medicine, court rulings have weakened affirmative action measures that many experts believe are necessary to achieve equity.

Today's supply of nurses appears to be seriously short of meeting the demands for nursing care. Nurses are by far the largest sector in the health workforce (more than 2 million) and although the demand for nurses is growing rapidly-particularly in nursing homes-fewer are entering this sector. Unlike earlier nursing shortages, graduations from nursing schools have declined significantly during the past five years. The average age of a practicing registered nurse is now over age 45. Experienced nurses are leaving hospitals at an alarming rate due to job stress and lack of staff support caused a new, cost-conscious, competitive marketplace.

At the same time, there has been a dramatic increase in the supply of advanced practice nurses (APNs). The amount of health care APNs deliver-that previously was provided principally by physicians-also has increased. APNs, which include nurse practitioners, certified nurse midwives and nurse anesthetists-many of whom traditionally were used as physician extenders-now typically operate with a new degree of autonomy as defined by changes in state laws and regulations. The defined scope of practice of these nurses overlaps in varying degrees with that of physicians, and they may even compete with physicians. The nurse practitioner sector may be the best example of where changes have had the greatest effect.

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