RCB Commentary 

Medicine's social contract entails the granting of many privileges to the profession in return for its willingness to be accountable for serving societal needs. But, on occasion, medicine is held accountable for solving a societal problem that is not totally within its power to resolve. A case in point is expecting the medical profession, in particular its academic component, to solve the dilemma of doctors' not choosing to practice in some areas where they are needed.

Medical schools do have responsibility and ability in this area. (Butler, Academic Medicine's Season of Accountability and Social Responsibility)

Medical education efforts have changed the way medicine is delivered through specialization and the support of facilities and technology. Many thought that the art of medicine could not be taught, but students now do a much better job of communicating and gathering information. (Ludmerer, Time to Heal) When medical schools have focused on areas of need, results have been forthcoming.

To claim that medical schools are powerless in the area of maldistribution is inaccurate. Medical schools have reshaped high school and college curricula. See Flexner’s Impact When schools want to add calculus or physics to entering requirements, colleges and medical schools have had to follow suit. (Ludmerer, Time to Heal) Medical education has developed the Family Medicine specialty whose graduates have made by far the greatest impact in rural areas. That academic medicine refuses to fully recognize and support Family Medicine is its own problem. Family medicine also needs some changes to embrace the underserved.

Medical education has been able to meet the needs of underserved communities when it has adapted to the unique needs of these communities. In particular, medical education programs that choose the right students have been able to meet underserved inner city and rural needs. Dr. Cohen understands this point well, and is not totally unaware of the potential for meeting the needs of the underserved in this important area!

Dr. Cohen does correctly point out the problems in education and admissions. Without a coordinated program, distribution is unlikely.

As we all know, many Americans living in rural and inner-city areas do, indeed, have limited or no access to physicians' services. The complaint that doctors don't choose to practice in these locations is valid. What is invalid is the expectation that the mere existence of a need for physicians' services will suffice to offset the many disincentives faced by physicians who might otherwise respond to that need. There are many factors beyond a given community's need for doctors that individual physicians must weigh in deciding whether to set up practice there.

Doctors do have free choice about where they locate and what specialty they choose. Medical education has learned that it is possible to choose students who will go to inner city and rural underserved areas. These students usually demonstrate far more emphasis on service in their education, volunteer work, admission essay, etc. This information is available to those who are willing to dig deeper during admissions interviews. (Service Orientation)

More about these disincentives later. Suffice it to say for now that the "disincentives" that this editorial suggests, might even be "incentives" for students with the right attitudes and characteristics.

Dr. Cohen represents a certain mindset that is becoming more common as medical schools admit more and more of higher income levels and as the medical school leaders come from the same elite schools, but there are other viewpoints from rural or inner city or humble origin or distributional perspectives. There are clearly physicians hungry to serve and communities who desire the best care, not just any physician.

But simply increasing the supply of generalist physicians will not, as some policymakers glibly assume, solve the problem.

Medical leaders in recent decades asked for and received governmental assistance to increase the size of medical school classes. They justified this by noting that they would be able to trickle down more students into underserved areas. It is possible that their requests were based on the needs of medical schools, not the needs of underserved areas. Another possibility is that they did not understand what they were proposing. In any case, they were unsuccessful. The funding for these efforts dried up.

Instead of learning from mistakes and from the positive results of other studies, medical leaders seem to be stuck in past ruts. After using the underserved and advocates for the underserved to lobby for increased funds, they have turned their backs on them and have washed their hands of responsibility.

Health professionals education represents one of the South's major successes….. despite increases in the overall supply ….. serious problems of distribution of professionals to geographic, subspecialty, and public service areas of need continue, except for those situations in which carefully coordinated strategies have been directed to specific problems Southern Regional Education Board 1983

Increasing the supply of generalist physicians has worked, when the right generalists were admitted into medical school.   PSAP     Duluth    

Such studies demonstrate that the needs of rural communities can be met.

A major issue is the economics of medical practice in many underserved communities.

This is way out of organized medicine's area of expertise. Where has the AAMC been in supporting the economics of rural practice? Why has it not fully supported training in rural areas that would deliver economic benefit to rural communities? Why has it not supported the establishment of training programs for physicians in rural areas? Where is the support for better pay for generalists, especially in rural areas? Where is the support of more teachers and better education funding for rural areas, again a major source of economics for rural areas? These investments in education and health would obviously help the economics of underserved areas.

Cause and Consequence - Economics http://srdc.msstate.edu/publications/207.pdf

By the numbers: Rural Doctors and Rural Economies

Leaving aside the not-inconsequential matter of medical student indebtedness (the mean for 1998 graduates with debt is $85,619), a physician considering practicing in a medically underserved area must ask whether it is economically feasible to do so.

AAMC data demonstrates that those senior medical students who are interested in rural practice are not as concerned about income when compared to their peers. By selecting more students with these values, medical schools will likely find doctors who are more dedicated to service and less influenced by what income and call and time off arrangements that they have. Any worker in America would be nauseated if they were present at discussions regarding the number of weeks that radiologists have off a year while making 10 times the average worker’s salary.

Incentives such as primary care loans and loan repayments to locate in rural areas are in plentiful supply. This more than offsets debt, for those truly interested in rural practice. Living in or near enough to some inner city areas to be able to practice is far more costly and may be more of an influence, but this is a cost of living issue, not debt. Cost of living is not a problem for those who need to located in nearly all rural areas.

Typically, communities that need physicians are populated by many people who lack insurance or who are otherwise unable to pay for their medical care.

While it is true that there are rural communities that are populated by those who are poor, federal programs such as Medicare and Medicaid and Community Health Centers and Rural Health Clinics and expansions of these programs for rural areas have reduced this concern. There are countless communities who have sacrificed much effort to ensure a functioning rural health system who have suffered because medical education does not select and train physicians who can locate in rural communities.

Often times those in rural communities choose to go to physicians based on who they know or not. People in rural areas can find out much about new physicians by just living in small towns. By supporting policies that push the most inexperienced physicians into rural areas, medical leaders are ensuring that rural people bypass the more isolated health services in favor of those in larger towns. Studies show that when people leave rural communities for health services, they also take other expenditures to other towns. This causes problems for the rural economy in many ways.

Anyone who is unable to support themselves on the average starting rural physician salary of $120,000 is not able to make good choices when making twice or many times this amount.

Many in our society feel that what doctors make is unconscionable. AAMC could do much to work with medical schools and medical students to reduce financial pressures on students and physicians. By decreasing monetary rewards, more candidates would be interested in medical school for the right reasons.

Each year for the past 3 decades about 600 graduates of family medicine residency programs choose rural practice. Chart FP Grads  This number has not changed much despite major changes in the number and composition (gender, minority) of residents in family medicine.

One of the most major errors in this editorial is the assumption that the poor rural economy is to blame. Rural Health is one of the greatest contributors to the rural economy. See By the Numbers For Data  The smaller the town, the larger percentage of the economy that is involved in rural health care. If medical schools adopted the right admission policies and admitted the right students, then more would locate in rural practices. This would result in major improvements to the rural economy. It would also tend to support the movement of more young professionals into small towns.

If medical schools did a better job in leading their states and helping them understand these issues, they would work for better education, better training for rural teachers, more feeder programs at the high school level, more high school career days, more cooperation with the small colleges that prepare preprofessionals and help them to stay connected with rural areas, etc Rural Health Opportunities Program.

Community Driven Approach

In order to accomplish these goals, medical schools have to give up some of the control that they have been unwilling to share. Medical leaders would have to pay attention to existing studies that demonstrate how successful rural medical education articles work. Leaders would need to work with rural peoples. They would have to lead their schools in areas such as willingness to take risks on service-oriented candidates. They would re-learn that they have the ability to influence college and high school programs to prepare medical school candidates in more than science and math. They would learn that they shape medical education and the role of physicians in society by who they select and how these candidates are prepared.

Consequently, many physicians who might otherwise choose to serve such communities are dissuaded from doing so out of concern about being able to support themselves and their families.

More important is the barrier of getting students that are dedicated to service. Also it is important to select students who are willing and capable of dealing with socioeconomic barriers and a variety of differences in race, occupation, and culture. The intellectual medical school candidates preferred by nearly all medical schools who grew up, attended school, and trained in exclusive high income zip codes may not be as willing to learn how to work in these important areas.

Finally, even if economic considerations can be met, the social and cultural characteristics of most medically underserved areas present daunting obstacles to many physicians who might contemplate practicing there.

 Most rural people would find this statement offensive. They feel that they work hard to support the quality of life that they have. They do not see their quality of life as inferior. In fact, they do not understand why people put up with urban culture.

Rural is not lack of culture, it is a different culture with different lifestyle, values, entertainment, etc.

If medical leaders worked with rural people, they would learn about these areas. If medical leadership included more who came from rural practice, the effect can be enormous. Even if it is too costly to use faculty to spend the extra time and effort to admit the right students, it is possible to find rural people who will assist admission committees in this task.

You Know You Have Chosen Students That Are Likely to Become Rural Docs When

In inner-city settings, these obstacles include concerns about personal safety, working in impoverished surroundings, and dealing with a host of intractable social problems inextricably entwined with the provision of medical care.

Again, there are means of dealing with seemingly intractable social problems. Medical school leadership and physician leadership can and has made a difference.

There are inner city setting with a good way of life as well. There are rural areas not different than the top city locations. The problems with society often involve extreme concentrations of poverty and wealth side by side. Many find areas such as the Midwest refreshing where there are fewer divisions and where children of all economic levels have a decent chance at college or medical school.

Concentration is the real problem and decisions that concentrate education and health are the major issues. This can be a problem in rural or urban areas, but is not exclusive to either.

In rural settings, professional isolation, lack of employment opportunities for one's spouse, limited educational options for one's children, and a paucity of satisfying cultural and civic outlets naturally enter the calculation when young physicians weigh their practice options.

Rural people would find the same "paucity of satisfying cultural and civic outlets" in urban areas. They would worry about the amount of heavy metals in fish caught in urban parks.

Rural is not lack of culture, it is a different culture.

The basics of graduating more rural doctors is to admit the folks who already like the rural lifestyle, prefer the others who may have the ability to grow to love it and then there will be more rural doctors choosing rural practices and staying.

Sometimes rural people miss having a certain store nearby, but they are used to driving long distances to get what they want.

Most physicians are too busy for the type of "satisfying cultural and civic outlets" that are mentioned. They are more interested in raising their kids well. Something that is often a bit less challenging in many rural areas.

There are even benefits for those who are forced, by National Health Service Corps, to select rural communities. NHSC physicians choose underserved locations far more often when leaving their obligation.

Policymakers and lawmakers representing the underserved seem to be unwilling to accept as legitimate these and other reasons that dissuade many young doctors from settling permanently in needy communities. As a consequence, their efforts to correct the geographic maldistribution of physicians have been notoriously ineffective. I believe it is time for us to cease beating our public-policy heads against a wall. We need to de-emphasize the necessity for permanent physician settlers in areas unattractive to most physicians. I believe, along with many others, that we can solve the geographic maldistribution problem by placing fully trained U.S. graduates in underserved areas for substantial, albeit limited, periods of time.

"The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best-trained physician that can be induced to go there." Abraham Flexner

Osler also had great respect for rural practitoners see Osler and Rural Practice

"The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but...this argument is insincere, and that the excuse which has hitherto been put forward in the name of the poor boy is in reality an argument in behalf of the poor medical school." Contributor: Murray, T. J. p. xi Flexner argued against the poor medical training of the time, often little more than an apprenticeship by a poor quality physician extracting work and pay for education.

The training is much more consistent and can facilitate distribution and retention, but this is a focus involving selection of those most likely to choose family medicine and choice of family medicine.

The model for doing so is already at hand in the National Health Service Corps. We need to greatly expand the NHSC, or initiate a similar program, to enable many more U.S. medical school graduates, after completion of post-MD training, to spend two or three years in public service, perhaps in return for substantial educational loan forgiveness. 

The NHSC has just celebrated its 25th anniversary, and is examining how it can be most effective in the future. The AAMC has stepped up its own advocacy on behalf of an expanded NHSC, and I think everyone in academic medicine would do well to vigorously support such an expansion.

(Translated NHSC is a good egg, but we also need a way for students to continue to afford to go to our medical schools.)

Should the nation continue to prop up exorbitant tuition levels from some schools instead of supporting 2 or 3 NHSC students for the same cost who happen to have less tuition and better probability of staying in underserved locations?

Even better, why doesn't NHSC require that they will choose the physicians that they want and place them in medical schools that they wish to use for training!!!

NHSC should set a minimum payment available and force schools to match the extra dollars if it hopes to be efficient with funding.

Substantial public education will be required, however, to wean many people from the notion that the only way to access quality medical care is to have a lifelong relationship with a single physician. Having a series of two- or three-year relationships with fully trained physicians is far better than nothing. As is so often the case, the quest for perfection can be the enemy of the possible.

Dr. Cohen is certainly capable of visionary leadership. See the Collaborative Care model and how he promotes it and how medical leaders could work to accomplish it. When compared with the above address regarding maldistribution with this address, his closing statement is perhaps the most compelling, "Rather than accepting the limits of today, let's harness that creativity and wisdom to explore the possibilities for closing the gaps for a better tomorrow."

Please, Dr. Cohen and other medical leaders, don't accept the limits that you have proposed for rural physicians and their patients. Please do promote policies that graduate more rural doctors. The baseline for the Collaborative Care model is still the same one for all of us, the doctor-patient relationship. Anything that promotes a series of temporary doctors rather than a longer term model where patients and doctors get to know one another and doctors get to know the environment and populations they serve, is less than the best and doomed to failure, Darwinian or otherwise.