Law and medicine may be similar in many areas, but the selection and
perspectives of the grads are quite different. Law is relational and
externally focused, that is why lawyers rule. Insurance companies are even
more relational, hiring the best of a variety of professions to keep their
ruling position. Of course by doing so, most insurance companies and
professionals live far from reality in terms of health care, the legal
system, etc. Medicine is internally focused and non-relational. That is why
medicine is constantly on the defensive. Groups of doctors can be even more
challenging. Medical associations say they are member-driven and
pro-active, but rarely give evidence of either. Since the relational
"stuff" has not been worked out in medicine and we tend not to select
relational folks to admit into medical school, even when we decide what is
worth doing, we rarely get the complex tasks accomplished. We also tend to
have difficulty finding enough for the more relational disciplines, such as
family medicine.
Regarding numbers of doctors and lawyers:
Before Flexner's report a century ago, we did have proprietary schools and
preceptorships that tended to keep doctor's wages low, distributed doctors
well according to the population, and tended to allow a greater variability
in the quality of physicians. Medicine took this opportunity to establish
several layers of accreditation and licensure to improve quality. This also
increased wages by creating a perpetual state of shortage, thus insurance,
etc.
Interestingly the proprietary schools as a source of US doctors are on the
rise, particularly regarding family medicine applicants and graduates. For
some applicants, medical schools outside the US are the only choice.
Inner city and rural folks are an important part of this group. Rural
background applicants accepted to medical school have gone from 27% to 16%
in past decades despite no change in the distribution of those taking the
MCAT. Minority applicants have also had difficulty. I think this has more
to do with the inner city and rural school situations and their home
environments. Remember these are low income origin folks whose parents do
not tend to know the ropes and they go to schools and colleges that have
advisors who deal more with delinquents than pre-professionals. It is my
belief that those who come from such origins and overcome are also more
devoted to service and are more likely to choose family medicine, even when
it is not the "in" thing to do. These are the folks that also choose rural,
underserved, military, and more. They are on the front lines fighting
poverty, disease, ignorance, and injustice, using tools that they learned
more before and after medical training than during.
If we truly want to impact the match regarding family medicine in a
significant way, we have to deal with origins and preprofessional rather
than apologetics, advertising, and marketing. The solution is already in
place in some locations and is relatively well known. It is usually ignored
and commonly relegated to a lesser priority by most. However, the
composition of graduates should be our top priority.
The principle is simple: find a way to improve the education and polish of
those applicants from lower socioeconomic origins and somehow manage to
expend more resources on people as compared to programs in the process.
After addressing this area, there is more. Family medicine had to be
relational to survive, but has lost this ability over the years under the
influence of medicine. It is getting more and more distant from the
family, the patient (especially the underserved), the practitioner, and the
political. The Medical Education Retardation that moves slowly and steadily
throughout medical education in this country. It impacts family medicine
more and more severely through liability, health plans, and traditional
faculty roles (teachers who do not know learners and vice versa). The
decision basis of the learners will not change. After all, who will ever
move on to attempt mastery of the relational until they feel comfortable
with the basics of medicine. Mastery of medicine now delays more and more
into the years of residency, critically delaying the development of today's
physicians, and especially family physicians, and especially family
physicians serving the underserved and attempting to teach.
To master the practice of medicine, students and residents must actually
practice medicine, which none of our systems (billing, privileging,
accreditation, liability) supposedly will allow. They must make decisions
and do procedures to develop competence and confidence. In happier times
this could be done with top notch supervision, given better resources and
modeling and attitudes. Now it is much more difficult, especially with the
decline of systems for indigent care and their finance.
In family medicine we are the most frustrated. We are more relational than
most, because of where we came from and who we attract to family medicine.
Education - We have better models of education, but they impact a smaller
number of students and residents and are often limited in application and
implementation and development. These smaller programs also tend to have
the most difficulties in finance and support and recruitment. We still farm
our learners out to others who clearly have thoughts, beliefs, attitudes,
and practices that are contrary to what we are all about.
Service - We are often so relational in our practices at the patient level,
that we are ineffective at family, community, and other levels. Perhaps
more damaging is that we all too often choose to escape into the typical
traps of medicine: pursuing disease or technology over patient care,
passing the buck to other doctors or professionals instead of investing
ourselves, and overuse of the prescription pad.
Beyond selections, we must ourselves fight the "evolution" of medicine as
it has become and get learners more and more into contact with
practitioners and those who primarily want to teach. We will never be
"accepted," but we can remain relevant. We can always make a difference,
because of who we are, where we came from, and what we have had to
overcome.
Robert C. Bowman, M.D.
rbowman@unmc.edu