Date: 10-09-2000 11:18 Links added 5/10/2002
Family Practice still produces the best graduates for the most needy locations. We have even documented it in some studies. Other studies are needed but we have enough evidence to take it to the public forum. We and our medical leadership have failed to bring these to the attention of the public so that the studies can be adopted.
In the Community Context reply online, E. Rawson Griffin, III M.D. used the example of John Snow and cholera in London. He stated that "John Snow cured cholera in London, England by building better sewers, not by medically treating the sick patient. If we start to clean up the "sewer's of our society" maybe we will go further in curing the illnesses of our patients. I agree with his perspective, but there are important steps that we leave out between discovery of important findings in research, and
implementation of this research. Snow did not cure cholera, but he certainly identified a potential cause. Once others utilized his
findings, cholera was prevented and a new era began.
The important steps have to do with public awareness, public priorities, and the political process. As a society, we do pick and choose what we wish to tackle. Some things, like the cholera of past centuries in most countries, threaten all of us. Any findings of value are likely to be implemented quickly. AIDS, dementia, and cancer therapies are often tried before full evaluation. In family medicine we have been guilty of becoming a guild, defending ourselves and our income more than we have defended the public and the needs of society. Perhaps we look good in comparison with other disciplines, but we are still poor in the context of doctors deferring their own need to take better care of their patients.
My job bounces between inner city needs of patients and rural doctor shortages. I would love to see more care for inner city patients, but I still see urban escape as more doctors flee these areas and leave us with more patients and more complicated ones in our clinics. I would love to see more rural family
doctors, but I see our medical center putting more and more emphasis on intellectual candidates rather than ones who are more interested in service. Most of all I am frustrated with our specialty's failure in these areas.
In both areas, family medicine has plateaued. In inner city circles, the last decade saw a dramatic increase in the number of FP Residents choosing inner city poverty practices.
http://www.unmc.edu/Community/ruralmeded/model/gradu/gradcht.htm.
In the past few years this percentage has stabilized and even declined a few points. Rural numbers did much the same, stabilizing at about 600 per year. Despite multiple advances in all types of areas in medical education, our measures of service to the underserved have not improved.
We have not done our job in family medicine to graduate the types of doctors that would go into underserved areas. We have been content with curricular revisions and we have been overwhelmed attempting to keep up with the needs, but we have not looked at the sources of the problems to deal with them as we should. Although we are indeed facing obstacles of education and ignorance and poverty, it is too easy to point the finger outside family medicine. We need to look at ourselves and medicine and medical education and what we can do and what we must do. We are part of medical education and medical education reforms should be part of us.
Inner city and rural areas are similar in that there appear to be obstacles that would prohibit locating in such areas. It would be easy to blame the typical obstacles of personal safety, income, lifestyle, economy, etc. Studies show that there is more than environment. Selection of the right candidates will result in the achievement of the desired goal.
Immediately you will see the researchers cringe. They will scream, selection bias. While this may be true with research studies with medical diseases, it is not an issue with admissions. Admissions today is a process of selecting the candidates that are most likely to graduate or in the
reverse, those least likely to have academic difficulty. We can debate whether this is for the benefit of the institution and its reputation or whether the brighter candidates make the job of teaching them easier, but this is not a matter of selection bias. It is a matter of studies looking at certain characteristics with desired goals in mind.
Cohen Encourages Admissions to Look Beyond MCAT
Madison's work on Service Orientation
When you are choosing plants for improved varieties, you don't randomize the
characteristics at the beginning. You pick the varieties with the characteristics that you most desire. Studies show that we can select properly and graduate doctors into the right locations. The question in family medicine is whether we will take the risk of dealing effectively with the medical schools in important areas such as admissions.
What happens when the right people get to admissions, but are socialized out of their beliefs?
Selection vs Socialization How can we get the needs of people to impact decisions on admissions? Once the priority is selecting the right candidates, then we can deal with what medical education should be. Again the question is, will we risk these major conflicts with those who are more established in academic
medicine?
I continue to be haunted by the words of America Bracho, MD, MPH at the 1999 STFM Annual Spring Conference. During her talk, she challenged academic medical centers to get involved more with the underserved. She noted that neighborhoods facing challenging circumstances surrounded most of our academic medical centers. She asked why these neighborhoods were not doing better despite decades of contact and proximity. A few medical schools are doing well, but the models are not replicated, especially as NIH funds escalate.
The question is the same one faced by John Snow and Semmelweis and Morton and Paponicolau. When your findings do demonstrate that there are improvements that can be made in health care, will society and its institutions understand them and embrace them. It will not be an easy task, but we will be fighting for the right reasons. The trick is to work collaboratively with AAFP, AAMC, and a host of medical leaders, even some at this conference. The torture is that they are so poorly informed.
AAMC trumpets studies noting the gains in minority admissions, but laments continued failures. Minority candidates are 4 times more likely to choose underserved areas upon graduation (except Asians). Candidates interested in family practice, rural locations, and with a rural background are 5 - 6 times more likely to choose rural practice. These are not associations. They are fact. These data have been published in leading medical journals. One program with 1% of the medical graduates of the state of Pennsylvania now has 27% of the rural family physicians to its credit. Unfortunately these studies are largely ignored. Dr. Jordan Cohen in
December 1998 in Academic Medicine in his President's Letter stated that the reason for the shortage of rural physicians was the poor rural
economy and the "paucity of satisfying cultural outlets". We must inform him that health care is a major contributor to the rural economy. We need leaders that embrace the studies in this area and who work to understand these important issues.
Rural living is not better or worse, it is different. Current attitudes delay the diagnosis and cure. In not so subtle terms, when medical education picks
the right students for admission, the shortages will end. It is most disturbing that some at the conference believe that shortages have been dealt with effectively. Remember the graph above. See
Economic
impact of a rural physician
Drs. Magill and Kane in their Opportunities paper for Keystone noted the following:
"The initial goals for the creation of Family Practice as a specialty - namely to re-invigorate primary care, to design innovative residency programs with Family Practice Centers, and to correct physician maldistribution, especially in rural areas, were valid in 1970 but achieved by the mid-1980s."
(Dr. Magill has noted an error in the text, he does not believe that we have
achieved the rural maldistribution goal- RCB addendum 10/10)
Family medicine still continues to struggle with these areas and likely will continue to do so. See my other response in Opportunities section online.
Magill and Kane also note, "While Family Practice has produced thousands of graduates and has numerous exemplary practices to point to, in general, it appears that the public, especially in our metropolitan and suburban areas does not believe that the family physician produces (or even causes to be produced) the best outcomes."
Rural areas believe in family medicine and have demonstrated their belief. Hundreds of family medicine clinics in urban areas testify the same. As Bob Boyer, first AAFP Doctor of the year, states in his discussions with medical students interested in rural family practice,
"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 fund doing it and find those moments where you too will be dear and glorious."
Bob Boyer Boyer Links and Presentations
I feel good about attempting to do this with patients and students and this is the vision that calls me to be a better teacher and doctor. It is time to get on to implementation rather than being hung up in cogitation.
words in italics are additions in 2002