Failure To Launch

Robert C. Bowman, M.D.

I have tried to find pieces of the nation that are not able to birth physicians. Using mostly county levels, I have combined the poorest, the most rural, and the most socially different. These are individually areas of the nation with the lowest levels of admission.

Normally the nation admits about 7 per 100,000. Maximum is regularly about 10 for populations with the most income, education, and professionals. Perhaps as a testament to the baseline above average US distributions, the minimum does not extend far "below the line" or national average. Despite attempting to suppress the figures by combining lower status indicators, it was rare to find less than 4 per 100,000 admitted for each medical school class year.

I will attempt to use the known distributions of physicians and their origins to combine it with what we know about certain areas of the nation, such as Florida which happened to be a group of counties with one of the lowest admissions ratios.

I used Ghelfi and Parker's various categorization systems developed in the 1990s and I could get some below 4 admits per 100,000 , but not many In the following table the national averages are demonstrated. There is also a great division between counties with a medical school (also contiguous counties if in the same city) and counties that did not have a medical school. Finally the lowest rates of admission are listed for various types of areas, states, and counties. The data is amazingly complete. For this group over 90% of birth origins can be matched to a county, over 95% for US MD Grads, 80% for osteopathic, and variable for the smaller international group that was born in the US. Those remaining who were coded were born in other nations, and not used in this analysis. Their origins were not listed in the US since they were born outside, but including the 16% foreign born for this group increases admissions ratios from 7 to 9 per 100,000.

Lowest Admissions Per 100,000 for the 1987 – 1996 Class Years, All Medical School Sources (admits * 100,000 / pop of county groups / 10 class years grads)

The above represent the lowest probability of admission in the nation and many of these represent the highest probability of distribution. The 25% choice of family medicine represents a maximum in studies or 1 out of 100,000 that eventually choose FP managing to gain admission despite the most serious obstacles to admission. Family Medicine Standards and Constants The FP plus GP figure was used because the Masterfile codes many osteopathic family physicians as GPs instead of FPs. The FPGP use does not impact this group for calculations except for public osteopathic schools, the largest % source of FP, PC, underserved, and rural docs in the nation.

Distributional Medical Schools: The Lost Lesson of Specific Forms of Government Support

No public medical school - Maine and New Hampshire could improve the potential for admissions with a public medical school or at least the addition of more funded positions working with existing medical schools. Some of these arrangements have already been made. It may take time for those born in counties to experience the increase in opportunity. This is a point that will be made later about rapid expansion or about building medical school positions in a state with a poor child development to admissions pipeline.

Foreign born populations - states such as California with 25% foreign born will have slightly lower rates of US born admissions, especially if the foreign born populations have high levels of education and professional degree. This is more common in Asian populations or all outside of Central American origin, given US immigration policy and immigration trends. Asian born medical students are 9% or over half of the 16% of US MD Grads even though Asians are 25% of the foreign born population. There are also differences based on proximity. Those from contiguous nations such as Mexico and others from Central America are different than those from more distant origins, who usually have same or better status compared to whites and fit the immigration standards with the highest levels of education, health, income, and profession. Changes over the past 2 decades for US Born medical students do show declines in admissions from certain types of US counties. These are counties that also have the highest levels of Asian population and Hispanic population. Florida has 13% foreign born. Miami-Dade County is the only US county that is predominantly foreign born. Since the most populous counties admit the most, this could suppress US born admissions for the state.

Fewer Young People - Counties with older populations are also seen as having fewer admissions. Although there are certainly direct reasons why such counties would not be admitting medical students (unless we admitted med students up to age 75), there may be even more to consider. Do certain populations shape counties in ways that make it difficult for education, income distribution, and opportunity? Do counties that have lost their professionals just become older and older over time? Many in some parts of rural America once hoped to turn leadership roles over to younger people, only to find none to assume these positions. Federal and state policies also do not reward the distribution of resources and education and health care. Given education and health care as the most important components of the economies of many of these counties, decisions made by a wide range of leaders and professionals can be crucial, or they may not be made because the people are unaware and unwilling to explore.

Dependent Counties - There are a number of county types that rely upon outside influences such as governments, trade agreements, and changes in economies. Nations do a poor job of anticipating problems when economies change. Without addressing declines in the early stages, the nation ends up adding another population in chronic poverty instead of addressing those already left behind. Rapidly increasing rates of child poverty in the Midwest in working parents with a high school education is a sign of adding to the burdens rather than addressing them. Much of this midwest change involves economies left behind and also leaders that did not diversify when they were on top (auto, steel, coal, manufacturing, mining). Education References, Distributions, Inequities, Child Development

Commuting Counties - losing market share to more urban locations in all areas of economics makes it difficult to support local services, schools, and more. Wahoo ("home" of David Letterman) Nebraska is sandwiched between the Omaha and Lincoln metro areas. It is perennially on the health professions shortage lists. Wahoo has good schools through lots of local effort, but large segments of the population head east to Omaha or south to Lincoln for work, drive by malls and shopping centers on the way to work, take their health services from or near work, and stop at the malls on the way home. Most rural communities, made fully aware of this to the point of action, change their own courses dramatically, but this usually is more successful for the more distant locations.

When I revised the birth origin figures to include all physicians such as osteopathic and international (schools in Caribbean, Mexico) who were born in the United States beyond just the US MD grads, Florida escaped being less than 4 per year, but barely. Of course every one else improved too, so the state's counties were still at the bottom. Even though Florida does have a mix of all of the above types of areas, the state still does poorly, basically at the bottom in medical school admissions for children in states that have a chance by having a public medical school available. Florida was also at the bottom of rural born admissions. From other studies, I can tell you that Florida is likely to be at the bottom for black male admissions. When states have difficulties with rural male or black male or any lower income origin male medical school admission, they also have a much higher rate of prison, social expenditure, to go with lower education and higher education outcomes. The Hispanic populations in Florida are a mix. Some do well, however overall across the nation Hispanics share the same lower admission rate with lowest income rural areas. Also lower income Hispanics such as from Mexico and Central America tend to choose family medicine and distribute to underserved areas, not so with Hispanics from higher income origins. Cuban populations represent many displaced professional families. Exploring zip codes across the nation also were interesting for Florida. Mostly I just zoomed through states as there were usually steady gradients by income and poverty stats or by moving geographically across the nation with adjacent zip codes by latitude and longitude. Florida was different. Few states have the income and poverty contrasts between adjacent zip codes as found in Florida. Florida may be one of the states that makes the best case for major early, often, and extensive childhood and early education interventions.

The story of Florida State medical school is also remarkable. The geriatric director for the state approached the state's medical schools once to give them money to train for geriatrics, they said yes and agreed on a figure, but medical school lobbyists killed the measure. She came back again to the medical schools and asked what went wrong. They did not give much answer but did agree that more money might be needed. They killed the bill again. This resulted in the most detailed studies ever done for the preparation of an allopathic medical school and the design to address geriatrics, rural peoples, and the needs of minority populations in Florida. A new model involving community based training was involved that modified or violated (take your pick) the Flexner centralized major medical center plan for medical education. The medical schools at Florida were not happy about competition and claimed there was no need, that there were not enough qualified students, or that FSU could not do the job. Of course the states needs were growing at rapid rates, the state's medical schools were more than willing to take students from the state and other locations, and FSU had long had admissions and a first year medical school class so it clearly had much of the expertise, structure, and initial personnel. The existing schools may have even influenced LCME, the accrediting body, although LCME focused mostly on the difficulties of the new model.

The key to the model was having personnel with a track record for working with medical students in their community practices. FSU had already hired the best in the state (Ocie Harris) who had decades of such experience. During the consultant work arranged by the skilled geriatric/political/marketer ML Dugger, FSU had also marketed itself such that it attracted some of the top medical educators in the nation. Finally the FSU president had enough. Assuming his other role as a trial lawyer, he told LCME in no uncertain terms to approve them or they would meet in court. LCME had little choice. FSU had more than done their homework. But......The school is still vulnerable for 3 reasons as noted in all of the above - specifically the poor state investment in children, the poor processing in needed state areas, and a very expensive medical education model of about $25 million. This model depends upon continued good favor with the legislature and also the practice outcomes of the graduates who are emerging in greater numbers, in other words it depends upon the people of the state of Florida. If the school does well and if it documents its graduates flowing to every legislative district to serve, it will likely survive - a tall order given other difficulties in the state. Their outcomes will also be limited by the general lack of social support, which makes the lives of all service oriented types from teachers to nurses to family physicians in the state.

It is doubtful that the legislature or the state or the other medical schools will give allowances for the background contribution of the state. For example, the other county groups in the table above have higher rates of Family Medicine and either rural or underserved locations or both. The fact that Florida born medical students have some of the lowest rates of all three does not make the task easy for FSU. Then there is the liability problem and massive increased cost of health care and cost of living. In my studies, these are factors that drive family physicians away from a state, the ones most likely to remain in primary care and to distribute to rural and to underserved areas. It is my personal feeling that family physicians value people, and have a difficult time with any location that does not value people, families, or children. Another interpretation is that efficient forms of health care have difficulty when costs of delivering health care are so high and health policy for the US is so low for those in primary care and outside of major medical centers.

Florida has become a concentration of future, current, and past professionals. Professionals do structure environments and they have structured Florida. One of the major questions regarding states such as California, New York, Texas, and Florida, who have the means to make changes yet do not, is what the nation will do to address member states who do not contribute teachers, nurses, family physicians, and public servants, who hire private security yet do not support public safety and police. What will the nation do now that millions of people are put in harm's way in territory regularly claimed by hurricanes and due again for floods and earthquakes. More people in these locations is a very bad idea. More people plus great divisions compacted together is a very, very bad idea. Then there is the basic problem of water for drinking, control of water, and water as a barrier to transportation.

The contrasts between Texas and Florida are remarkable in other ways. The lesson of Katrina was seen and Texans evacuated from Rita, but the same was not true for Florida, few even stored up provisions for a few days as asked by the governor. The Texas response involved leadership from the top and at the beginning. The Mayor of Houston asked for and received $1 million each from 5 major oil companies and used it to turn Houston apartments into real housing for Katrina victims, many of whom remain. This was a boost to established businesses, not fly by night temp housing manufacturers. The State of Texas requires millions in reserve of school districts for emergencies. These huge reserves were tested to the limit and only provided the first 6 months for Houston ISD to take care of tens of thousands of new children, but 6 months was enough time to make a number of adjustments in space, personnel, and more.

The bottom line is that Florida and similar states are very inefficient places to live and the nation is heading more and more to this model. This model is just not supportive of lower and middle income types. It is a model for higher income types who are retired, professionals, and others who can afford to live in such areas of the nation.

Florida might consider fixing the front end at age 0 – 6, education, and pre-admissions. This might be more cost effective that adding at the tail end with more total admissions, especially from the newer medical schools that have not worked for years to plan, prepare, and implement plans specific to the state’s great and growing needs.

There is one clear location defined by the current physicians born in Florida that graduated from medical school from 1987 - 1996. Over 72% were found in major medical center locations. This is equivalent to the national average and nearly the same rate as those born in cities and counties with medical schools across the nation, the ones most likely to be children of professionals.

The massive expansions of medical school positions in Florida that are in progress could easily add many more children of professionals to the ranks of physicians, with little or no improvement in physician distribution. The example of Mississippi and South Dakota is similar. Probability of admission tables When you admit more medical students than the state has capacity to prepare students, you end up with more urban and higher income origin types and greater ratios of these students. You can do the same thing with a sudden expansion. Cost, Quality, Access, and Physician Workforce Expansion When there is a sudden opportunity with a rapid expansion of medical school positions, then the only ones around to take advantage of this are the highest income types. They can convert to medicine and still finish college on time. Lower income, minority, and rural types respond to new opportunity more slowly and depending on the education, higher education, and career orientation efforts. This can take years or decades to respond to new opportunity unless education efforts have preceded, as in the fortuitous Sputnik impacts on the 1960s and 1970s (top education and higher ed emphasis) before the med school expansion of 1970 - 1980. As for Florida or other areas, whether those admitted exceed the state's capacity for caring, dedicated, empathetic physicians is as yet to be studied. This will be left to another time when physicians are first considered because of who they are, rather than who their parents are.

Many of the categories are derived from work from USDA, Urban Influence codes, and types of counties by Parker and Ghelfi. Other constant sources have been Tom Ricketts (UNC) and Gary Hart (WWAMI). These folks not only helped categorize the nation, they have also helped people to understand what is happening in the nation and in the world.

Most importantly were the living experiences extending from my own birth to professional parents in engineering and nursing, my teachers and school teacher wife, my children who have overcome the barriers placed in their way by education systems, my patients who encounter these and other barriers daily, and the environments provided to me by those who have paid enormous sums to educate me and train me to become a professional, one who helps shape societies.

Robert C. Bowman, M.D.

rbowman@unmc.edu

Some of the wisest people on the planet realize that interventions are not much help without changing the attitudes that resulted in the problem. This was illustrated by the 2004 Nobel Peace Prize winner, Wangari Maathai, as noted in a recent NPR story. She was an unlikely recipient. She was one of the first women to gain an education in East Africa. She was one of 300 invited by then Senator John Kennedy to come to America. She maintained her connections throughout her college and graduate degree. She faced an overwhelming task of improving an environment where trees were felled by the millions, often without real purpose or benefit. She focused on new approaches at the basic community level. She worked with thousands of women in her native Kenya to plant trees. They realized that planting trees would not help if these resources were poorly managed. To gain public recognition of the need to manage well, she and others were arrested for protecting trees. Her success is measured in her Nobel prize, her position as Deputy Minister managing the environment in Kenya, the 30 million trees (and growing) that she has had a role in planting, and the billions that she has influenced by her accomplishments and example.

Her story is also important for another reason involving empowerment. In her recent interview on National Public Radio she noted how important it was to give poor people more than alms. They needed healing, strengthening, and empowerment. She cited Acts Chapter III in the Bible in this area. A man who was lame positioned himself daily at the entrance to the temple to get alms. As Peter was passing the lame man, the man reached out for help as he had done for many years. Peter took his hand. He told him that he had no money to give to him but he could give him something else. He pulled the man up and the man was given strength in his legs. NPR is good at painting visual pictures and I still have this vision of the lame man reaching out and Peter reaching out to him. The life of Wangari Maathai reflects this reaching out and having others reach out to her.

Reaching out and having others reach out to you is the primary model for health care, child development, education, and opportunity.

It is the most important model for civilized societies and the model that must be disrupted to allow child destroyers at the individual, family, local, state, national, and international level to succeed.

Kennedy and Crisis: A Long Term Blueprint for Conduction the Nation

Probability of admission tables

Physician Workforce Studies

www.ruralmedicaleducation.org