Power, Maldistribution, Leadership, and Primary Care:
Pursuit of Equity for Underserved Peoples 5/31/2002 updated 3/2003
Robert C. Bowman, M.D.
In recent studies I have examined the relationships between medical education and various other societal characteristics. In particular I have taken a look at the factors that can lead to graduation of more doctors for rural and/or underserved areas. The early results are in and there seems to be a relationship that involves political power, leadership in education, and emphasis on primary care.
States with a higher percentage of rural people graduate more rural physicians from their medical schools (Which Medical Schools Produce Rural Physicians?, Medical Schools and Rural Graduation Rates) and family medicine training programs Bowman and Penrod Grad of Rural Family Physicians. States with a higher percentage of black voters graduate more black physicians (Bowman minority studies). The variance is not explained as well (16%, likely because race is such a diverse term Race Is a Poor Measure. This is probably not a surprise. However it is not much use in interventions because it is most difficult to change the percentage of the population in an appreciable way. This data is mainly useful to states and regions where they do not seem to have the same bang for the amount of political punch that is present. It can be a call to action. Minorities, Admissions, and Underserved Admissions Package
Admissions has the best potential for interventions that will be lasting. There are many successful models that have verified the importance of effective leadership and primary care models of education.
Leadership in Medical Education
Clearly those with a broader perspective must help shape decisions in medical education. This is particularly true of admissions Basco and generalists. Directors of residency programs also have more influence on rural practice locations of graduates Bowman and Penrod Grad of Rural Family Physicians.
One man has made a big difference in the State of Pennsylvania for many rural communities. Howard Rabinowitz started the Physician Shortage Area Program in Jefferson Medical School over 30 years ago. This program selects rural background students into a special track. This program with only 1% of Pennsylvania medical students has resulted in 21% of the rural family physicians in the state Physician Shortage Area Program Links and Info .
The Minnesota effort would be far less effective if not for Jim Boulger. His efforts to work with students, colleges, health advisors, rural physicians, and leaders in the state are largely unnoticed. He has been interim dean of the Duluth Medical School 3 times. The students from this school have perhaps the highest primary care and family medicine graduation rates in all of allopathic medicine, and are competitive with osteopathic schools. His willingness to study and apply what is known about graduating more physicians for underserved areas is an example to us all.
No less a contributor to Minnesota, with more of an impact nationwide is Jack Verby Verby Articles. His Rural Physician Associate Program RPAP is one of the best medical education programs in the world. Why a Preceptorship Is Better
Robert Waldman set the tone in Nebraska for selecting the medical students that were most likely to be able to meet the needs of the state. He did this without federal or state funding. He interacted with rural communities and directed admissions and faculty to continue in this process. A rural family physician, Jeff Hill, implemented this process as chair and then dean of admissions and students. He continues to meet with students, advisors, and faculty. He has a major role in selecting and training admission committee members. Nebraska has been able to develop specific rural primary care training because the medical school, for the first time, had enough graduates interested in rural practice. These graduates have gone on to underserved communities across the state. The
Rural Health Opportunities Program RHOP has been a big part of this effort. Rural high school students are screened by advisors at Chadron and Wayne State. They are interviewed by Dr. Hill and a few each year are admitted into medical school, pending satisfactory completion of the next 4 years of college. RHOP students come from the smallest towns and the program has restored Chadron and Wayne State to a level competitive with the urban colleges in the state. This should also help restore the flow of young people in a variety of professions back to small towns in the state. Rural Contributions of the UNMC Department of Family Medicine
Jeff and Marge Stearns have also done innovative work to get more doctors to underserved areas through admissions. Stearns, Jeff and Marge
These programs been effective in graduating more for underserved areas. It is also important to notice that they have all involved college health advisors in some significant ways.
Primary care emphasis is a bit tougher nut to crack. Simply generating more numbers by economic or political pressure is not enough to make a difference for underserved areas. Primary care infrastructure is essential to training physicians for underserved areas, but studies fail to show a relationship between direct funding and outcomes of graduates going to underserved areas. In this case the secret to the mystery is combining two or more characteristics. The most documented approach is that of combining family practice interest at matriculation with rural background in students (Rabinowitz). Minority students are far more likely to choose underserved populations and patients Minorities, Admissions, and Underserved. Primary care plus minority background often results in inner city underserved practice locations. Service orientation is closely related to primary care career choice (Madison). Service Orientation
The educational standards set by medical education helped shape high school and college education in this nation over a hundred years ago. Only the massive response to Sputnik comes close to the overall educational impact initiated by Flexner and others when they raised the bar by setting high standards for medical school matriculants Flexner’s Impact on American Medicine. In more recent decades, the willingness of medical education to take a leadership role in higher education seems much more limited. A few schools have worked with colleges and high schools to improve education and admit more physicians from underserved areas, but these programs remain models with little in the way of replication. The same is true of rural medical education models where Even insiders such as medical school deans (Butler, Petersdorf, Cohen) have presented and published regarding the importance of better selections and training, but their words go unheeded. Best and Brightest vs Best Fit For the State
Perhaps the major problem is that the process of becoming a physician is a long one involving several disconnected levels of training and education. We also know that the earliest links are the most important. Interventions at these levels are the least costly and generate the best results. Later efforts to force physicians to go where they are not interested are temporary and costly in more ways than tuition, loans, and scholarships.
One of the keys to successful approaches to graduating more rural physicians is the people who bridge the gaps between the various levels. Health professions advisors are often the first and most important contact for students interested in underserved practice.
Students from underserved communities face some daunting obstacles. Some lack career orientation. Some have significant weak points in their preparation. Others have cultural or family barriers. Others lack the polish or the skills in writing or organization needed to get accepted for an interview. Some have rarely had feedback of any kind on their strengths or deficiencies. Others do not understand the series of temporary failures that they will need to overcome. Some students need little advice while others will need someone to share significant time and resources to be able to succeed.
The absence of good health advisors basically means that graduates from small or rural or minority colleges cannot compete well enough to be admitted. Good health advisors can make a mediocre school better because they help their students to get admitted into professional school. As they do so, they attract the attention of students and parents, and help make their school more competitive.
At larger colleges the sheer number of students may be overwhelming. In discussions on the health professions list serve, it seems that the way advisors interact with students may play a key role in who gets into medical school. In my own instance I had an interest in medical school, but had not pursued it until the health professions advisor at my school had a discussion with me. I am sure that he did so on the basis of my grades, class performance, and relations with other professors. I am not so sure he would have encouraged someone with less obvious credentials.
College advisors are not the only ones overwhelmed by numbers and information. Medical school admissions committees do face a difficult task with a number of conflicting priorities. The members are also some of the busiest and time is at a premium. In particular it is difficult for those with primary care patient responsibilities to participate. There is a tendency to rely on numbers such as grades and MCAT scores, because they are available and concise. The greater problem is deciding
Medical school admissions could be improved by having leaders, by more specific training, by better composition of the committee, and by different emphasis on criteria for admission. College health advisors are in a good position to advise committees in many of these areas.
What I have really enjoyed by being involved in the health professions list serve, is reviewing the efforts of advisors who know the students that they know would make good physicians. I also share some of their greatest frustrations when they and the student face great difficulty in accomplishing this.
Good health advisors and partnerships between advisors, admissions, colleges and medical schools can reverse the major obstacles that keep rural and underserved students out of professions Centralization and Regionalization.
Some of my contacts in Canada as well as in the United States share my concerns regarding policies that "steal" physicians from other nations. Even though these physicians do temporarily meet the needs of some underserved communities, they are not suitable for others. Our own National Health Service Corps physicians often are not a good match for their initial practice locations. They are also expensive in several areas. They cost more to support, train, orient, and replace. They are inefficient due to cultural, language, and other barriers. Also they are costly to the nation when they leave underserved areas to go to urban locations and specialties with plenty of physicians.
There is another way to approach this situation and this involves selection, preparation, and training the students who are most likely to return to underserved areas and serve them well. The models noted above involve this kind of approach. Our country is not the only one that needs this approach.
Only a few days ago I had an opportunity to share some time with a Nigerian physician who is charged with the rural medical education duties of her nation. I am not sure we helped her much for the first 95% of her visit. She was given tours and saw great technology and model programs. She was polite, but her host noted that internet, phone, and computer access was limited, costly, and unreliable.
I begged for an hour or so to meet with her and was given her final appointment of the day. AS is often the case, my time was compressed into the last 10 minutes of her visit. As we talked, her family medicine escort was packing in the background. I hope the ten minutes changes her approach, but changing minds and approaches is a difficult task for a lifetime, not to mention just a few minutes. As we talked, she conveyed that a single set of exams at age 17 basically determined the career of a Nigerian student. As you might suspect, the students that do well on this exam have to better and more urban schools, higher income parents who tend to have professional careers, etc. I advised her to go back in time to 12 - 14 year olds who were actually from the areas that she needed to serve. I asked her to do what she can to find those that are the most likely to return to rural villages. I told her that the next step was figuring out how to get "her kids" prepared for this 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. This is a daunting task given the impact of nutrition, poverty, centralization of education, and other factors. I hope that she is able to do so. I hope that those who supervise her do not expect immediate results. I hope that I can visit and help her and others, in this nation and others.
Community-driven models have great potential for reducing our dependence on foreign physicians. 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.
People can work together because they have to, or because they are aware of needs, but the best way is to work together for mutual benefit. Then it is not town vs gown, or having to visit those people, but us working together.
Rural Faculty Development: Facilitating Town Plus Gown
The Case for Involvement in Rural Communities
Robert C. Bowman, M.D.