Robert C. Bowman, M.D.
If push came to shove and the governor, senator, etc., blamed your school for not graduating enough rural physicians, you could blame the lack of rural physicians on a multitude of other rural problems. These include low resources, poor organization, and inadequate finance, etc. Rural physicians in Canada were incensed by comments from a medical school dean that more government dollars to the medical school could address rural needs. They point to various government programs that have expended millions of dollars at the medical education level without producing more rural physicians.
It is time to quit blaming and start working in multiple areas. The longest delay, however, is in the medical education pipeline, so it makes sense to work on it first. See also Admissions Package. Also see Centralization of State Resources and the Impact on the Location of Young Professionals in order to understand some of the areas that impact the choices of medical students.
Can We Select Better Based on Quantitative Data?
The president of AAMC thinks that we can and should See Cohen on Admissions.
A study by Don Madison in Academic Medicine (Oct 1994) 69:10;825-831 did an extensive review of the class of 1986 at UNC-Chapel Hill regarding predictors of generalist careers. The best predictor was evidence of Service Orientation in the applicant's background or personal statement. The next best was socioeconomic status where lower status correlated with more generalist careers. Madison's work involved lots of time to compile the data, but the data used was available to the admissions committee members. Madison noted,
"Yet, having identified certain attributes that would appear to predict medical students' recruitability as generalists, it would not serve either their schools or society at large, were admission committees to discount those qualities that are desirable in all physicians simply because they fail to predict the decision to become a generalist. In the best of all possible worlds the majority of all entering medical students would end up as generalists, but all physicians - family practitioners, physiatrists, urologists, allergists - would be well-educated, highly intelligent, well-rounded, personable, honest, altruistic, highly motivated individuals who had tested themselves prior to medical school in some tangible way against their goal of a medical career and a service profession."
Are Rural-Interested Students Different?
Some studies have noted that higher admissions test scores are associated with a reduced probability of rural practice choice (Dona Harris, studies in Utah). Others note that rural background students have somewhat lower grade point averages, but more extracurricular experience. I have done some brief work with national data on Rural Interested Senior Medical Students (1995 AAMC Graduation Questionnaire) and have found several differences in students who are interested in rural practice. Twice as many rural-interested students took rural and international electives when compared to their classmates as a whole. Twice as many did volunteer work during medical school.
In the process of upgrading our applicant pool regarding rural interest, we would also be likely to get the kind of students that are interested in primary care, geriatrics, general surgery, mental health, service, social issues, and leadership. I guess I am fortunate to work with these folks as students, faculty, and colleagues. I can't think of a better group to work with. Couldn't we have a few more come our way?
Should We Select for Qualitative Characteristics in Physicians?
Studies of physician workforce (COGME, Pew, and others) Papers and Policies To Review have noted that we need more students to be interested in primary care, chronic care, care of the elderly, and prevention of disease. Some have begun to raise questions whether the "best and brightest" are well equipped to deal with many of these situations. Physicians who are quick to diagnose and great at cures may not be interested in plodding along, relating to others, supporting, or maintaining.
Perhaps many of our problems in rural areas are that even rural physicians are too ingrained in the "curative" mode and less interested in working out relationships and problem definition, with solutions worked out in the future with others rather than immediately on your own.
In my own experience at residency, our resident group was a select group of the best and brightest. We nearly wrecked a fine community-based residency program McLENNAN CO FP Program that had done quite well with average folks who related well. Seems like the ability to communicate and the willingness to serve are more important, at least to primary care and rural practice and hopefully to all medical careers.
Is Selection the Problem, or Is the Real Culprit Socialization During Medical School?
Further listserve deliberations centered on the issue of whether medical students were either selected for the wrong characteristics or whether they were socialized into non-caring roles (as per anthropologist Melvin Konner and others). Medical Student JAMA Book Reviews
Frankly, I think it is a little of both. Experienced faculty lament those lost to medical school socialization. On the other hand, even the most cavalier students seem to fall in step when our small group discussion involves them in a personal fashion. Poverty and medicine gets some polite attention when presented in didactics and brief discussion, but students shine when they debate the ethics of our medical education system in which the least-trained practice their skills on the poor or disadvantaged - those with little on no ability to complain.
It is also easier to do quantitative presentations than qualitative experiences. It took me two years and 10 presentations to get superior evaluations from students when I talked about teenage pregnancy. It took me two months and two talks to get there when teaching the same students about electrocardiograms. Good educational experiences often take time and multiple resources.
When Bob Boyer, a rural FP from Kingman, Kansas, tells his stories about rural practice at the national meeting of family practice residents and students, we always have a few of the residents comment about how they have been recharged and refreshed. Their faith in their primary reasons for becoming doctors has been restored. To me these are all signs that medical education has a negative socialization effect. School missions, attitudes, curricula, and reward systems all influence students along with selections. If the same students can respond, even at senior levels, there is a reason for change. Boyer Links and Presentations
Jordan Cohen commented on this area in his annual address to AAMC in 2001:
The Acculturation Process
"And speaking of colleagues raises the second unique contribution we, as medical
educators, can make to enhance the image of medicine for prospective applicants.
And that is to come to grips with the way we acculturate our students and
residents
to become our professional colleagues after we admit them. Unless we can covert
our
learning environments from crucibles of cynicism into cradles of
professionalism, no
amount of effort on the admissions front end is going to suffice.
"If we wish to increase the attractiveness of medicine for those intelligent and
dedicated idealists, we can't continue to kid ourselves about our tarnished
reputation
as responsible educators. You know as well as I do, we are viewed in many
circles as
making frankly dehumanizing demands both on our students and on our residents.
Many in the general public are convinced that we purposely haze students and
residents as some kind of rite of passage. How, they ask, can medicine be all
it's
cracked up to be if it allows its own acolytes to be treated harshly in the
process of
educating them?
"However discomforting those perceptions may be, the fact remains that we do
appear
to systematically replace some of the nascent virtue evident in our matriculants
with a
lot of cynicism by the time they finish their residencies - cynicism arising
both from the
way they are treated and from the way their mentors model - or fail to model -
the
avowed values of the medical profession. We have tended to assume that the good
people we admit to medical school will remain good no matter what kind of
behavior we
visit on them or parade in front of them. All the evidence points the other
way."
"If we wish to deepen rather than drain that reservoir of nascent virtue, we are
going
to have to do more to reconcile the values we actually teach our students and
residents with the values we profess to teach them -- what my old Stony Brook
colleagues Coulehan and Williams have called the tacit versus the explicit
values of
medicine. I urge you all to read their provocative article in last June's
Academic
Medicine entitled "Vanquishing Virtue: The Impact of Medical Education." It is
but the
latest in a long string of passionate pleas for us to address the gap --
arguably the
growing gap -- between what kind of doctors we say we want our students to
become, and what kind of doctors we actually teach them how to be. In our
various
courses and pronouncements on rounds, for example, we talk about the importance
of
caring, compassion, empathy, respect, and fidelity, and about what it means to
be a
good physician -- about the need to be trustworthy, honest, and committed
primarily
to patients' welfare. That's the visible, explicit curriculum."
"In the hidden, implicit curriculum that students actually experience in their
day-to-day interactions, they typically encounter different values. Our learning
environments tend to revere, in Coulehan and Williams' words, "objectivity,
detachment, wariness, and distrust of emotions." And because those implicit
lessons
are endlessly repeated, and are imbedded in actions rather than just in words,
they
are much, much more powerful and enduring. The result is that technical skills
come to
be valued more highly than interactive skills. More important, our idealistic
students
who hear us say one thing and see us do another are often quick to sour on
virtue,
many opting instead for cynicism."
"No matter how successful we are in attracting idealistic, properly motivated
students
to medicine now or in the future, we have little hope of delivering the same
number of
idealistic, properly motivated doctors to society unless we can close the gap
between
rhetoric and reality."
"I know I'm preaching to the choir here. We all want to find ways, not only to
make
medical school and residency training more humane, but to ensure that what we
value
is indeed what our students and residents learn from us. I don't have a magic
solution
to offer - there is none, of course, - but I do have a concrete suggestion to
make
that might help move us a little further in the right direction."
end of Cohen comments
However, there is also the problem of admissions of more and more from higher status, who may be less able to adapt to careers and locations with more patients of lower status Admissions and Social Status
Can We Modify the Socialization Process?
Having taught at some of the newer medical schools, there is a different attitude and mission that does seem to influence students. There are different relationships between faculty and departments and students. Students there are more open to cultural, interdisciplinary, public health, primary care, and rural items. Obviously we cannot continue to build more medical schools, but we can reconstruct the medical education process. It is unlikely that we can modify the major medical centers, but we can move students out of these areas for training. Many are overcrowded and give students a passive style of training that is poorly suited to rural practice where decisions have to be made more independently and where more procedures are done.
At medical centers, rural student interest groups can band students together to resist urban and specialty pressures. Rural rotations, particularly the longer ones such as RPAP in Minnesota, can get students away for some time. Rural campuses for the first or last two years can also be a help. Basic science faculty could also be rewarded more for teaching, especially if this involved developing web-based teaching modules so that students did not have to live in urban areas.
Faculty need to be made aware of rural needs through focus groups and visiting rural practices. Academic medical centers could contract with rural networks for specialty care to preserve or increase their patient base, rather than ignoring rural practitioners and giving them little or no information about patients when they come to the centers for care.
Medical schools should improve efforts in doctor-patient communications, community-based care, and physician leadership skills so that those considering rural practice can build the skills and confidence needed for a rural practice choice.
For the most difficult populations, medical schools will need a different type of preparation. Natives and many Asian populations have a great need for physicians to be able to deal with the spiritual aspect of health. Why should a native go to college, medical school, and residency to become a second class healer, one who cannot deal with spiritual issues? Also the urbanization that occurs would inhibit a return to the reservation or underserved population in need. Admitting urbanized natives or other minorities is less likely to meet the needs of the truly underserved.
What Are Medical Schools Doing?
Other than a few models, medical schools are doing little. Few, if any, have the kind of comprehensive program that reaches out to rural secondary education and extends to graduates in practice.
There are pre-admission programs in some states Kentucky's Professions Education and Placement Program (PEPP) that have worked for years successfully to bolster rural admissions. In more recent weeks I have had a chance to tour rural medical education programs in Minnesota (Duluth and RPAP), Rockford Illinois (RMED), and Missouri. At each location, there was a similar effort to work with small colleges, agricultural schools, and even rural high schools to get more rural applicants. Some states such as Missouri were also targeting the gifted health-oriented students with scholarships to state colleges to keep them from leaving the state.
There are still major barriers with admission committees. Few have significant training. With busy schedules in many other areas, few have time or motivation to take up the challenge of shaping the next generation of physicians. Rabinowitz has demonstrated that a small program Physician Shortage Area Program Links and Info with 1% of Pennsylvania’s medical school graduates can produce 21% of the state’s rural family physicians Selecting for rural and true family practice interest can help with retention.
Few also help the "right" candidates improve their chances of admission, even though rural and minority studies show that this is possible and desirable. Nearly every medical school has a program to enhance their minority admissions. Studies at UTMB Galveston note that minority applications and admissions can continue or increase with these programs despite the reversals of affirmative action. There is reason to believe that more and better rural candidates can enter, especially rural candidates who are also a member of an underserved minority.
What Happens If We Graduate Fewer Physicians, Will We Have More or Less Rural Physicians?
In the past the nation increased the number of medical students so that we could produce more physicians. The "Trickle Down" theory pledged that the excess physicians would eventually distribute to the smallest towns. One Rand Corporation study noted that this theory was working, but the authors later retracted their work as invalid since they excluded the smallest towns and practices from consideration.
We have now entered another era where various groups clamor for less physician production. We know that the more physicians that we allow to graduate or come to our country, the higher the national health bill. Physicians have themselves to blame. The primary rationale for foreign immigrant physicians and non-physician practitioners has been the failure of medical schools to meet the needs of the underserved. Now the nation faces a number of provider excesses. Physician assistant graduation levels will soon be double the numbers of family practice graduates per year. Nurse practitioners continue to expand with no end in sight. Various workforce studies cry out for a reduction in medical school class sizes.
Medical school student reductions could worsen the situation for rural health. The only study of reductions in class size noted that decreasing the class size of U.S. medical schools in the 1980's resulted in a decrease in the family practice match when these matriculants graduated (Fahey, Sachs, Bauer in Academic Medicine 67:10;680-684). One explanation of this is that those admitted from the ranks of the "best and brightest" nosed out those interested in family practice as well as primary care, rural, and those with the service orientation that perhaps distracted them from the kind of effort that resulted in higher GPA and MCAT.
We do know that we are not graduating any more rural physicians from family practice residencies despite huge increases in the number of family practice residency programs, the number of graduating residents, and the number of programs with rural training. Grad Chart Table of rural graduate programs Increasing the number of generalists has not resulted in more rural physicians in needy areas of the nation. Now, more than ever, we should try to select the kind of physicians that will go where they are needed.
What Questions Should We Be Asking?
Unfortunately there is little data and analysis of the more qualitative effects. We are currently not asking the right questions or studying the right outcomes. I heard of a study of cows the other day. Researchers were trying to differentiate cows that might do better in relatively plush lowlands from those that would do better in highland locations. It seems that some cows do more damage to certain types of grazing lands. Who would have thought of such a concept? Someone did and has devised a tracking system that will help analyze and select cows that use certain types of land more appropriately. This person had to get down on hands and knees and work closely with all involved to come up with a solution. This method works in Medical Education also - See Community Driven Approach
How much more information could we collect and analyze on the more responsive students and residents, if we committed to the process of evaluation at all stages from before training to after graduation? What more could we do if we fed that information back to admissions committees and others involved in preparation and education as Madison and others have suggested. Currently most medical schools shred much of the information about their graduates to protect themselves from future legal issues.
What if we stopped listening to the lawyers and kept admission information to use for future admissions. Is a rare lawsuit over the quality of graduates worth the lack of information that could shape the next generation of physicians?
How Could We Get Better Information?
The current process of GPA, MCAT, statement, and interview is just not adequate. Just as we know that a few days are just not enough to help recruited candidates find out all they need to know about a small town, one day is just not enough time to examine a candidate for medical school. Quantitative data is just too easy to collect and use when compared to qualitative for busy people and schools with declining resources. We need a screening process that involves months, rather than a day. There are at least three ways to address selection of the "right" students.
Obviously I favor the pre-admissions method. It involves a more deliberate reward system for those that can demonstrate service and communication. It involves more service to rural communities and less medical school resources. Whatever the process chosen, I feel confident that the students selected through a more intensive process would be a joy to work with now and in the future. They would be physicians who could help restore the public's faith in the medical profession.
For those less willing to put in the work to do the best evaluation and admissions, there is a way to select much better, based on existing information Service Orientation
There is an added benefit of a longer evaluation process. One of the most damaging and difficult physician groups to deal with is sociopaths. I attended the AMA Conference on Physician Incompetence years ago and the conference admitted that these physicians could not be identified or excluded by admissions or licensure processes. My experience has also taught that disciplinary actions only tend to help the sociopath learn how not to get caught. Long term preceptorships (4 months in one program and 9 months in another) are unique in that they identify both students and preceptors who are pathological or impaired. If a similar long term process assessed students before they were admitted, they could be excluded before they had a chance to make decisions that prioritize themselves over their patients. At this early stage, they would also be easier to screen as they would have less chance to adapt and play the game. Unfortunately for medical schools and the public, it is too late to do much about the students after they have been accepted.
In Summary
Various policies and practices exist that limit the numbers of medical school graduates that can truly serve rural communities and possibly the rest of the nation as well. We should work at all levels to encourage better preparation, selection, and training. Medical schools play a pivotal role not only in selections and training, but in advising the state about preparation as well. Rural faculty are in a unique position to influence the many levels and encourage solutions that are efficient and effective.
Recommendations
Factors to consider regarding obstacles to a rural location
Community Level
* Improve education and job availability in rural areas to attract young professionals/spouses
* Health career orientation early at the local level
* Better organization/recruitment/planning in rural systems
* Combat local rural attitudes that local people and services are not as good. It is not a failure for kids to return to their home town to raise families.
* Support rural professionals locally with dollars and people
Higher Education: Colleges and Academic Centers
* Educate and train in the most rural locations possible
* Evaluate students more thoroughly for the right characteristics
* "Take a chance" on rural, minority, or service-oriented students National Rural Health Association Policies Service Orientation
* Reach out to facilitate rural health needs,
AHC's should not be a burden regarding resources for health education
AHC's should help facilitate rural health systems organization
* Support students interested in rural practice with career information, advice, and student interest groups. A particular need is to address specific needs of young professionals, especially the unmarried, minorities, and females.
State Level
* Combat centralization of education resources at all levels
* Prioritize rural economic development
* Retain gifted students and return them to rural communities
* Continue to value educational activities even though some students will leave rural areas and the state.
Environment of Medical Education: Challenges for Generalists and Servants
Hope: Students From the Underserved, For the Underserved