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Still Crazy after All These Years

by Emily Friedman

First published in the May/June 2002 issue of Health Forum Journal

There's no point to hauling out old solutions to the worker shortage. We need to make radical changes.

The news is pretty grim. The lack of physical therapists in hospitals and rehabilitation centers is intensifying. The chronic shortage of gerontologists and geriatricians is approaching crisis stage. And the cyclical insufficiency of hospital and long-term care staff nurses appears to be the worst in history. In rural areas, there is a reported lack of a variety of health care professionals, from physicians to pharmacists. Everyone is wringing his hands over what to do.

The year is 1982.

I was a young (well, at least 20 years younger than I am now) reporter working the story. I became deeply interested in the history and future of nursing and started studying it. In the course of that research, I encountered a 1985 study by Professor Irene Butter and her colleagues at the University of Michigan on gender and status in the health care workforce.

Using data collected from 1979 through 1984, they found that the health care professions were very gender-segregated, with, for example, medicine being 83 percent male; nursing 96 percent female; pharmacy 81 percent male; occupational and speech therapy 89 percent female; dentistry 96 percent male; and aides, attendants, and orderlies 88 percent female.

In addition, Butter and her colleagues found that the male-dominated professions had the highest median incomes, and most of the female-dominated professions had the lowest. Although it was beyond the scope of their work, had these researchers included race and ethnicity, they would have found a parallel consistency: the more white a profession, the higher the income.

At the time, many approaches were being used to lure members of the scarce professions into hospital work, especially in inner-city and rural areas. Bonuses were offered. Child care was expanded. Flexible hours were made more widely available. Workers from other countries, especially nurses, were imported. Money was thrown at the problem. Conferences were held. Studies were duly funded, conducted, and published.

Then as Now

Yet here we are again, in eerily familiar circumstances. As was true then, there's a recession on, despite what Alan Greenspan thinks. Many people in traditional industries, especially manufacturing and e-commerce, have been laid off or have otherwise lost their jobs and are looking for work. Health care inflation is rising, fueled in no small part by hospital costs. Need for health care is strong. And yet many health care providers, especially hospitals and long-term care facilities, can't find qualified employees.

Applications to medical school continue to decline, according to the Association of American Medical Colleges: there were 37,137 applicants in 2000 compared with 46,968 during the record year of 1996. This still means there are several applicants for every slot, however. And although the number of white men entering medical school is down, most minorities are still underrepresented; indeed, of 16,303 medical students enrolled in U.S. schools, a whopping 426 are African-American men.

And although the overall supply of physicians seems adequate (wildly maldistributed, but technically adequate), we continue to suffer an acute shortage of gerontologists and geriatricians; there are around 7,000 practicing, but according to the RAND Corporation, we need about 20,000.

The nursing story has been well told, and I will not dwell on it here. Hospitals, nursing homes, and other care settings are hurting for registered nurses; in many cases, vacancy rates are more than 10 percent, and often more than 20 percent. Vacancy rates for RNs have grown in 60 percent of hospitals since 1999, according to the American Hospital Association.

By 2020, the federal government predicts that the United States will need 1.7 million nurses, but that only 600,000 may be available.

Many of the same statistics hold true for pharmacists and imaging radiology technicians, according to the AHA, which adds that there are vacancy rates above 10 percent for LPNs and nursing assistants, and above 5 percent for lab technicians, billers and coders, information system technologists, and even housekeeping and maintenance workers.

What all this means, of course, is overtime, often mandatory--and skimpy staffing The Department of Health and Human Services issued a report in February that found that "more than 90 percent of U.S. nursing homes have too few employees to take proper care of patients." To address these shortages, too many homes have employed workers without making sufficient background checks, which has led, as recent Congressional hearings sadly demonstrated, to the hiring of serial elder abusers; some of their attacks have been fatal for patients.

In the face of all this, of course, the usual avenues are being pursued. Salaries are being raised; signing bonuses and special benefits such as luxury cars are being offered; retention efforts have been intensified; immigrant workers are being imported; and the usual studies are being conducted and discussed.

Some new twists are appearing as well. The Bush administration has launched a nationwide effort to entice schoolchildren to consider nursing as a career. The University of Colorado is working to increase the number of minority students in its pharmacy program. The California legislature is debating a bill to allow Spanish-speaking physicians from Mexico to work in underserved areas in the state. In several Southern cities, the for-profit hospital firm HCA and the Department of Labor are cosponsoring an effort to subsidize health care training for workers from other sectors who have lost their jobs. Some of these initiatives will no doubt lessen the shortages, for some professions and for some employers. They always do.

But let's step back for a moment and ask the obvious question: Why does this keep happening? Health care is currently experiencing double-digit inflation; there's a hospital building boom; an aging society means more demand for, and financing for, health care services. Why don't people want to work for us?

Shall we speak frankly here? Oh, let's do. And let's start by considering that 17-year-old University of Michigan study that found that the more men in a health profession, the more money those professionals make. And let's talk about the demographics of health care employment versus the demographics of the United States of America.


It is true now, as it has been for the last 200 years, that more than 80 percent of the health care workforce is female. Should another broad gender study be done, the only major change it would identify is that there are large numbers of women physicians and pharmacists in the pipeline--but the ranks of practitioners (and medical school faculties and deans) are still dominated by men.

And when it comes to the top of the heap--administrators, other executives, and trustees--it is still a man's world, even after all these years of a female-dominated workforce.

Indeed, a very thorough study by the American College of Healthcare Executives, recently released by their director of research, Peter Weil, Ph.D., found that of ACHE affiliates, 11 percent of women are CEOs, while 25 percent of men hold that position.

Even with equal levels of education and experience, the study found, women health care executives earn an average of $84,900, whereas men earn an average of $104,300, or 19 percent more. That percentage has actually increased slightly since 1990.

Asked why women are not doing as well as men--despite the fact that a majority of M.H.A. students are now women, as has been true for some time--72 percent of female ACHE affiliates cited "male stereotyping and preconceptions of women's abilities," whereas only 31 percent of male affiliates did. When it came to "exclusion of women from informal networks of communication," 68 percent of women affiliates saw this as a barrier, whereas only 20 percent of male affiliates did. (That's okay; I don't play golf, either.)

As for trusteeship, well, it's difficult to obtain numbers on just how many women sit on boards; but I do recall vividly a hospital spokesman in one of the most rapidly growing areas of the country saying recently that the reason that most hospitals in a five-county area had no female board members was that "there were no qualified candidates." Right.

Race and Ethnicity

Just to mention a few demographic facts: The population of the United States is currently approximately 75 percent white, 12 percent African-American, 1 percent Native American, 3.6 percent Asian-American, 0.1 percent Pacific Islander, 5.5 percent "other," and 2.4 percent of two or more heritages. The population is also 12.3 percent Latino (as Latinos may be of any race, they are counted separately by the Census Bureau).

Of all U.S. physicians, 53 percent are white, 2.5 percent are African-American, 0.0006 percent are Native American, 8.9 percent are Asian-American, 3.5 percent are Latino, and 32.5 percent are "other" or "unknown." Of medical students, 66.2 percent are white or "other," 7.4 percent are African-American, 0.8 percent are Native American, 19.3 percent are Asian or Pacific Islander, and 6.4 percent are Latino.

Of registered nurses, 86.6 are non-Latino whites, 4.9 percent are non-Latino African Americans, 3.7 percent are Asian Americans or Pacific Islanders, 2 percent are Latinos, and 1.2 percent are of two or more races.

On the other hand, of nurse aides at nursing homes, 57 percent are white, 32 percent are African-American, and 11 percent are Latino or other ethnicities.

I could go on, but you get the idea. At the top end, the health professions have either intentionally or unintentionally excluded minorities, and in many cases women, from entry into or real success in their ranks.


Most top health care executives make six-figure salaries; if they are on the for-profit side, they make a whale of a lot more than that. (Richard Scott, the former CEO of Columbia/HCA, who presided over one of the worst cases of provider Medicare fraud in history, walked away from that job with $200 million in cash and stock options and holdings.) The top executives at 10 of the biggest for-profit managed care plans averaged $11.7 million in pay in 2000; each also had an average of $68 million in stock options. The big winner was William McGuire, M.D., head of United Healthcare, who had a take-home pay of $54.1 million in 2000, plus $357.9 million in unexercised stock options.

In 1999, the average hourly wage for nursing home aides was $8.29; for home health aides, it was $8.67; for aides in hospitals, $8.94. In Louisiana, a nurse aide made 57 cents more per hour than a fast-food cook.

It isn't a pretty picture, and there is no way to make it look prettier. Health care work is difficult and demanding as well as rewarding, and yet, for its entire history, too many employers within the modern U.S. health care system have followed certain unfortunate principles--actually, conveniences--in seeking workers.

Those conveniences include a belief that there are a limited number of jobs that women can do, and most of them are in health care (no longer true); that because much health care work involves compassion, empathy, and close human contact, women will not mind being grossly underpaid for doing it (not true); that minorities will take any old job for any old pay (not true); that because it is a fact in much of the rest of the society, it is perfectly okay for most of the money and power to gravitate to and remain at the top with a small, mostly male, mostly white elite (never has been true); and that you can always recruit somebody to do stressful, underpaid, disempowered work, because we have always been able to (no longer true).

We can import workers from other countries, but they tried that in Hawaii during the days of the sugar cane and pineapple plantations, and once these workers (almost all of them from Asia) finished their indenture or contracts, most of them left and set up shops and had children who grew up to be lawyers and physicians and bankers. Those who stayed on the plantations eventually unionized and changed the power structure of the industry.

If health care leaders are unwilling to share the wealth and power, and if health care professions are unwilling to open their ranks (and the ranks of their schools' faculties) to women and underrepresented minorities, then people will go elsewhere for career opportunities.

Problem is, there will be a nation full of aging, sick, and disabled folks who will need care, and I don't think those who have hoarded the power, the privilege, and the money will be able to provide it all by themselves.

This article first appeared in the May/June 2002 issue of Health Forum Journal

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