Robert C. Bowman, M.D.
The tales of the hunt will not change until the lion tells the tale. - African Proverb
Perspective 1 - The primary flaws have to do with the natural tendencies of humans and their institutions. Medical schools, family medicine people, government folks all want to claim success and avoid blame.
Perspective 2 – With physician workforce studies involving choice of career and location it is important to view as much as possible from the student perspective. Students flow from birth to education and community to college to admissions to medical school etc. The primary impacts involve many years, not just a few months in medical education.
Perspective 3 – Although there are 126 allopathic medical schools and 24 osteopathic schools, the impact of the few elite schools tends to drive policy and practice in all schools. There are several examples of policies that work in the top 25 that do not work for the rest in physician distribution and even in graduation of researchers
Perspective 4 - The current health policy era should be titled the Return of the Major Medical Center. Attempts to rein in health care costs with managed care and health reforms have been defeated, resulting the most recent of the Five Periods of Health Policy that impact Physician Career Choice
Perspective 5 - The medical students that are admitted, those that become physicians, and especially those that become physician leaders, are very different than most Americans in income, parents, and mostly in connections to major medical centers. Lack of distribution, problems with awareness of how most Americans live and have difficulties with live and health care, and quality problems are just a few areas that stem from major differences between those admitted to become physicians and people in most need of health care.
Assumptions - most medical education leaders appear to still believe in a world where all types of physicians eventually leave primary care and return to Major Medical Centers. This is not true for family medicine. Family Medicine Standards and Constants
Many of the most recent errors involve errors in timing. The last 15 years have involved the greatest swings in choice of family medicine, primary care, rural locations, and underserved careers. Nothing about this swing from poor to best to poorest ever has anything to do with family medicine departments, student interest groups, or Title VII investments. Changes in career choice outside of major medical centers have involved health policy support of patients and populations outside of major medical centers through Medicare, Medicaid, Community Health Centers, and other policy supports. Massive changes in funding have been followed by massive changes in career and location decisions. Five Periods of Health Policy and Physician Career Choice
This does not prevent researchers from claiming credit or placing blame. With the correct period of time studied, it didn't matter what you studied then, it all looked good if you compared times before 1993 graduates to those graduating in the l995 - 1997 graduating group.
Just as the pre-post studies of the early to late 1990s looked good for FP and PC, those starting in the late 1990s (lifestyle studies) look bad for FP PC etc. Reimbursement policies are the real reasons for the recent changes in career choice. Flaws in the Concept of Controllable Lifestyle
Another contributor may be lack of preparation for the more challenging physician careers fueled by liability, lack of support for med ed forcing less and less teaching time from faculty, etc. The nation has put almost every conceivable barrier in the way of preparation for such careers as FP, PC, OB (who gets to deliver even?), surgery, etc. If you look at the surveys of students that are the basis of such studies, there is an alternative hypothesis. Those careers not "lifestyle" oriented also involve much more preparation, experience, orientation, and comfort with challenges.
There are also major differences in career choice by age with older students choosing the more challenging and complex careers. Age at Graduation and Physician Specialty
Also Emergency Medicine is in a honeymoon period with ER positions available and waiting with only nurse practitioner and physician assistant competition limiting total numbers.
Also, why do we assume that students have suddenly changed? There are a whole lot better and easier ways to make money than medicine. It seems that students are an easy target.
The studies of career "choice" assume that there are real choices. There really is no career choice free will. Graduate programs have been increasingly limited and allow less real option. Can you really include careers such as dermatology and ophthalmology that have no real "choice?" Also those who have higher income, urban, and professional parents have the top standardized test scores and claim the lion's share of subspecialty positions.
The studies were based on student surveys. Students who are the most humble origin and the most elite types for about 10% at either end of the spectrum appear to have chosen careers long before clinical years. Older students in particular are immune to health policy changes and appear to base decisions more on life experience.
Title VII provides one of the only sources of primary care infrastructure, particularly during periods when the federal government, state governments, and medical schools do not support primary care. The errors involving Title VII go both directions.
Overestimations - Attempts to link Title VII efforts to outcomes are fatally flawed in a country where health policy regarding primary care involves drastic changes between supportive periods (impacting classes of 1965-1978, 1992-1997) and periods of less support or rapidly declining support (2000-2005 so far).
Underestimation - The US has removed increasing numbers of family physicians from the primary care workforce. Family medicine supplies 4 - 6% to academics and another 4 - 6% to the military. These involve a greater proportion of lower income types that have the highest level of rural and underserved distribution.
It is not a surprise that those who respond to the military have lower income levels, more humble origins, higher debt, and higher tuition. Again these are the characteristics of those most likely to choose primary care, family medicine, rural locations, and poverty locations. The military is the major source of osteopathic tuition (AOA Annual Reports). Military family physicians as a group also tend to be rural born and lower income white males with increased current income needs (previous debt and families).
It is not a surprise that Black, Mexican American, Puerto Rican, and Native American family physicians are found in academic programs. They have been heavily recruited in some cases even from before admission to medical school.
The issue is not military service or losses to academics. A broader view of health policy would facilitate the rural family medicine careers of those with characteristics predictive of long term retention.
A broader view would also carefully examine the nation's policies on education funding. Australia has developed a "scheme" for funding college and higher education that is repaid later through income taxes, with higher taxes paid for those who realize the most income gain through education. This has increased access to college for those of lower income in Australia.
National support of college and medical education should be revised in a way that facilitates the opportunities of those of lower income, the ones that choose family medicine, rural locations, and underserved practice locations. The nation should also support medical education such that medical student tuition is not considered a source of revenue for medical schools.
States and nations that adequately support education will not need Title VII programs. States and nations that adequately support primary care in health policy do not need primary care support programs. Without a consistent effort in both education and health policy the nation would require massive new expenditures and major admissions changes to improve physician distribution. With supportive education and health policy the nation needs virtually no additional expenditure for primary care "infrastructure." With better education and health policy, the nation will likely save trillions in health care costs (and other areas), will markedly improve health care quality, and will resolve most problems in primary care, women's health, and mental health access. The improvements of the last century began with a major reconnection of education and medical education with better preparation of students prior to medical school.
The great medical school expansion of 1971 - 1981 with a doubling of allopathic medical students actually doubled those born in metropolitan areas without appreciably changing rural born or underrepresented minority students. Increasing the students who are least likely to choose family medicine, primary care, rural locations, and poverty locations without supportive primary care health policy will not change distribution. How the nation designs medical school expansion can result in better distribution. The new allopathic schools created since 1971 and emphasizing family medicine and primary care emphasis and admitting greater numbers of instate born, older, and rural born students had 16% of graduates in rural areas in 2004 as compared to 10 % of graduates of older schools (other indicators also up in primary care, poverty, family medicine also). Such schools unfortunately have smaller class sizes that limit their impact. Expansion in the schools most likely to distribute physicians and involving admissions of those most likely to distribute will improve distribution. Admission of major medical center origin physicians and expansion during a health policy period that may well be the worse distributional policies in 40 years are unlikely to distribute physicians. Five Periods of Health Policy and Physician Career Choice
The nation continues to experiment with untried methods instead of replicating the Osteopathic public schools, or the Duluth or early Mercer type efforts that graduated 50 % into family medicine and 30 % into rural locations.
Those choosing primary care underserved locations are the ones who are most likely to have had such experiences at some point in their lives from birth to admission (rural, lower income, suburban). Those least likely to do so (core urban, foreign born) are the ones who have rarely if every had continuity medical home experiences, even during medical school.
Primary care is complex and underserved primary care is perhaps the most challenging medical career. Solutions involve science, education, behavior, sociology, and multiple components of society are difficult. Medical students at 3 months of underserved primary care are overwhelmed, at 6 months are neutral, and at 9 months do not want to leave (Verby in RPAP studies). Medical students with a few short weeks or months are not likely to see the long term approach that can help restore those with poverty and any number of medical conditions. National Health Service Corps scholars with a few years of service are likely to choose careers involving underserved populations.
Older students are more likely to choose distributional careers such as primary care, family medicine, psychiatry, and poverty careers. The greater people experience of older students is apparently a great advantage. Specific training such as 4 - 9 month preceptorships when combined with admissions can greatly facilitate distribution. Briefer efforts, especially when not couple with lower income admissions or admissions of students with past primary care experiences, are not likely to succeed.
Specific tracks such as accelerated family medicine training programs (3 years medical school and 3 years FP residency) have 50 % rural location rates in 150 recent graduates in 11 programs even with urban born, females, no rural practice bias in selection, and no rural training location. The facilitation of training in a mix of urban and older medical students is the likely reason for success and an important model for replication given the increasingly urban admissions in allopathic schools. Unfortunately accelerated programs have been terminated.
Those likely to choose family medicine (older, less urban, lower income) are much more resistant to medical school and health policy influences (debt, managed care, training or lack thereof). Without a major coordinated effort it is unlikely that medical school training influences the career choices of family physicians. The same factors in medical schools and students known to influence choice of family medicine also influence the proportion of internal medicine physicians choosing office based care.
Even those least likely to distribute, the most urban and foreign born, will chose primary care, family medicine, and rural locations with favorable health policy. Such students when choosing family medicine or when older, do not need health policy to distribute well. However when health policy influences others to choose office based primary care and family medicine, they fill the urban and large rural practice locations in primary care. This allows the students with enhanced distributional potential to fill medium and isolated rural positions and poverty locations as predicted by Newhouse and others. The key to the rural component is the broad distributional market of family medicine. Without supportive health policy, the entire mechanism of distribution is impacted.
Nations, states, and medical schools that facilitate the admission of more students who will distribute will also have improved distribution of health services, economics, education, and leadership in areas in most need of such important contributions. Restoration can only occur when education and health and other professionals are more broadly distributed in this nation and others.
Studies involving reduced numbers of rural born and rural interested students have indicated that there are not enough to meet rural needs. The reverse is actually true. The students admitted from 70% of the United States prefer to return to these locations and do so, especially when choosing family medicine. However only 30% of the medical students are admitted from this 70% of the population. Also when students choose other careers, they are limited to major medical center locations. The nation already has 70% of medical students from the top 30% in income level. This continues to grow with the increasing income inequalities in the nation. Even medical experts fear that only the rich will gain medical school admission (Whitcomb, Academic Medicine.
The primary motivation for distribution, however, is health policy. Without health policy favoring primary care, admissions and training are the only recourses, and even then a losing battle.
Flaws in the Concept of Controllable Lifestyle
Underserved - Overview and Models
Physician Distribution in the United States