Flexner, Med Ed, Maldistribution, and Restoration

The real contribution of Flexner was improving the standards of the applicants, with great improvements in high schools and colleges nationwide.

Med ed quality = quality of applicant, ability to make decisions as a learner, environment, quality of faculty

Another contribution of Flexner was to the quality of facilities and faculty.

Medical education pre-Flexner's time was provided as a business transaction, with the usual results that the degrees were bought, but meant nothing. Preceptors were not good quality and were not teaching well.

Pre-Flexner we had better distribution of physicians, perhaps an excess, and not as good a quality

Post-Flexner, we had better quality, but not as good distribution. This has everything to do with the urbanization of the country and the improvements in high school and college education in the urban areas.

Flexner, Osler, and others lamented this. We have spent billions trying to understand and remedy this. The solution is still the same one as in Flexner's day - it has to do with the quality and characteristics of the medical school applicant.

Where we have restored the quality of the candidates from rural high schools and colleges, increasing numbers have been admitted to medical schools and have returned to rural practice.

Therefore the problem of maldistribution is the same in health care and education, a maldistribution of resources. With fewer docs to rural areas goes fewer resources to rural areas ($1 million in economic impact per rural doc per year in inpatient, outpatient, pharmacy, nursing home).

It is not the poor rural economy that prevents rural docs from going to rural areas, it is the poor medical education and education policies in the nation that prepare poorly and select the wrong candidates.

Flexner was not wrong, his concepts have been distorted by leaders and accrediting bodies. Bigger is not necessarily better.

If Flexner were alive today, I think that he would be a proponent of the rural preceptorship, especially for preparation for rural practice. Liability and lack of continuity have made it difficult for students and residents to actually have responsibility for patients. The constant shifting of patients in insurance plans in urban areas stands in stark contrast to rural areas where docs know their patients. Docs in rural areas also know that doing is the best teaching, that prep for rural practice involves high quality hands on teaching, and that the best way to get docs back to practice with them is to treat them well. The treatment of students and residents in academic settings is not great. Also anything less than 100% practice means that valuable experience is being lost, making rural docs practicing 100% the best teachers. To repeat:

2. Best faculty, those who actually practice and enjoy teaching, can usually pick around those who do not enjoy or desire teaching, not the same in academic settings where I have witnessed disagreements over who had to teach

3. Best settings -

The Solution is the same: The sad fact is that any governor of any state can dictate that one or two rural colleges will become feeders with 3 - 5 admissions from that school to be admitted to medical school. A flurry of activity would make sure that rural high school kids and teachers and counselors know this. A rural high school career fair at these two colleges can facilitate this activity. A handbook for rural high school teachers involving certain curricula, health career orientation, motivational pieces, and with some preventive efforts thrown in (they are risky teens after all) would also help get the word out. Result - first years, expect trouble with academics in the first 2 classes, since it takes some time for the academics in the rural colleges to get a bit more competitive, keep selecting the kids that are most likely to return to rural areas however.

End result, a level playing field where kids who wanted to stay rural for college can do so and not get penalized by missing out on professional careers. In our current situation, rural kids who really want to go professional have to go urban and then can fall prey to urban spouses and lifestyles and sub-specialized spouses. These prevent a possibility of a return to rural areas. Support of young professionals stabilizes the economy, retention, education, leadership, and more.

Robert C. Bowman, M.D., Co-Chairman

Rural Medical Educators Group of the National Rural Health Association

UNMC Department of Family Medicine Director of Rural Health Education and Research

983075 Nebraska Medical Center

Omaha, NE 68198–3075

(402) 559–8873 or fax at –8118

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