This is a commentary about how our national medical leaders say they want to help the underserved, but seem to avoid taking the steps that would actually do so. The link for this site is broken, so it is reproduced. The comments in italics are mine. This article was written by Dr. Cohen to support the National Health Service Corps, i.e. continued funding for tuitions for a small number of medical students. We can hope that we can educate our medical leaders, but the task is difficult and will take much time and travel and interaction, and also reading major journals such as JAMA and NEJM which support rural medical education and major reforms.
From the President of AAMC Jordan J. Cohen, M.D., December 1998 in Academic Medicine
Medicine's social contract entails the granting of many privileges to the profession in return for its willingness to be accountable for serving societal needs. But, on occasion, medicine is held accountable for solving a societal problem that is not totally within its power to resolve. A case in point is expecting the medical profession, in particular its academic component, to solve the dilemma of doctors' not choosing to practice in some areas where they are needed.
As we all know, many Americans living in rural and inner-city areas do, indeed, have limited or no access to physicians' services. The complaint that doctors don't choose to practice in these locations is valid. What is invalid is the expectation that the mere existence of a need for physicians' services will suffice to offset the many disincentives faced by physicians who might otherwise respond to that need. There are many factors beyond a given community's need for doctors that individual physicians must weigh in deciding whether to set up practice there.
For openers, the individual's specialty is a major consideration; the greatest need in most underserved communities is for primary care physicians, not neurosurgeons. So, for practical purposes, the first step in addressing the need is to enlarge the pool of generalists, who then might be persuaded to fill the gap.
On this one, academic medicine clearly has been responsive; since 1992, the number of medical school graduates planning to practice as generalist physicians has increased almost threefold. (Sadly this was temporary and market-related rather than medical school related - RCB note 2003) But despite these increases, the numbers of doctors choosing rural has not increased. The reason is likely that the numbers choosing rural practice will not change unless admissions change, to have more with rural background and service orientation - RCB)
But simply increasing the supply of generalist physicians will not, as some policymakers glibly assume, solve the problem. A major issue is the economics of medical practice in many underserved communities. Leaving aside the not-inconsequential matter of medical student indebtedness (the mean for 1998 graduates with debt is $85,619), a physician considering practicing in a medically underserved area must ask whether it is economically feasible to do so.
Debt is a consideration for those from lower socioeconomics and especially for minority students struggling through an extra year or two before going underserved, but the major barrier for rural choice is background and fp interest. Studies show students interested in rural practice expected less income. People go rural because it is a part of them, not influenced medical school or debt or externals. - RCB
Typically, communities that need physicians are populated by many people who lack insurance or who are otherwise unable to pay for their medical care. Consequently, many physicians who might otherwise choose to serve such communities are dissuaded from doing so out of concern about being able to support themselves and their families.
Rural communities and hospitals organize for health care. Again the question is not who is going to support me, but whether it is in me to go. If communities decide to support health care they will survive. It is crazy for a community not to support such efforts. Health is one of the greatest contributors to the rural economy. A town of 2000 generates 3 million dollars in health care (figures by George Wright in Textbook of Rural Medicine p 286). The smaller the town, the larger percentage of the economy that is involved in rural health care. If med schools did the job that the could do and has been shown in scientific studies (PSAP in Pennsylvania, Rabinowitz) then more would locate in rural practices, the rural economy would improve, more young professionals not in health care would choose rural towns, etc. If med schools did a better job in leading their states and helping them understand these issues, they would work for better education, better small colleges feeding other doctors and other young professionals into rural areas, etc.
Finally, even if economic considerations can be met, the social and cultural characteristics of most medically underserved areas present daunting obstacles to many physicians who might contemplate practicing there.
This is an inflammatory statement that most rural people would find offensive. Rural is not lack of culture, it is a different culture with different lifestyle, values, entertainment, etc. You know you have chosen well when...
In inner-city settings, these obstacles include concerns about personal safety, working in impoverished surroundings, and dealing with a host of intractable social problems inextricably entwined with the provision of medical care. In rural settings, professional isolation, lack of employment opportunities for one's spouse, limited educational options for one's children, and a paucity of satisfying cultural and civic outlets naturally enter the calculation when young physicians weigh their practice options.
The basics of graduating more rural doctors is to admit the folks who already like the rural lifestyle, prefer the others who may have the ability to grow to love it and then there will be more rural doctors staying.
Policymakers and lawmakers representing the underserved seem to be unwilling to accept as legitimate these and other reasons that dissuade many young doctors from settling permanently in needy communities. As a consequence, their efforts to correct the geographic maldistribution of physicians have been notoriously ineffective. I believe it is time for us to cease beating our public-policy heads against a wall. We need to de-emphasize the necessity for permanent physician settlers in areas unattractive to most physicians. I believe, along with many others, that we can solve the geographic maldistribution problem by placing fully trained U.S. graduates in underserved areas for substantial, albeit limited, periods of time. The model for doing so is already at hand in the National Health Service Corps. We need to greatly expand the NHSC, or initiate a similar program, to enable many more U.S. medical school graduates, after completion of post-MD training, to spend two or three years in public service, perhaps in return for substantial educational loan forgiveness. (
Again this is unacceptable to most rural people. While there are trade-offs that allow medical students and residents to train on those less fortunate, I hardly see why rural people should have less than the best, most experienced, most dedicated care givers. Besides, those living in small towns can actually find out about their care givers. They refuse to go to the new, the inexperienced, or the bad ones, in stark contrast to their urban peers who don’t know about these areas.
The NHSC has just celebrated its 25th anniversary, and is examining how it can be most effective in the future. (Translated NHSC is a good egg, but if we don’t get money for student debt, we won’t be able to keep tuition so high at medical schools.) The AAMC has stepped up its own advocacy on behalf of an expanded NHSC, and I think everyone in academic medicine would do well to vigorously support such an expansion. Substantial public education will be required, however, to wean many people from the notion that the only way to access quality medical care is to have a lifelong relationship with a single physician. Having a series of two- or three-year relationships with fully trained physicians is far better than nothing. As is so often the case, the quest for perfection can be the enemy of the possible.
Surely this reasoning is not the best that a President of AAMC can do. This is similar to saying that even if you cannot find a life long partner to have a family, a series of 2 or 3 year affairs is the best that can be done. Rural practices like marriages are found through courtship, and become effective only after three or more years of experience.
Italic comments are by Robert C. Bowman, M.D.
For the SARH presentation Student Association for Rural Health at UNMC.
Web site for Rural Medical Education http://www.unmc.edu/Community/ruralmeded/
Dr. Cohen attempts to broaden our perspective regarding admissions at http://www.aamc.org/newsroom/speeches/99amspee.htm In this address he envisions a Collaborative Care model and promotes it and how medical leaders could work to accomplish it. When compared with the above address regarding maldistribution with this address, his closing statement is perhaps the most compelling, "Rather than accepting the limits of today, let's harness that creativity and wisdom to explore the possibilities for closing the gaps for a better tomorrow."
My take on this at Character, Color, Admissions, and Physicians
Please, Dr. Cohen and other medical leaders, don't accept the limits that you have proposed for rural physicians and their patients. Please do promote policies that graduate more rural doctors. The baseline for the Collaborative Care model is still the same one for all of us, the doctor-patient relationship. Anything that promotes a series of temporary doctors rather than a longer term model where patients and doctors get to know one another and doctors get to know the environment and populations they serve, is less than the best and doomed to failure, Darwinian or otherwise.
My final question - When it is all said and done, does this mean that medical schools will now try to admit students who can 1. Communicate, 2. Care better, and then last, 3. Be intellectuals
or will we prioritize board scores, MCAT, accreditation, and looking good rather than being good. - RCB
Even medical students and those who work with them understand some of the priorities in rural health. Prescribing a Cure for the Shortage of Rural Physicians Why can't medical leaders learn too?
Research on the Declining Match
Please see Why Doctors Do Go to Rural Practices