Admissions and Involvement

Robert C. Bowman, M.D.   Originally on Hlthprof

Wrote this for the Hlthprof folks today. I still believe that those we choose are more important by far than what we do after they are in or how they are truly influenced. In routine FP we will always have fair weather folks who chose FP, but the core group is committed beyond curriculum and environment. Madison noted that service orientation could discern primary care better than other indicators. I believe that this work, if extended beyond residency to practice location, would have indicated more service to the underserved by those who had "service orientation". Service Orientation Rabinowitz noted rural background plus FP interest as primary determinants, but to me those were just markers of service and involvement measured a different way. My own work with AAMC GQ 1995 data points out the connection between medical students with interest in rural practice and service, with twice as many doing volunteer public health work, international rotations or missions, military, or rural rotations as compared to their peers. Income markers also hold the key to selecting more from diverse and rural backgrounds without violating recent Supreme Court rulings. Such graduates are also likely to embrace the underserved. Minority graduates choose underserved areas at a rate 4 times other med school grads (40% to 10%) with also a higher rate of caring for those from disadvantaged and Medicaid pops. Again underserved minority is a proxy for lower income origin. Rural background studies note a 6 to 1 ratio, just for rural practice location, not to mention the other service aspects. Is it the rural or the values such as service orientation or characteristics such as lower income, more focus on people, leadership opportunities, size of classes and school, and other differences between rural and urban candidates.

Today I had a chance to talk with a student groups and some medical school and physician assistant faculty regarding what we have admitted as compared to what we need to admit. I took the opportunity to complimented the student groups who were reaching beyond curricula to impact lives in Omaha and overseas. I noted that it was their work that resulted in the AAMC Community Service Award that we received and that we could only claim credit for choosing them. It is a blessing to see the growth of involvement and leadership.

As we continue to have fewer admitted to professional schools who have been able to overcome barriers of income and education and social status, we will have  more problems with health care. Since we continue to have more from professional and higher income families who have come to expect all conveniences all of their lives, we should expect less and less from this group except in the area of complaints.

The Haves don't tend to appreciate and give. The Have Nots appreciate what they have and share much more. My source for this last statement is not so much an observer of society in general as it is a criticism of my own parenting efforts as well as those of many higher and upper middle income families that I have had contact with as a physician, neighbor, etc.

My perspective as a physician, teacher, parent, and writer leads me to note two significant problems in American Society that result in much pain and suffering and costs beyond health care alone. These two are loneliness and fatherlessness.

Both are increasing rapidly in this country. Both are best addressed primarily through involvement. Incidently it was involvement and interaction that most impressed de Tocqueville in his observations regarding American culture nearly 2 centuries ago. I am not sure if this characteristic would be as readily discerned by someone observing the US from the perspective of another culture or country these days.

There are basically two types of involvement. Involvement with things and involvement with people. Those who have developed a primary involvement with things will have a difficult task oriented themselves toward people in a meaningful way to supply the teachers, counselors, and health professionals that we must have. Involvement with things, particularly in our society, leads to increased pursuit of the latest and greatest, all the more tragic when technology is in a logarithmic progression. This of course puts more and more control into the hands of those who are most involved with things.

In an information-video-computer-electronic-digital society the life phase of adolescence and the involvement with things have become enmeshed in our country. It is not surprising that those choosing medical training, which is known to retard personal development in the pursuit of thing-knowledge, have incurred a risk of even longer adolescence and thing-involvement. Of course we do not wait for such personal development and maturity before we admit students.

I am increasingly amused by those who expect medical school curricula or residency training to change people who have already made thousands of life-defining choices that have made them comfortable with their current relationships with things and people. For the Scrooges of our society, only God, tragedy, and circumstance can break them or re-orient them in a significant way. This impacts far too few a year although some broken this way have made outstanding contributions.

Who is chosen for medical school, is therefore of primary importance.

As always, I continue to encourage you to reach out to those middle school, high school, and college students that you would most desire to have caring for you. I know that this is difficult given the requirements of admission committees, but even a small improvement in who is chosen can be a significant one for those most in need of help.

After all, it is the caring and the involvement that best address the root causes of loneliness and fatherlessness and other areas where we truly can make a difference, in lives, costs, communities, state budgets, taxes, etc.

With the choice of people-involved students there is a more important principle to address rather than which discipline they choose, where they locate, or who they serve. The most important principle to address for such students is getting out of the way of the significant, creative, and restorative work that they are already doing.

Robert C. Bowman, M.D.

University of Nebraska Family Medicine