Global Shortages in Healthcare Professionals: How Do We Reach Human Resource Sustainability in Our Practices?

The theme of this month’s edition of AAOS Now is environmental sustainability, with several excellent articles to spur individual thought and group discussion on the environmental impact of the decisions we all make in our healthcare systems. Given the position of healthcare as mission-driven to provide for the well-being of the population, it may seem like we ought to be further ahead in reconsidering practice models with a lens to environmental sustainability.

As noted in the article “Bringing Sustainability to Orthopaedics: Greening the Future of Orthopaedics and Healthcare,” by Bellaire et al on page 6, ESG (environmental, social, and governance) scorecards have become integrated into the strategic plans and everyday work of many for-profit organizations that would not be considered part of the social sector as is healthcare. We must act now to ensure that our efforts to keep the population healthy do not cause unnecessary burdens on our physical environment. Don’t forget to also read the fascinating Final Cut by Stuart A. Green, MD, FAAOS, recounting the transition from glass to plastic syringes as an illustration of the move to single-use items in medical care and the problems caused by disposal of all this waste.

In preparing for this Editor’s Message, I considered another aspect of sustainability in healthcare—training and retaining sufficient high-quality professionals to meet our local, national, and global needs now and into the future. Manpower shortages are not evenly distributed or equally impactful for all practices. In my practice and the wider region, we have daily conversations on how to fully staff ORs and increase inpatient bed availability to meet current demand. These discussions have reached a crescendo in recent times; many consider the situation as a direct result of the “Great Resignation” seen in many fields in the aftermath of the COVID-19 pandemic. However, employment statistics show this problem was building momentum long before the pandemic, affecting nearly every aspect of medical care.

A positive effect of the tight healthcare labor market can be improved pay and working conditions used to attract nursing staff and other professionals to join our teams. However, is one system’s gain another one’s loss? I recently read an interesting piece in Forbes magazine titled “Solving the Global Healthcare Providers Shortage,” which discussed the large number of qualified applicants for medical, nursing, and physician assistant training programs who are rejected annually. Although no one can argue against maintaining high admission standards, many applicants fail to enter their chosen healthcare field primarily due to insufficient training sites. At the same time, a 2021 report by the Association of American Medical Colleges (AAMC) estimated that the United States would experience a shortage of 37,800 to 124,000 physicians by 2034, impacting both primary care and specialties such as orthopaedic surgery. According to the American Association of Colleges of Nursing, 2022 saw a 1.4 percent decrease in bachelor’s degree nursing students, the first decrease in 20 years.

One avenue available to the United States is increasing recruitment of medical and nursing professionals from international schools. Roughly 8 percent of U.S. nurses, or approximately 300,000 individuals, are foreign-trained. The Philippines stands out as a major source of foreign talent, accounting for more than 30 percent of U.S. foreign-trained nurses. The AAMC estimates that 20 percent of practicing U.S. physicians trained outside North America. The importance of these professionals is enhanced by the recognition that more than 70 percent of internationally trained physicians practice primary care and tend to serve where clinician shortages are most prevalent.

However, the shortage of healthcare professionals is a global problem driven by aging populations and increasing chronic illnesses. The World Health Organization estimates a shortfall of 10 million healthcare workers globally by 2030. Many physicians and nurses recruited to the United States arrive from lower-income countries. The history and tradition of the United States are to welcome those seeking improved opportunities for themselves and their families. However, there is concern that overreliance on international healthcare professionals can exacerbate shortages and inequities in regions that can least afford the losses.

Of course, sustainability issues in healthcare are not limited to the United States or lower-income economies. Other countries with highly developed healthcare systems have their own unique challenges that can help inform domestic policy initiatives. As one example with both similarities and important differences, a benchmark defined by the Canadian Institute for Health Information states that patients needing a hip or knee replacement should wait no longer than 182 days for surgery following consultation with an orthopaedic surgeon. Data from 2022 showed that roughly 57 percent of patients with hip arthritis and 50 percent of patients with knee arthritis received treatment within the benchmark timeframe. This is a deterioration from 75 percent and 70 percent, respectively, in 2019. This is after waiting a national average of more than 10 weeks for referral to specialist consultation. Looking one more step upstream, access to primary care in Canada has also deteriorated in recent years, and many patients, including seniors, are on lengthy waitlists to be assigned a primary care physician. These numbers suggest a shared problem of difficulty in training and retaining a variety of healthcare professionals.

However, Canadian orthopaedic surgeons and other hospital-based specialists simultaneously face a very different challenge. According to 2020 data from the Canadian Orthopaedic Association (COA), 430 orthopaedic surgeons graduated in the previous 6 years in Canada. Of those, 127 recent graduates were listed as “looking for work,” including 28 who were actively seeking immediate work and 72 who were working full-time outside of Canada. Although this represents an improvement in the employment situation, it results from the decrease in orthopaedic positions nationwide from 81 in 2011 to 54 in 2017. As the COA explained in its summer 2018 bulletin, “We recognize that the needs of the population and the training programs are not necessarily best met by reduction in resident numbers, but the unfortunate reality is that public funding for new permanent positions, as well as the hospital-based resources required to support them, are inadequate in many regions.” There is clearly much to be learned by both the successes and challenges faced by a variety of health systems as we chart the best course for our own future and advocate our positions with policymakers.

So where do we go from here? A global perspective demonstrates that there is no perfect healthcare system, and each one needs to be judged on the resources, culture, and priorities of the country or region. It would seem evident that longer patient wait times would naturally decrease the concern about resource over-utilization, as these waits counterbalance negative effects of legacy fee-for-service payment systems. However, greater scarcity of resources places greater responsibility on each of us to achieve the much discussed “quadruple aim” and maximize equitable access such that the greatest number of those in need can benefit from efficient treatment. We simultaneously must balance this responsibility with retaining healthcare professionals who are feeling the stress of being continuously asked to do more with less.

Orthopaedic care has evolved tremendously since the start of my career, when surgeons were often seen as leading a team in the OR but otherwise largely working individually with patients. Integrated care teams have been of tremendous benefit in the pre-, intra-, and postoperative periods, and I predict that these teams will continue to expand in breadth and scope. As team leaders, orthopaedic surgeons will need to increase our awareness and attention to all stages of health management to improve overall wellness and prevent or delay musculoskeletal disease. Like measures to protect the physical environment we live in, our healthcare systems and individual practices will need to continue innovating to improve treatment outcomes with fewer resources and fewer professionals, while striving to improve the mobility and health of the entire population.

Robert M. Orfaly, MD, MBA, FAAOS, is a professor in the Department of Orthopaedics and Rehabilitation at Oregon Health and Science University. He is also the editor-in-chief of AAOS Now and chair of the AAOS Now Editorial Board.

References

1. Moon K: Solving the Global Healthcare Providers Shortage. Available at: https://www.forbes.com/sites/kristenmoon/2023/12/01/solving-the-global-healthcare-providers-shortage. Accessed July 1, 2024.
2. Association of American Medical Colleges: AAMC Report Reinforces Mounting Physician Shortage. Available at: https://www.aamc.org/news/press-releases/aamc-report-reinforces-mounting-physician-shortage. Accessed July 1, 2024.
3. Canadian Institute for Health Information: Surgeries impacted by COVID-19: An update on volumes and wait times. Available at: https://www.cihi.ca/en/surgeries-impacted-by-covid-19-an-update-on-volumes-and-wait-times. Accessed July 1, 2024.
4. Canadian Orthopaedic Association: Unemployment and Underemployment of Orthopaedic Surgeons. Available at: https://coa-aco.org/unemployment-and-underemployment-of-orthopaedic-surgeons/. Accessed July 1, 2024.