Robert C. Bowman, M.D.
My view of the problems that we have in medicine in all of the current (and future) major problem areas is that they are related to admissions interacting with education and health policy. This has relevance not just for medicine, but for a nation that selects leaders for its future. Those given the privilege of higher education are the future leaders of our nation. The attitudes of these leaders are shaped from birth and throughout life and are unlikely to be influenced in professional school or the final years leading to such efforts.
Being more professional, being the dedicated person that is most likely to avoid or prevent quality problems, and being the different person who will distribute to primary care, family medicine, rural areas, and poverty primary care is not something that can be trained.
Not only that, but when we put the policies together that attempt to force or enforce professionalism, quality, or academics, we actually frustrate those who are the best physicians or those who would be the best physicians.
We are all experiencing the consequences of other physicians who have not kept faith with the profession. This is not uncommon in human existence. The states with the most standards are the ones that are having the most problems in education, and now the entire nation is suffering under the No Child Left Behind standards. The more standards and laws imposed, the more societal breakdown involved, before, during, and after.
I am more concerned, however, about selections. It is my belief that the "make a difference" type people are the ones most likely to be different in choices involving rural careers or poverty, primary care, or family medicine. I know that all these groups are connected by socioeconomics, overcoming obstacles of income and education, dedication, and different attitudes. Family medicine is the group that depends most upon these humble origin overcoming students.
These humble origin students appear to be eliminated from college and medical school. The students that do make it somehow despite our major education problems in this nation, also have other choices away from the 2 most important areas:
1. education
2. health care
Others would add economics to this, but it is increasingly clear that economics depends upon education and health care. The nation recovered from Sputnik, recession, and other areas with education. We also became a much more competitive nation during the 1990s because health care was improved, with improvements in inflation, cost of US goods and services, and more.
How have we changed in education and health?
Changes in our society have greatly limited the primary source of top quality schoolteachers in American, women, especially in the critical early grades. This is not a bad or good thing, just a fact that we have yet to deal with in America. We also do not respect and reward teachers. Teaching is now no longer a viable option for a male or female who is the primary provider in the family. Despite this, we somehow have some teachers, but the nation has yet to realize a major teacher shortage and quality crisis already in place. This will greatly worsen as baby boomer echo increases in students overlap with baby boomer retirement teachers. Just a short time with national education studies will confirm this, or even census data on migration patterns of teachers and state education data.
Because of the education and teacher crisis, it has become imperative for children interested in more than poverty existence to access private schools or to move to the few remaining public schools that do have college prep education. Of course those in poverty cannot afford to move and have little choice regarding the quality or investment in local education. Because these students in rural or inner city areas are the most likely to choose school teaching and family medicine, we have an accelerating cycle involving underserved communities. Poor quality teachers and low income and bad state policies mean poor education outcomes and then fewer who can return to rural and inner city areas, etc. Not only that, but there is a related accelerating cycle. Poor education in a state means greater state inefficiencies in education, health, workforce, insurance, prisons, social costs etc. This means more state dollars that need to be invested in areas other than education. Growth imposes additional demands of roads and infrastructure that hamstring education investments also. Education takes cuts and the brunts of the cuts involve lower income areas which feed into the above cycle. After only a few cycles there is chronic poverty, hopelessness, increased violence, and worse.
The populations most likely to choose family medicine are not in chronic poverty or in luxury. The populations most likely to choose family medicine are first and second generation college attendees: rural students, Vietnamese and other refugees, Mexican Americans and other immigrants, and others whose parents are working poor. Studies confirm increased choice of family medicine at 19% or above for each of these. These peoples are left out of current US society. They have enough status and improved status and expectations of their children to be able to get ahead. Their vision is next level, but not too much to be pressured to "do more" than school teaching or family medicine or nursing, etc. Their world view as a child and teen is limited to the ones around them that are “make a difference” types, their teachers and their family docs.They want to be like them. They have usually had little chance to see other professionals, an advantage for family medicine and teaching. Those mired in chronic poverty can only escape in a few ways, all related to great gifts of intellect that result in test taking ability. This depresses their level of choice of family medicine to that of elite students. These students do not choose family medicine, likely because they have been treated as elite by our society. They are just as elite as those of higher income who also make the lowest choice of family medicine, primary care in poverty, and rural locations. Even with the elite treatment, black and Mexican American and Native career choices overall does involve increased choice of office-based primary care in poverty locations, but my view is that there is even more potential leadership and restoration for underserved communities available if education was distributed more broadly in this nation.
It is elite upbringing, elite education, elite admissions, and elite training that is the root of our health care problems.
When you are raised elite or treated "elite," you have different attitudes and responses and behaviors. Even when choosing a career like medicine which by necessity involves people contact, you avoid contact with people.
Elite means that you (or your parents) structure your life to avoid contact with others not like you. You avoid choosing a less exclusive career such as family medicine. Those who have “made it” who are your parents, your advisors, your role models, your professors, your medical school faculty all reward these choices. Those who have made it do not understand students who would want to do something mundane such as family medicine.
There are other clues as well. Younger students, higher income origin students, and others who have clearly elite credentials may well train for a people career such as medicine, but then after graduation the whole professional life changes. With graduation the specialist increasingly isolates from patients through the use of assistants and technology and procedures, all of which are rewarded by current health policy. It is this distance from patients which causes so much of our problems: poor communication, lack of trust, not really caring, etc. My wife’s last specialist visit involved 29 seconds with the physician, or about $5 a second. These are the kind of encounters that have long term repercussions and that are spread by people talking, or writing about them, and therefore major image problems for all physicians.
Society feeds into the elite. We invest less in poor schools, school districts, and districts with more minorities. We invest more in wealthy districts and students. We allow the dedicated parents to move their kids out of poor neighborhoods to elite schools. We lose their example in the neighborhoods and schools that most need their help, and all of our help. We create magnet schools in urban areas and special programs that concentrate students and help them become elite, and less likely to choose school teaching and family medicine. We focus on the elite that can make it and some that might make it, but we end up concentrated the poor children in classrooms together even though studies show that academic performance is retarded in the higher performing students in the top portion of the class who face such environments, students who would also do college and more, if they were given a chance.
1. So education is sending us fewer potential family physicians because of the local, state, and national choices we are making.
2. High school and college students who would be family physicians are seeing the health care problems in the nation, and avoiding health care careers and especially getting caught in the middle in a career such as family medicine.
3. Health policy which has increased choice of family medicine by 50% by changing the incentives for choice of primary care during two major periods (1965 – 1978 and 1990s) has deserted primary care entirely.
The solutions
1. Invest in nurturing, child development, and early education and redistribute, partner with schools, colleges, and admissions.
2. Reach out locally to potential family physicians, the real future of family medicine. Use current college students and medical school students to reach out.
3. Change health policy to favor primary care before we collapse the economy and other systems in America.
4. Restructure GME positions to force primary care and behavioral choice and complete filling of primary care and behavioral positions, before allowing less essential GME positions to be filled or funded.
5. Leadership willing to act independently and for ultimate long term top national priorities, instead of focused on current short term areas.
Robert C. Bowman, M.D.