by Robert C. Bowman, M.D.
\Per*en"ni*al\, a. [L. perennis that lasts the whole year through; per through + annus year. See Per-, and Annual.] 1. ing or continuing through the year; as, perennial fountains. 2. Continuing without cessation or intermission; perpetual; unceasing; never failing. Syn: Perpetual; unceasing; never failing; enduring; continual; permanent; uninterrupted. Source: Webster's Revised Unabridged Dictionary, © 1996, 1998
When I moved to Nebraska after years in southern climates, I learned about perennials and annuals. With annuals, you have to spend money each year and plant and weed and watch them carefully so that your investment pays off. Finally you can then enjoy them, for a short time. Then the process begins all over again, year after year.
Native perennials are tougher and come back each year. They multiply, saving time and money and effort in the long term. You can transplant those you like all over the yard and share their contributions with neighbors. They may not be as flashy, but they have lasting impact.
After many years and much frustration, I have made a change. More perennials and less annuals. This change is dictated by my wisdom and experience and also by my advancing age.
It is amazing how much we can learn from natural systems that are applied to human systems. Our nation has the same choices in health and education policy specific to “growing” physicians. We can choose perennials or annuals. In a nation that has always seemed to have unlimited resources, this choice did not seem to matter. Some are beginning to observe the consequences of our actions.
Perennial programs include those who emphasize “Growing our own.” Such vehicles often involve working with rural students or inner city students. A Texas program called JAMP - Joint Admission Medical Program works with both. Perennials are often born in less urban locations, they are older, they were born in the same state as the medical school, and such students choose rural locations, family medicine, and office-based primary care poverty practices more often, even in urban areas. Perennials also include lower income students born in urban areas. The urban perennials even nose out the rural born students in internal medicine office practices in urban poverty areas.
A focus on perennials can mean less maintenance. Students with rural background and interest in family medicine are more likely to go and stay in rural areas, as noted with the Physician Shortage Area Program in Pennsylvania and graduates of Duluth and other similar medical school programs. Somehow the nation continues to attempt to send annuals to places where people prefer perennials. This is the case with many National Health Service Corps scholars. The nation's J-1 Visa program also attempts much the same. The J-1 Visa physicians have urban and foreign-born origins. They are internal medicine physicians, lacking broader training in pediatrics, women’s health, and other areas. The patient acceptance levels regarding such physicians are low and the turnover is high.
Sometimes we uproot perennials that need to be left in place. The students with the most connections to rural communities are white, male, osteopathic, and born in rural areas. This combination of student characteristics results in over 50% choosing rural family medicine. These same characteristics apply to those choosing military family medicine. Upon reviewing the subject, the common bond is high medical school tuition rates and lower income student origins. Over 200 family practice residents enter military careers each year. Most of these are uprooted perennials and many have characteristics suggesting long term rural practice retention. This multiplier effect makes perennials much less costly and far more effective. The issue is not military service, but why health policy moves those most likely to choose rural family practice away from such service. Any US physician could be encouraged or incented to join the military, however those who respond are service-oriented, lower income, a bit older, and have families – in other words they are looking for a support package that will best meet the needs of their family, especially in times when liability and tuition costs are rising out of control.
The “annual” oriented efforts that we have embraced for so many years are expensive. They require costly maintenance and they foster dependence. We turn good perennials into annuals. This is something that can happen when plants are moved out of their climate range too. The annual losses must be replaced each year. Turnover cost alone for primary care physicians is over $200,000 with the burden placed on those communities who can least afford to pay. The turnover costs may be higher when considering lost market share for sites with continued high turnover of physicians. Patients just choose other locations or just stop going for care.
Perennials are a much better choice. Preparing and choosing the right students, ones with roots already in the soil where you want them to grow, is the best way to insure bountiful services for many years with much less maintenance and expense.
Australia has a funding method that involves support for tuition for college and professional education that may have some advantages for perennials. In the Australian “scheme” students attend college and medical school and defer payments until later. As they begin to make income, they pay back their education expenses according to how much income they make. This has resulted in improvements in lower income students accessing higher education.
The nation has a long history of locating medical schools
in the most urban, highest income, and highest cost parts of the nation. This
forces those of the lowest income and most "different" origins to make
significant adaptations. It is time the nation made efforts to accommodate the
perennials by understanding who they are and why they are important. We must
adapt training to their needs and the needs of underserved communities that they
serve now and could serve even more in the future. Black students (particularly
males), rural students (particularly males), and lower income origin students
are tied for last in admissions to medical school with half the admissions rate
of the usual 18 – 24 year old. When not admitted, some try again later. As older
students they make make significant contributions in all needed primary care
shortage areas and also mental health. Efforts to grow our own must begin in
these areas. You will not be alone. There are many successful efforts. The
fields are ripe with human potential.
If you want to see some perennials, check out these pictures of a
preprofessional group of native Americans at
http://www.unmc.edu/Community/ruralmeded/photopriest/june2002.htm
The older girl in the photos is a college student
volunteering to help out and learning about minority issues in the process,
thanks to Roxanna Jokela's project. We had three stations, a lung function
machine, suturing oranges, and using the stethoscope. It was controlled chaos,
but a lot of fun and I learned about Susan LaFlesche Picotte MD when I got
prepared for the class.
http://www.unmc.edu/Community/ruralmeded/susan_la_flesche_picotte.htm
The other white folks are the ones that continue to volunteer when they "round
up the usual suspects." The real "braves" are the adult volunteers from the
Winnebago tribe who watched the 11 - 13 year old teens at all hours of the night
for 5 days. They enjoyed the demos also. Keep things moving and active and hands
on and you will have a good time! Anatomic stuff, slices of bad liver and lungs,
fun with x-rays, geiger counters, etc.
Robert Bowman, M.D.
rbowman@unmc.edu
