Robert C. Bowman, M.D. About the Site and Author 2/24/2003 update 3/10/03
My field of expertise is rural medical education. This is the process of getting doctors to underserved rural communities. There is broader application of this than my small area, however. My real medical education began as I began rural practice. Although my practice was a financial failure, my rural experiences have shaped my life in ways that few could imagine. I have since become a medical educator and then a rural medical educator, with a focus on getting doctors into small towns. I can tell you many reasons why we parted ways, but I would rather tell you ways where we can be brought together. I offer the following as a proposal to the AMA, AAFP, NRHA, AHECs, AAMC, and others regarding one method that has worked and will work to address many of the problems in our nation regarding health care. Full version at http://www.ruralmedicaleducation.org/hope.htm
Each time a person stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, they send forth a tiny ripple of hope. by Robert Kennedy submitted by Dale Dewar
The point of my work is to find solutions to some of the major inequities that continue to plague our nation, in education, and health, and other systems. Some of those solutions may apply to other areas. Restoration of Communities, Nations, People Often I find that we are sadly mistaken in our approach, with too little emphasis at the early stages and far too much effort when it is too late and way too expensive.
It's not what we don't know that hurts, it's what we know that ain't so! Will Rogers
These are very difficult times for rural health and rural medical education. Never have we known more about how to graduate more doctors for underserved areas, yet it is a very real possibility that we have been moving further from our goal. This drifting process may become an avalanche.
For the next few years, state budgets will face stronger and stronger challenges. No longer will horizontal cuts be possible. No longer will states be able to cut out programs for the poor or mentally ill, or tax segments of society with little voice through lottery, cigarette, and other taxes. See Medicaid Great need remains and there is less and less available. Substantial cuts will be made and there will be consequences to our communities. Many have been propped up by dependency for so long that they are in a sad state of repair. See various reports from states at State By State Education Status from Education Week report cards sponsored by Pew Charitable Trusts. Many states and school entities will have to adapt, but there will be great tribulation in the process. Centralization and Regionalization
Medical education has already faced some major cuts, and as expected, the underserved are taking more than their fair share of cuts. Already there have been challenges to two major rural medical education programs, not weak or new ones, but significant programs with great impact across this nation and the world.
One of the problems of educating physicians for challenging environments such as underserved areas is illustrated below:
“An important attitudinal problem is that of 'learned helplessness'. The highest that many new medical graduates aspire to in dealing with medical problems is being able to assess to which specialist to refer the patient. Consequently, it is a frightening prospect for them to contemplate rural practice." -WONCA Policy on Training for Rural Practice 1995
Current medical education is floundering. At a major conference of 15 medical schools in 2001, leaders admitted major problems including loss of focus, lack of coordination, major decreases in teaching (especially attending time with learners), and far too much concentration on the in-patient team with a loss of focus on the patient. Millennium Conference on the Clinical Education of Medical Students The conference summary included the following finale:
As Ludmerer demonstrates in Time to Heal, this is a great challenge that will require leaders with “the ‘ability to think outside the box,’ the flexibility to act quickly, the courage to act decisively, … the fortitude to make difficult and painful decisions for the sake of the general good, … [and] the wisdom to know what not to change—namely, the timeless core mission and values of the academic health center.”
Perhaps going back in history to what worked in the past may be a more difficult form of "thinking outside the box."
Generalism, Medical Education, and Family Medicine: Complimentary Not Competitive
Almost missed in the various deliberations regarding medical education is the lack of focus on students. In Family Medicine we have long focused on student interest groups, but we did not realize that the real deal was not energy and ideas devoted to students, but energy and ideas from students. It is not what we can give students, it is what students can give us, and medicine, and the nation.
It has been my great fortune to work with medical students, some of the most gifted people on the planet. They hold the key to the solutions that we need.
This is my theory, backed by the evidence of student performance when given opportunities. I feel that the students that we want to become physicians, the ones that will care and serve and communicate, are very discouraged by not only medical education, but education and higher education as well. By losing these students, we are failing medicine, and society.
Others started in poverty, had to fight to get sufficient education, and cannot see past the burden of debt and the slavery of our current educational loan system. Others have to work during high school and college and just cannot put forth the kind of effort that our rigid admissions committees require just to be considered.
Higher education can make a difference in all the above. No, I have not discovered some new source of funds. Nor do I have the charisma or expertise. But I have seen models and people who can make a difference.
At East Tennessee State, highly motivated students helped put together a rural high school career fair. The most important element of the fair was the impact of the students as they listened to medical students who were just like them. I could not give them this hope and motivation, nor could any program do it. All they needed was some time with medical students who were as much like them as possible. This is the heart of the feeder programs which can transform our medical schools, medicine, and even high schools in underserved areas. Such is the power of higher education.
Minority and Rural Early Admits: Overcomers
Remember what happened to the poor students in an elementary school in New York City who were told that they would have their college paid for, in other words if they put forth the effort they could make it. What happened was remarkable, they actually did make it! There are millions like them out there.
Research demonstrates that rural kids have been disappearing for years (Kassenbaum DG, Szenas PL (1993). Rural sources of medical students and graduates choice of rural practice. Academic Medicine 68;3:232-6). Those serving on admissions committees have seen the lack of polish in the applications of these kids. They need so little advice to do so much better. Most of all they need to believe in themselves.
Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented and fabulous? Actually, who are we not to be? You are a child of God. Your playing small doesn't serve the world. There's nothing enlightened about shrinking so that other people won't feel insecure about you. We were born to make manifest the glory of God what is within us. It's not just in some of us, it's in everyone. And as we let our own light shine, We unconsciously give permission to do the same. As we are liberated from our own fears, our presence automatically liberates others. Nelson Mandela: Inaugural Speech, 1994 (originally from a poem by Marianne Williamson, via RuralMed - Canadian Rural Doc list serve).
It takes so little to make a difference. In Nebraska admissions leadership began paying attention to rural background students, especially those with maturity and other outstanding characteristics beyond GPA and MCAT. Beyond this the admissions team formalized a partnership with rural colleges and communities by reserving a few positions a year for students from the smallest high schools in the state. Students were accepted as seniors in high school and attended two small rural colleges. These colleges are thriving in academics, admissions, and finances at a time when other small colleges are on the chopping block See RHOP. These RHOP and other students like them have set new standards of volunteerism in the state, especially in underserved areas. The impact on the medical school, its programs, and its department is significant, including national awards for service to community and the National Rural Health Association program of the year award, all for harnessing just a bit of the incredible energy of these students.
Not surprisingly they continue to serve. Having overcome so many obstacles, it is unlikely that future obstacles will impact such overcomers as severely as so many of our medical students and graduates who have not had to face such challenges. This is as true now as it was over a century ago with the first female native physician in the nation:
Dr. La Flesche commenced her studies of English at the school on the Indian reservation. Coming East, she continued them for awhile at a boarding-school, and later at the excellent school for her people at Hampton, Va., where she graduated in 1886, and came at once to Philadelphia to study medicine. The impulse to a professional career was not of recent growth nor from friendly suggestions from those who had watched her course. It came as an inspiration when at home with her people and was born of a desire to see them independent, so far as she could make them, of the too frequently unskilled and oftener indifferent attention of the reservation doctor. What must those who oppose women physicians as impossibilities or monstrosities think of such a course? Thoughtful of a service to her people, child though she was, she permits not the magnitude of her task to stay the inspiration, but bravely, thoughtfully, diligently pursues the course, and to day receives her fitting reward. All this without a precedent. She will stand among her people as the first woman physician. Surely we may record with joy such courage, constancy and ability. Commencement address of Dr. Walker regarding the First female native physician, more at http://www.ruralmedicaleducation.org/underserved/picotte_graduation.htm.
If the predictions of Dr. Walker above could be made at or before graduation, certainly our own medical leaders can make similar predictions today, if we only gave students the chance.
Remember these words: inspiration, desire, desire to see her people independent
Remember the situation: educational barriers, indifferent doctors who really did not want to be there Obligations and the Potential for Indifference and Increased Health Costs
Remember the character and what made it: courage, constancy, ability, longstanding desire, overcoming significant obstacles Character, Color, Admissions, and Physicians Character: the Narrow Road
Actually there is no surprise that this worked. It is exactly what happened in medical education a century ago when Flexner and others told high schools and colleges that medical schools needed a better student. Flexner’s Impact on American Medicine at http://www.ruralmedicaleduction.org/flexner.htm Medical schools began demanding a better student, at least in terms of education. The result was an incredible boost in education and higher education in the nation. Unfortunately underserved areas and populations were left behind. Not only that, but to some degree, increasing with each passing year, we have less emphasis on character, and that too has shaped medicine and medical education.
What Nebraska did, as well as many other successful programs for rural and underserved populations, is help the kids to believe in themselves. There have actually been medical leaders that have taken such programs to the highest levels, but somehow we failed to pay attention. Butler Promotes Accountability
Now there is another chance to move to a deeper level – an earlier one.
What is the American Dream? Doing something more significant than what we would do for ourselves Pastor Roger Theimer 7/8/01
An extraordinary medical student, John Klein, has put together a special program that again brings together medical students, rural communities, and students that need some encouragement. It is called the PRIME Program. John Klein: PRIME Developer http://www.ruralmedicaleducation.org/prime/prime.htm
The PRIME program takes the early steps of medical education to high schools and middle schools. Students from the medical school go out to rural high schools and give one hour sessions on algebra (half-life of drugs, alcohol), biology (genetics), chemistry (acid-base), and physics (vision and anatomy of eye). John has chosen topics that have clear application to the study of medicine and are also of great interest to teens.
The most important part of the program may be the fact that a medical student, preferably one from that town or a similar neighborhood, as much as possible with an origin similar to the secondary students, stands before the students as clear evidence that they also can make it and become physicians or health professionals or professionals.
The PRIME program is not the only answer, but it and many others like it are certainly key parts of the solution.
The final piece of the puzzle fell in place when I was looking at great leaders and great people and began reading about the obstacles that they overcame and how their viewpoint was different, because of where they had been previously.
Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions. -- by some school drop out named Albert Einstein
It is difficult for medical leaders, focusing on major crises, to get away from the day to day operations and see what rural docs, towns, med ed, and people have to offer.
I may be naïve, but I still think that a career in rural family medicine offers the best opportunity for the best doctors to be at their very best and have fun doing it and find those moments where you too will be dear and glorious. Robert Boyer, M.D. reference to Taylor Caldwells book about Luke, the physician in the Bible who wrote Luke and Acts Boyer Links and Presentations
What we have to offer is indeed the best of America, getting the best education, and being the best – the young professionals that we need to restore underserved areas, to encourage others like them further, and help return America to greatness.
I look forward to a practice where I will see my patients in the office, deliver their babies, and treat their emergencies in the local hospital. All of this will allow me the privilege of becoming an integral member of my community. -Hillary Lawson, Medical Student, Globe and Mail July 28, 2001
Is there any doubt that Hilary is on the road that others have already traveled:
In one year the student develops surprising professional maturity. In the classroom of real life he has learned that sound medical practice is born of sound medical theory. He has seen how rural family practice can bend or break a man but how it rarely bores him. He has witnessed the challenging clinical mix of the mundane and the monstrous. And he returns to academia a wiser, more confident, more searching student. JK Heid RPAP preceptor 1979 Duluth Plus RPAP
Not only is this best effort important to small towns, it is also important for inner cities, Appalachia, native reservations, border areas, and communities or nations of poverty everywhere.
Hopelessness, ignorance, disease, hunger, and oppression will war continually with education, health care, leadership, and young professionals.
One destroys while the other restores. There is no neutral ground. Powerful reinforcing interactions move people, communities, and nations one way or the other. Restoration of Communities, Nations, People: Role of Rural Family Docs
I hope that you come to this conclusion, and work in your town, your group, your association, and your state, to bring this about. PREPARE: Rural Student Interest Groups
Higher education is about hope, hope for a better future for those educated as well as the lives they will touch. Abraham Flexner understood this. He was not a physician. He was controversial and often disliked. But he was a person of extraordinary experiences coming to medical education at a critical time. His experiences as a high school principal and one who did studies on college education move medical education into greatness Flexner’s Impact on American Medicine.
We have many complex problems, but there are some simple solutions that have worked and will work again and again. Higher education can stagnate our society, or renew it. Flexner knew that the strength of medical schools was mainly in the quality and qualities of the students who were admitted. Today’s students and the way we higher educators facilitate their work and energy can lead the way.
The wise family physician is one who knows how much he/she is but is more concerned with how much more he/she can become Hunter Woodall, Family physician
My plea to those in higher education and medical education about students:
Lead, follow, and get out of their way!
Academic Leaders Deans Organizations
Thanks to Mike Floyd, and others: Early in my academic career it was my good fortune to work with a rural educator, an EdD who was as interested in rural education systems as I was rural health systems. When working together we both realized that we could take his work on rural education and substitute the words "rural health" for "rural education" or take my work and reverse the terms and get a pretty good article. I have used this to develop research capacity into Rural Medical Education Capacity and have converted industrialized agriculture vs family farms into a reasonable semblance of rural health systems. Consider also the impact of technology in shaping all of these areas Technology: Shaping It or Shaping Us?.
I think that when residents are trained intensively and together and specifically in full service primary care for underserved areas, they will not be satisfied unless they get the opportunity to do what they have long desired and have trained for! Robert C. Bowman, M.D. 2003
In reflection, it seems that now that we think we have spanned the frontiers of the land, and sea, and space, we humans think that we are all powerful. Yet few of us ever span human dimensions, such as the gap between rich and poor. Those in our world who are rich, are likely to be poor in spirit. Those in our world who are truly poor, are likely to be rich in spirit. In fact it may be all that they have and all that keeps them going, just as Jesus said he had food that His disciples was not aware of. If only it were possible to be rich and truly generous, now that is a challenge to overcome. - Robert C. Bowman, 2002 Vast and Endless Sea
April 12 An Encouraging Word And let us consider how to stimulate one another to love and good deeds. Hebrews 10:24 I once was speaking to a group of several hundred singles, and I asked, "How many of you grew up in homes where you were told you were great?" Perhaps a dozen raised their hands. The rest of these young adults remembered words of criticism from their parents more than they remembered encouragement. More of this at Encouragers
