Bob,
I believe the greatest issues we face at this time are the following:
1. Perception that Nurse-practitioners can replace Family Doctors
2. The continually engaging debt of Medical Students.
3. The persistence of American Medical School Graduates not choosing Primary care fields, and particularly not Family Practice.
4. The generalized problem in which Medical Schools (Academic Health Centers) do not encourage a choice of Family Practice and/or Rural Practice.
Of course, there are others, but these problems continue to re-surface regularly in my interchange with Residents and Students.
Best wishes, Dennis LaRavia, MD
PA and NP folks face the same issues that we face in family medicine, the same lifestyle issues, salary discrepancies, and more.
I find it interesting however that many nurse practitioners have spent 6 - 9 months with family physicians, particularly rural family physicians in the early parts of our NP program. Given their past experiences as nurses, the long term training with the best teachers in the best locations with the best opportunity to learn by doing, these NPs may well be able to work as colleagues and replacements in rural areas, if they are not stolen to other locations because of their superior training.
When I hear the word tuition, I see this as a synonym for slavery. I certainly like the partnership program ideas (WV, others) with no requirement. These have only the long term expectation that the impact of origin and improved education and career work by working with students throughout high school and college and medical school will lead to more and better physicians who want to be in rural areas and will stay there. Anything less is temporary, ineffective, and will not reverse the poverty, access, education, and leadership problems that are the basis of maldistribution. (NHSC, J-1, high salaries, etc.)
Also I find it interesting that the largest single source of funding for osteopathic tuition is the military. Students from underserved, lower socioeconomic backgrounds have to have support for college and medical school. Military support is more available and FP is encouraged in same. NHSC funding is limited. State funding is variable. The strings attached to funding and uncertainties are great.
Senior allopathic medical students graduating in 1995 who were interested in rural practice did twice as many rural, international, volunteer, and military experiences as compared to their peers at all levels of medical education. To me, this is a pool of servants waiting for a service to give and someone to assist them in this area. A good portion of these are rural kids and another segment is inner city kids. Both have overcome much to get where they are. Others like them have been turned away because they lack "polish". In other words they did not have the professional parents and the knowledgeable advisors in high school and college. Some manage to get into international schools, others are lost from rural and underserved practice forever. Some international schools do very well in fp choice and rural graduation rates.
Declines in admission of rural background folks from 27 to 16% of matriculants over past decades in allopathic med schools is but a portion of those lost that could be rural docs. Military grads in fp are at least 150 a year with some years up to 180. If incentives were the same, possibly another 40 - 80 rural docs would enter rural practice. I am proud that fp docs serve, but am not sure the current admissions process at medical schools does enough work to recruit enough servants for the military, PHS, IHS, NHSC, rural, inner city, etc. In fact this pool continues to decline, and with it the fp match, rural docs, etc.
Medical schools are important, but mainly in who they choose. There are confirming impacts of preceptors, student groups, national meetings, etc, but frankly the ones who choose rural do so anyway. Some from the most unlikely spots resist all the negative influences and go and stay rural.
Often we find that various efforts with students and residents are "parties" for the converted.
Have some new data regarding AAFP Student Resident meeting. In 1995 there were 820 student attendees, mostly year 3 (n=206) and 4 (n=339) students. So far I have tracked 484 or 59% of attendees of this meeting who have chosen family medicine residencies. There are others remaining as I sort through additional sources, including name changes, etc.If we truly want to have impact with our limited resources, we should target M-1 (only 48 attended) and M-2 students (189 in 1998) and even find a way to get college health advisors and students to integrate into our FP meetings. We have great material and contacts, but we are having no impact. Encouraging college health advisors to seek out the doctors that they would want to care for them is a great perspective and principle.
John Wheat could also add volumes about helping small colleges and small college advisors also. Unfortunately many are no longer able to graduate professionals for medical school, or other professionals at all. Many face further reductions or closure. Then there is the problem with rural education, funding based on property taxes, distribution of quality teachers, etc. Getting rural kids interested in education and health care as early as possible is perhaps one of the best interventions. Rural administrators can be a great resource.
Robert C. Bowman, M.D.
rbowman@unmc.edu