Commentary Season of Accountability

This important address reviews the last 100 years of medical education in the United States. It highlights the efforts that have made a difference in addressing the needs of the underserved. This also led to increased focus on primary care and generalism. Butler also predicts the accountability efforts by the government, leading to the managed care era. The models that Dr. Butler has listed are updated and still can help the country meet the needs of the underserved. There are too many important points to just list paragraphs or use as a bibliography resource. The tables and italics enclosed are my highlighted comments (Robert C. Bowman, M.D.). The rest is from Dr. Butler as per Academic Medicine 67(1992) 68-73. The full version as it appears is at

Previous Seasons

The Season of Standards - The first 30 years 1900 – 1930 “centered on elevating standards of medical school admission, curricula, and instruction and of medical care.”

The Season of Faculty Development- 1930 – 1960 “Admissions and curricula were still key issues… but leaders of the 1950s stressed how society should support the expansion of medical education and research.”

The Season of Academic Medical Centers – 1960 – 1990 “modern academic medical centers began to evolve and were embraced by their communities.”

The Present Season

Now we have entered a season dominated by societal concerns about the overall health system. This is the “season of accountability and social responsibility.” Accountability is defined as being “answerable” and “explainable.” We should champion both vigorously.

I propose that the AAMC immediately marshal leadership from within academic medicine toward providing near-term remedies to pressing concerns. Without delay, we should initiate actions to

Two Issues Demanding Leadership

I would like to focus on two issues of national concern where I believe academic medicine can – and must – exert strong leadership in working with others to correct deficiencies in our nation’s system of health care.

(1) How should we respond to meet a perceived shortage of generalist physicians?

(2) How can we assure access to medical care in underserved rural and urban areas?

Therefore the admission office is the first gateway of opportunity, a point emphasized by Kay Clawson in his 1989 chairman’s address. 21 We will only perpetuate the trend toward specialization, which began in the 1950s and 1960s, if medical schools continue to admit students narrowly trained in biological sciences at the expense of broader education.

We must teach students about their future roles as educators of patients, a concept emphasized by Daniel Tosteson in his 1974 chairman’s address. We can link medical schools with community clinics. Several primary care advocates suggest mandatory time in community service for all medical students or graduates – a suggestion that merits serious consideration.

A third factor in career selection that cannot be overlooked is financial. The average income of pediatricians and family physicians is only 68% of the average income of all US physicians. Obviously the level of income deters some students from careers in general practice. Federal legislation has been proposed to provide more equitable financial reimbursement for general care practitioners. We should work for such incentives.

We should find ways to waive tuition when students select special primary care tracks in medical school. We can seek government support to pay much higher stipends to residents in general care programs – say $50,000 per year – to encourage residents to maintain commitments to be generalists. These incentives would discourage young physicians from gravitating, solely for financial reasons, toward specialty training.

Undoubtedly, the need for highly skilled specialists will increases in the years ahead, but, as surgeon William Anlyan told us in his 1971 address, we also must provide a better balance of specialists and generalists. The generalist, after all, is the cornerstone of the medical profession.

Health Care in Underserved Areas

We must be aware, however, that merely graduating more general care physicians may not directly address the immediate needs of the medically underserved in America’s rural and urban areas. Family and general practitioners provide over 90% of the medical care in counties with populations of less than 10,000. Yet an 8.1% decrease in primary care physicians per 100000 population in non-metropolitan areas occurred between 1963 and 1986, and the number of new physicians interested in practicing in communities of fewer than 50,000 declined by almost 50% from 1981 to 1989.

It is important to understand that this 8.1% decrease in non-metropolitan areas occurred at a time when allopathic schools doubled output from 8000 a year to 16000 a year and family medicine was graduating over 25% into rural practice. The reasons are clear. The expansion of medical schools and class sizes involved students born in the most urban parts of the nation. These students are far less likely to choose primary care and rural locations. The probability of rural and under-represented minority admissions decreased during "expansion" while urban born student probabilities increased.

WWAMI (Wyoming added now) remains the rare example of a medical school that has managed to combine top primary care with research. The decentralized effort involving Area Health Education Centers and keeping students in their native states in the first year and during rotations seems to be effective.

Jefferson has admitted an average of 14 students a year and this 1% representation of all graduating Pennsylvania medical students now makes up 21% of rural family physicians coming from Pennsylvania medical schools. Jefferson's program links with small college health advisors. The program's director, Howard Rabinowitz, has attempted to replicate the program and also obtain state funding, but these efforts have not been successful. It remains puzzling why such programs remain models with incredible records of success meeting the needs of underserved areas.

The Minnesota RPAP is one of the best models of medical education, period. This community-based model gains strength with each passing year. The traditional urban academic model faces more and more challenges from a variety of forces that divide students from patients - liability, faculty priorities on income generation, health system problems resulting in lack of continuity with patients, and revolving door rotations where students rarely get to know faculty and vice versa. RPAP is one of few medical education efforts that

can identify students who might become problem physicians contributes to workforce support in underserved areas
gives students enough primary care experience (over 6 months) so that they can actually be comfortable with the complexities of primary care, especially dealing with all kinds of patients, uncertainty, emergent and urgent care, behavioral aspects, birth to geriatrics, and more. Typical medical school exposures of 3 - 4 months just overwhelm students and drive them into less direct patient care.

If merely producing more general care physician in the near term will not solve the medical needs of rural communities, what can academic medicine do? Again we can learn from existing medical school initiatives.

In Jefferson Medical College’s Physician Shortage Area Program, for example, approximately 24 students admitted each year from non-urban areas pledge to enter family medicine and to practice in underserved areas.

In the University of Washington program, almost twice as many students from the WAMI program choose to practice in non-metropolitan areas as do those without WAMI experience.

In the Minnesota program (RPAP) 59% of the graduates who have remained in the state practice in rural communities. The premise underlying these programs is that new physicians cannot be expected to locate in rural communities unless they are exposed to them.

Academic medical centers should also seek ways to encourage physicians who aspire to practice in medically underserved areas. We can, for example, work for student loan forgiveness and for government support of graduates’ clinic start-up costs, continuing education, and consultation with colleagues in academic centers.

Not all schools can bring about uniform changes. However, whether slight changes are made in all schools or substantial changes in a few, strong institutional leadership will be essential. The AAMC already is exerting leadership to bring the primary care issue into perspective. Two focus sessions on primary care were sponsored by the AAMC in the fall of 1991. Their input will provide guidance in the development of an AAMC Action Plan to facilitate change.

Organizing a Regional System

As we review selected medical school initiatives we become aware of another and perhaps more troubling problem: the organization of the health care system itself. We must address this fundamental issue.

I propose that academic medicine take the leadership to bring mainstream medicine directly to every underserved area of this country in a “National System of Regional Medical Care.” To succeed, a national system must be tailored to regional needs. The diversity of requirements for health care has posed and almost insurmountable obstacle to devising a simple, uniform federal system. The types and magnitudes of required medical services vary greatly from one area of the country to another, and nobody knows local needs better than those who live in the area.

It makes sense, procedurally, first to identify places throughout the country where populations, both urban and rural, are medically underserved and then to delineate a series of regions where planning would be coordinated around the particular medical needs and requirements of each region. The regions would be obliged to comply with general mandates in order to qualify for federal funding. One example might be the inclusion of population-based health services research. But each region would be given broad flexibility to design and implement its own system of medical care.

Academic medical centers and medical schools, by virtue of their expertise, resources, and positions of prestige throughout their domains, should be delegated the leadership – under a federal grant program – to facilitate planning for structures and systems most suited to their regions. This planning responsibility would be undertaken with the full participation of a broader range of persons and institutions, all with the potential of contributing to an integrated health system in their areas.

We should re-examine the concepts underlying the Regional Medical Program proposed in 1964 by the President’s Commission on Heart Disease, Cancer and Stroke. That proposal envisioned linking every physician and community hospital to a national network capable of transmitting the newest and best in health service and research. The Regional Medical Program did not fulfill its potential, partly because academic medical centers – critical to any regional solution – had not matured sufficiently to provide the essential leadership and support. Also, 25 years ago, modern telecommunications, indispensable for implementing any regional system, had not been developed.

We can also learn from the successes of the Area Health Education Centers, or AHECs, which have existed in various forms in 37 states and have involved 55 medical schools. These have fostered the education of health professionals in non-urban settings, in some cases for nearly 20 years. In North Carolina, to cite one program, the physician-to-population ratio in rural communities is higher than that for comparable communities nationally, a difference attributable to the state’s AHEC program.

AHECs involve urban under-served locations also. Arkansas has also had similar improvements in physician-population ratios. North Carolina's success may not be the AHEC admissions component so much as it is impact on recruitment and support of physicians. NC has superior recruitment efforts as noted in recruitment of family physicians from most other states. Patterns of Rural Workforce NC is matched only by Wisconsin in this. North Carolina rural born students have one of the lowest ratios of admission in the United States, although this ratio is improving. Probability of admission tables State education must be improved if NC hopes to "grow its own" and reduce dependence on other states and nations. NC efforts to support physicians in practice are unmatched, including outreach efforts from medical schools.

Space constraints preclude mention of many other recent initiatives in regional planning, but one other that I would like to mention is the Health of the Public program, a pilot study funded in several academic medical centers by the Pew Charitable Trusts and the Rockefeller Foundation. Academic medical centers are challenged to assume institutional responsibility for maximizing the health of a defined population and to be involved in decision making about the development and deployment of community health services. Clearly this approach attempts to integrate individual and public health services, which unfortunately have been separated from each other for the better part of this century.

To establish regional systems integrated within a national plan will entail great effort and commitment from many persons, agencies, governmental entities, and the practicing medical community. It will require shifting some health care resources and funding. It will rest inexorably on the political will of the President and Congress.

A Proposal

Academic medicine must work with others for the enactment of a well-conceived legislation. I propose that an AAMC task force be commissioned immediately to examine the feasibility of establishing the “National System of Regional Medical Care” that I have briefly sketched. This task force also should look at existing, innovative programs to enhance rural and urban medical care and recommend the best way for academic medicine to exert leadership to solve these problems. I challenge this task force to devise a model that can be applied nationally and be in place within this decade.

I am convinced that as an obligation of the extraordinary public trust held by academic medicine – a trust described by Robert Petersdorf in his 1978 chairman’s remarks – the AAMC can and must take this leadership role. We can be the catalyst in building a national health program to include all Americans and reduce per-capita expenditures for medical care. As Virginia Weldon told us in her 1986 address, “The challenge of leadership…is the ability to command the public’s attention and to engender political will. In providing this leadership we can demonstrate clearly that we are sincere about equitable health care for all citizens – and that continuing public support for our tertiary care centers is fully justified.

The nation’s political climate now favors a workable national health plan. We must be prepared with a realistic proposal and willing leadership to utilize medical resources in each region of the country most effectively to achieve this national priority. The alternative is to invite a government-mandated program that probably will not be sensitive to local community needs or the most efficient use of medical resources.

Let us affirm – in this new “season of accountability and social responsibility” - a vigorous commitment to leadership that will ensure the public’s trust of academic medicine in the seasons of the twenty-first century. As Hippocrates observed, “For extreme diseases, extreme methods of cure…are most suitable.