Social Accountability in Theory and Practice

James Rourke

doi:10.1370/afm.559

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Health needs, demands, and workforce issues
Barbara Starfield

Published on: 06 October 2006

Published on: (6 October 2006)
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Health needs, demands, and workforce issues
Barbara Starfield, Baltimore, MD, USA
Justification for increasing the number of medical students based on community needs(1) and “social accountability”(2) is a refreshing departure to current exhortations to expand physician supply based on increasing consumer demand.(3)
Documenting need for more physicians is not easy. Evidence suggests that ageing of the population is NOT a main contributor to increasing need.(4) The increased prevalence of di...
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Justification for increasing the number of medical students based on community needs(1) and “social accountability”(2) is a refreshing departure to current exhortations to expand physician supply based on increasing consumer demand.(3)
Documenting need for more physicians is not easy. Evidence suggests that ageing of the population is NOT a main contributor to increasing need.(4) The increased prevalence of diagnosed ill health, the particular interests of different types of physicians and their distribution in the population, and standards of practice are, in contrast, changing the playing field.
Artificially created “need” is rampant. Rates of increase in frequency of almost all diagnoses have been documented.(4) Changing thresholds for diagnosis of diseases are widespread, and new diseases (such as “restless foot syndrome”) are appearing as a result of a pharmaceutical industry interest in developing new markets for its products.(5) Changing standards of care resulting from implementation of guidelines is putting increased pressure on practitioners, especially primary care practitioners, even though not all recommended interventions are warranted or of high priority.(6) Justification for training more specialists is contradicted by evidence that an increasing supply and use of specialists often results either in no added benefit or worse outcomes.(7) Thus, following the call for more physicians, under circumstances in which most will become specialists, is not a benign strategy. Following the dictum that the number of physicians should follow from the health needs of populations and be pursuant to “social accountability”, the major challenge is to make training more congruent with these principles.
Most of the changes in health needs are for outpatient services, not inpatient services. The dangers of hospital-based training for physicians who will end up in community practices are documented both theoretically and empirically.7 Now more than ever, we need a concerted effort to document how hospital-based and community based physicians could better work together to define their relative roles and their inter-relationships in the care of patients and populations. There is much that can and should be done to make specialists better serve the needs of both patients and primary care physicians, in the interests of avoiding unnecessary care and the adverse events that follow from them. Evidence-based advocacy for greater effectiveness and greater equity can be found only in the case of increasing the supply of primary care physicians. Arguments for increasing the overall production of physicians, most of whom will end up in specialty practice, is not based on evidence of need, at least not in the United States. Uncritical movement in this direction is at the peril of population health and social accountability.
References
1. Berg AO, Norris TE. A workforce analysis informing medical school expansion, admissions, support for primary care, curriculum, and research. Ann Fam Med 2006 September;4(Suppl 1):S40-S44.
2. Rourke J. Social accountability in theory and practice. Ann Fam Med 2006 September;4(Suppl 1):S45-S48.
3. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff 2002 January;21(1):140-54.
4. Thorpe KE, Florence CS, Howard DH, Joski P. The rising prevalence of treated disease: effects on private health insurance spending. Health Aff 2005 January;W5:317-25 (also available at http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.317v1).
5. Dyer O. GSK breached marketing code. BMJ 2006 August;333(7564):368.
6. Coffield AB, Maciosek MV, McGinnis JM et al. Priorities among recommended clinical preventive services. Am J Prev Med 2001 July;21(1):1- 9.
7. Starfield B, Shi L, Grover A, Macinko J. The effects of specialist supply on populations' health: assessing the evidence. Health Aff 2005 March 15;W5:97-107 (also available at http://content.healthaffairs.org/cgi/reprint/hlthaff.w5.97v1).
Competing interests: None declared
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Competing Interests: None declared.