Regarding career advice and rural studies on admissions, plus community
driven medical education CDMED in a nutshell
My study with the AAMC in 1995:
16000 medical student seniors graduating
400 interested in practicing in towns of less than 10,000
Characteristics of those 400 compared to the 16000:
Rural interested 2 times as likely to have done volunteer work locally at each
year of medical school
Rural interested 2 times as likely to have done electives in another nation
Rural interested 2 times as likely to have done a rural rotation
Rural interested 6 times more likely to be interested in practice in a
socioeconomic area (60% vs 10%)
Almost all interested in Family Medicine
Rural interested 2 times as likely to know their final career choice as rural fp
compared to urbans
would an excess of these kids ever be bad? what if we had a whole class of them?
wouldn't they change the med school environment even if faculty or the school
wasn't willing. this is certainly what we see with our accelerated residents
where they are active in shaping their program, their career, branching out to
rural sites all thru residency and serving, etc.
Data from my studies on FP residency programs nationwide in 1995
Programs with mission for rural, located in a more rural state, that did more
obstetrics and more required rural rotations and with program director who was
rural contact were more likely to graduate docs for rural areas (of course it
may be that the rural interested sought them out
Data from Verby studies on 9 month clinical rural preceptorship in Minnesota
By far the best educational outcomes of any medical education program. Took
students below the mean and moved them above. Equaled or outperformed
traditionals in 21 measures behavioral, cognitive, procedural. Program directors
in FP glow about these and the Syracuse kids (12 months in senior med school
year with rural FP). At 3 months the RPAP kids overwhelmed with primary care, at
6 months they were neutral, at nine months they did not want to leave. In fact
they and the Canadian students coming to the US for electives and 4th year
medical school rotations do not like it at all because they have learned to be
hands on and make decisions on patients (something Flexner and Osler noted as of
prime importance), but they are 5th in line. Such is the deterioration in
American Medical Education nationwide, very slowly over time almost undetected
and unspoken. I think this treatment at ours and other medical centers also
ensures that the medical centers get few referrals and little respect from such
students.
It is my opinion that this delay in medical maturation and decision-making is
what inhibits a number of decisions in career and specialty, especially primary
care and underserved. When maturation is accelerated, such as with our
accelerated rural training program or RPAP or any long term rural preceptorship
where they get to make decisions, they master medicine and move on to practice
management and understanding interactions with the community, government, the
need to find a location that is a good match for them, etc. These programs have
already graduated more than their share of FP and rural community leaders, with
more coming.
My studies on RPAP with 900 graduates in 30 years at a cost of $30,000,000 -
economic impact to rural Minnesota alone is 2 billion dollars, making it perhaps
the best rural economic development program ever.
Data from Rabinowitz (Jefferson PSAP program in urban private Jefferson in
Philadelphia) and Boulger (Duluth). The keep staying, and staying, and staying.
Rural FP Grads in rural practice in these states there since 1970's and still
there. In PA the PSAP is only 1% of the class, but now represents 21 % of the
rural fp docs in the state with the largest rural pop in the nation. Data from
Mindanao program in Philippines where only 20% of traditional grads stay in
Philippines, this program retains 80%. They are great in community health and
primary care, weak on therapeutics. Of course they also have a poor pop with
virtually no resources so the ability for meds and treatments beyond basic
public health is nil.
You are correct about minorities, according to AAMC data. Minorities 4 times as
likely to locate in underserved areas (40% vs 10%), but not rural according to
my studies.
Changes in admissions to meet the needs of the state thru Waldeman and then Jeff
Hill: basically have been choosing these kids for years, thank God. That is why
we have the 8 different FP residency programs that we have serving a variety of
regions across the state, all with a focus on underserved (7 rural, 1 urban
inner city). It is why we are the NRHA Program of the Year (did you know this?)
We could do nothing without these kids and would still be graduated 30-40% rural
instead of 60 - 70% rural in the past 6 years. Evidence of meeting needs: PA
program and NP program in balance or exporting a few to urban or out of state
areas each year. FP graduates in balance with needs currently.
National and state policies to pay docs to go rural and underserved are
expensive, temporary, and inefficient. They steal tax dollars from the poor.
They steal physicians that would have gone to more underserved areas, but allow
them to go to less underserved. The J-1 Visa folks in particular may help for a
short time of 2 or 3 years, but they the go get a subspecialty and locate in
areas that have enough docs and cost the national health budget $400,000 a year.
This continues because a few states are absolutely dependent on them. Getting
the right kids is less costly in the long run. Of course in some areas it means
changes in education and small colleges which may look more costly, but also
serve a broader purpose of restoration and equity.
RHOP basically restored small colleges at Chadron and Wayne, academics,
admissions, competitiveness, ability to get young professionals of all types
admitted (not just the few RHOP kids). They have given rural kids a choice to
stay rural with their college education, rather than going to Lincoln or Omaha.
They are more likely to marry a spouse at these locations that will (want to and
be able to) return with them rural, as compared to going to urban areas and
subspecialized colleges. Fairbury lost their small college years ago and
devastating for area and Peru may go if we are stupid. Small colleges are the
breeding grounds of young professionals, they are the bounce back capability for
a region that loses a major employer or in recession or major change in
economics or workforce. Canada and other nations with no small college system
doing well enough to get folks admitted is hurting for kids with the right
stuff. Rabinowitz in PA depends on small colleges for admits and works with the
small college health advisors on admissions, a key role for them.
Any governor in the nation could recreate RHOP with no money, only an executive
announcement needed and follow up to make sure state medical schools found a
Jeff Hill to implement it and did so. It would help for the small college to
have a rural high school career fair like Chadron does. I wish our career fair
would be at Wayne State.
All except a hand full of medical schools basically shape their admissions
because they shape health advisors that shape who is interested by encouragement
or discouragement. They do so for a variety of pressures such as making their
admissions to professional school look good. This shaping is almost all
intellectual. College health advisors lament the fact that they know kids with
the right stuff, but they cannot get in due to a variety of obstacles such as
income, working during school, grades, performance on standardized tests, lack
of polish on interviews, difficulty completing academic and "look good"
prerequisites.
College advisors and med school admissions teams try not to frustrate the
marginal intellectual kids with the right stuff by getting them all enthused
only to watch them 1. not get in, 2. "waste their lives" trying to get in over
and over, 3. get frustrated with debt when they get in and cannot do well enough
to graduate. Of course studies show that the academic risk or performance of
those from the most underserved areas cannot be predicted as well from the MCAT
and GPA as can the usual white upper class or upper middle class college student
with professional parents who came from a class college where they have a track
record of getting in with the usual polish such as research summers, cultural
experiences (likely summer vacations), etc. Howard University documented this
well. University of Toronto documented the movement toward extinction of those
getting admitted from the lowest socioeconomic quartile.
We are losing more and more kids from
1. rural areas due to deterioration in education, consolidation, population
(some areas), loss of role models in service and professions
2. Centralization of state resources cutting jobs in more peripheral areas plus
above leads to a downward spiral only reversed by reversal of state policies on
centralization, return of professionals, services, education, and local
leadership
3. loss of small colleges due to extinction of these colleges and their
preprofessional training
4. loss of service ethic to a nation become more and more uncaring and dependent
on institutions and bureaucracies rather than caring people and caring
communities
5. loss of generalist perspective in medical education, broad preparation,
service ethic, broad choice, maturation and emotional intelligence over
intellect
6. loss of working class kids due to finances and their need to work during
school and other pressures to support their families, parents plus the slavery
that we have regarding medical school debt and its impact on kids that could
make a difference
These impacts are worse in the South and some Midwest states, usually education
and lack of tax base are too much for many counties in these areas to overcome.
In these states more reaching out is needed to encourage kids at younger and
younger ages, with the risk that you will encourage the kids who want to escape
or will socialize them out of wanting to return. In Pennsylvania and other
states they can choose at the small college level. In Tribal reservations,
Appalachia, and other regions and disadvantaged nations, there is a need to move
into the earliest education levels to have hope at all.
Solutions:
1. Get kids from underserved areas, train them as much as possible in
underserved areas, support their practice in underserved areas
2. work with rural high schools and small colleges, link with health advisors
3. work with these kids and underserved communities
4. keep from providing obstacles as much as possible
5. develop leadership people that rise to decision making in health professions
schools
Bob Bowman
Longer version with links Restoration of Communities, Nations, People: Role of Rural Family Docs
