I have done a lot of work recently on my Rural Medical Education web site. This site is involved with getting more and better rural physicians. Some have commented about getting some of the items published. My main excuse regarding publication is that current medical leaders are not paying attention to what has been published.
We actually know how to graduate more
physicians for underserved areas. These works are published. We have chosen
not to pay attention to these works. My work in this area would be
repetition. My work to get attention to these works seems to me to be more
valuable. Doing this in a way that is cooperative is an even greater
challenge, but since my model is rural and academic communities working
together, I must follow this same approach. see
Restoration
I suppose I should take the time to publish some of these, but most of this
info is scattered, or not on line. When I really want some info, I go back
to the web site. If the info is not there, I add it so that it is handy
next time. Most of the items have originated from questions from various
list serves, HLTHPROF or Health Professional List Serve, Family-L list serve, AAFP Rural
list serve, Rural Med Ed List Serve Postings in
US, RuralMed in Canada thru admin@srpc.ca
, also Rural Medical Educators in Canada at
redlist@www.cfpc.ca or
topps@ucalgary.ca
In
many ways the web site belongs to all of those who have contributed to
discussions on these lists. Those of you who are authors and writers will
realize that my work needs lots more work. Getting the concepts down is one
thing. Being concise and to the point takes far more work.
The following links will take you to specific documents on the web site.
The first page may answer questions by students interest in a rural medical
career:
http://www.unmc.edu/Community/ruralmeded/model/medsch/questions_by_students_and_other_.htm
The next link is the overall theme of the web site. The major idea is that
underserved communities themselves should drive the strategy for medical
education that would meet their needs best. The journal of rural health
will have an editorial published in this area in about 6 months. You can
read the longer, more verbose, and richer version here, plus there are many
links to explore:
http://www.unmc.edu/Community/ruralmeded/community_driven_article.htm In
this one the college advisors can play a key role in selecting the right
students, the best students are not always the brightest.
Admissions Package
The following makes the case for choosing students with specific
characteristics in order to graduate more for underserved locations:
http://www.unmc.edu/Community/ruralmeded/service_orientation.htm
The basis of this is Don Madison's work on service orientation on UNC
Chapel Hill students and some work I did involving the 1995 AAMC GQ.
Choosing students with rural or minority background, service orientation,
and those who are older or from lower socioeconomic groups makes sense if
we want more doctors for underserved areas.
There is a subtle process going on at the state level in education and
other areas. For small towns to have services, leadership, and jobs, they
need young professionals. Young professionals come from small towns and
small colleges. Centralization can basically destroy the small college
breeding grounds where rural professionals would go if they could.
Restoration of two small rural colleges in Nebraska has had a major impact
on the colleges, our medical school, our family medicine department, and
rural areas in the state. This was set in motion by Robert Waldman, a
visionary dean of our medical school many years ago.
http://www.unmc.edu/Community/ruralmeded/central.htm
With the problems of consolidation and centralization and lack of young
professionals, few young people can go to rural America. True success in
any rural intervention is getting more people into small towns.
http://www.unmc.edu/Community/ruralmeded/fewyoung.htm In this I
highlight
some attitudes that we constantly deal with regarding the maldistribution
of physicians. A particularly editorial by Dr. Cohen in Academic Medicine
illustrates many of these concepts. Before I get into difficulty with AAMC
or Dr. Cohen, I would note that what he has written has many supporters in
other medical leaders, but the information that he has been given is not
completely accurate. Much is assumed from past medical leaders.
Leadership Factors in Developing RME There is
much better information, from the past and from recent research. To state
that there is little that can be done is in direct conflict with what
several medical schools, states, and even the Southern Regional Education
Board noted in 1983. I would only note that Dr. Cohen needs to make some
rural visits. Here is what can be learned by academic faculty at a rural
visit. I assure you it is much more stimulating in person, especially with
someone like Joe Hobbs to be a guide.
http://www.unmc.edu/Community/ruralmeded/facil/research/authors/Hobbs_Invisible.htm
This posting thanks to STFM and the Family Medicine Journal.
If CMS people can leave their Medicare and Medicaid activities in
Washington DC and visit rural Nebraska, certainly AAMC can visit Joe Hobbs
in Georgia, or visit West Virginia and see what they are doing with their
Partnership program. This is a community-driven model for the nation that,
if implemented widely, could end dependence on the National Health Service
Corps and foreign physicians. We also do need to quit stealing physicians
from other countries and grow our own. In the process we just might balance
out rural and urban areas, and rich and poor countries, and make permanent
inroads regarding dealing with hopeless people - the root cause of
terrorism. Until people have assurance that their children will have better
lives, including food, education, jobs, and health, we will continue to
have increasing terrorism. Young health professionals to rural areas
restore health, enhance education, bring jobs, and become community
leaders. Medical education has a critical role to play in restoring equity
in this country, and across the face of the earth, not in government
programs, but in people working with people.Restoration
I have done a lot of busy work, but much will have little or no impact.
Only a few days ago I had much more opportunity. We hosted a visit by a
Nigerian physician who is charged for graduating physicians that will go to
rural Nigerian villages. She was given tours and saw great technology and
web pages and model programs. I got the last 10 minutes of her visit and I
hope this changes her approach. As we talked, she conveyed that a single
set of exams at age 17 basically determines the careers of Nigerian
students. As you might suspect, the students that do well have better
access to better schools, higher income parents, etc. I advised her to go
back in time to 12 - 14 year olds and do what she can to find those that
are the most likely to return to rural villages. She needs to figure out
how to get "her kids" prepared for the exam at age 17 so that they can
continue on a pathway to return to the rural villages in medicine and
likely in other professional careers. I hope she is able to do so. I hope
that I can visit and help her and others, in this nation and others.
Canada and other nations lack the small rural college system as well. It may
well be that small colleges in rural areas are the key to helping all
professional schools in the process of restoration.
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
Email: rbowman@unmc.edu
http://www.unmc.edu/Community/ruralmeded/
Although I am a New York City boy, born, bred,
educated, and employed there, I applaud your
activities and sensible proposals.
One problem I see for medical education in general,
and rural/inner city education in particular, is the
tyranny of high grades and high MCAT scores. I have
known for years that the academic criteria for
admission to medical schools are much higher than
necessary to produce competent physicians. And now,
with the backlash against "affirmative action"
academics and MCAT scores will continue, for the most
part, to rule.
While I was an advisor, I supported many students I
believed had the characteristics, but not quite the
necessary numbers, to be fine physicians in the best
sense of that term. Through my personal contacts with
admissions folks I was successful often enough. From
feedback from the medical schools, I was pleased to
hear that my instincts were good often enough.
Anyway, keep up your good efforts. I sincerely hope
you have more success than Sisyphus.
Dan
In medical practice, success is location, location, location
In admissions for providing students who will graduate into underserved
locations - selection, selection, selection
In verbal scores it is also selection, selection, selection. The
characteristics of those who chose to go to a school usually determine much
of the measurable outcomes, such as verbal scores.
Now if you can show that a large group of students, who are performing
below the mean at the onset of an intervention, then perform significantly
above the mean after the intervention, then this should not only be
reported, but your method should be widely adopted at a number of
universities ASAP.
In clinical research with patients, it is considered unethical to continue
placebo treatment of the control group when an effective treatment is
apparent.
That is why it is so frustrating that certain forms of rural medical
education (RPAP in MN) involving 9 months in a rural area with a rural fp
in a preceptorship are not more widely utilized. Students in this program
do satisfy these pre and post criteria in a series of dozens of
educational, behavioral, and procedural measures, but medical education
does not actively replicate this kind of training. Med ed actually puts
obstacles in the way of schools that do embrace this type of decentralized
training.
Mentioning specific schools would likely insure that medical leaders call
my dean again regarding my critique of American medical education. Not a
very American thing to do of course.
Not mentioning these obstacles will not get the kind of physicians and
other health professionals that we need for the nation.
More about a great role model soon. Anyone heard of Susan LaFlesche Picotte
- no fair internet peeking!Role Model
Natives Others
Robert C. Bowman, M.D.
rbowman@unmc.edu
Rural Medical Educators Group of NRHA
Education - the entire pipeline