Summary: Absolutely no risk! Studies of those who are most interested in serving the underserved (Characteristics of Rural Interested Students and Minorities and Education) note many positive changes beyond distribution and access. Changes would include more volunteerism, more international experiences, less pursuit of income, more emphasis on primary care, prevention, public health, and communication. The economic changes with better selections and training are tremendous Breeding Young Professionals and Healthier Rural Communities .
Risks - academic performance, debt situation, more faculty effort, better support for rural and minority kids out of their element
Obviously at graduation time, if the sites that these students and residents prefer are filled, they can choose other locations. Trying to produce too many of the usual students to hope to have them trickle down to underserved sites does not work. The approach that selects and trains for the underserved has to have the right students.
For decades the nation has had a shortage of physicians for underserved rural area. Millions remain with poor access to health care in inner city neighborhoods. The nation has attempted to approach this problem in various ways.
The Flexner reforms changed medical schools. The apprentice methods of training many rural docs came to a close. Many other medical schools closed. In urban areas, 3 of 5 black medical schools closed. It is not known how this impacted care for those in poverty or rural areas, but it is likely that access declined. With the decline in the numbers graduating from medical schools and the increase in the quality of training, physician income began to rise.
The remaining medical schools were located in large urban areas. Medical schools realized that indigent populations were a ready source of patients for learning purposes. They worked with hospitals and local government to access these patients. These efforts were at the discretion of the medical school and not without protest from hospitals and private doctors (Ludmerer). These partnerships served medical education and urban communities well, but such mechanisms did not work well for all underserved populations.
In the 1960’s several the nation made some important changes. The first efforts that would become Community Health Centers began. The nation declared a war on poverty. Medicare and Medicaid were initiated. Indigent and elderly patients now had the potential to access care. Unfortunately there were not physicians available in the most needy areas. The early studies that resulted in the specialty of Family Medicine began.
The nation financed other studies at this time. These convinced the nation that increasing the supply of physicians might force them to go to more and more needy areas. In the decades since the nation financed more medical schools and medical students, the shortage areas have remained.
In more recent years many have touted increases in primary care physicians as the solution for underserved populations. Increases in primary care numbers have not improved access for underserved patients. Physicians who chose primary care specialties based on convenience and economics may not be the ones who choose underserved areas. Among the primary care specialties, Family Medicine benefited most of all from pledges to serve indigent populations. Family Medicine responded with a product that did distribute throughout the nation. Family physicians are the most critical provider in shortage areas. Despite this, shortage areas remain. In the past 30 years of Family Medicine, there has been no change in the numbers choosing rural practice each year. This number has remained a constant at 660 – 800 despite massive increases in the numbers choosing family medicine. Family physicians choosing inner city poverty locations did rise at the height of family medicine match glory, but in recent years these numbers have receded. The nation has invested 1 billion dollars in Title VII in just the family medicine component.
Overall funding for Community Health Centers, National Health Service Corps sites, Tribal Reservations, and migrant populations has increased. You can make a case that we have tried everything except a coordinated approach to selections and training from and for the underserved.
Perhaps the nation has taken the wrong approach. At no time has the nation consistently focused on the admissions process. While it is considered an honor to serve on an admission committee, it is one of the most difficult and unrewarding academic tasks for faculty. Committee members meet once or twice a week for months and interview hundreds of applicants.
Despite a century of faith in the scientific method, medical schools rarely study one of their most important areas, their graduates. It is the rare school which takes the time to prospectively record, store, and analyze data. Committees have been told to even destroy data for fear that the school might become involved in a competency lawsuit regarding one of their graduates. Medical schools barely keep track of addresses to help with alumni and fund raising.
In recent decades studies of minorities and those with rural background and family practice interest have noted that students with these characteristics choose underserved areas. Delays in recognition of these studies are a reflection of other priorities for medical schools.
There is growing recognition that medical schools can select physicians who are more likely to go to underserved areas. This may take extra care in selection and more preparation for certain students, but the end result will be more who can choose underserved.
Have there ever been successful initiatives to encourage or mandate medical schools to select students that are more likely to choose underserved areas?
· Affirmative action has increased the number of underrepresented minority (URM) students graduating from medical school. URM students are known to be 4 times more likely to choose underserved areas (40% vs 10%) AAMC studies. Now of course the nation has deflated affirmative action programs and lawsuits threaten to curtail the few remaining efforts.
· A state senator in 1970 threatened to withhold funding from the University of Minnesota if it did not meet the needs of Greater Minnesota. The Duluth 2 year medical school and the University of Minnesota Rural Physician Associate Program resulted. These programs have graduated over 500 physicians into rural practice for an economic benefit of over 1 billion dollars to rural Minnesota alone.
· Studies clearly demonstrate that preferential admission of students with rural background and family practice interest can result in increases in the number of rural physicians graduated by the school (Rabinowitz). A select few medical schools have also had success with this approach, but their numbers are not increasing.
Basically medical schools have not elected to change their admissions process.
Medical schools have not even tried a common sense approach. In order to get physicians to put forth the effort to serve challenging underserved communities, it makes sense to select candidates who have prioritized service in their words and actions. Madison studied service-orientation and noted that these students were more likely to choose primary care. Studies did not examine eventual practice locations. Other studies suggest that this effort might result in success, perhaps for both inner city and rural underserved locations.
· Students interested in the smallest rural communities, those less than 10,000 people, have some interesting characteristics.
Medical schools selection committees may be emphasizing intellectual intelligence to the exclusion of students with other important qualities. Students with more altruistic motives may have other options. They may be turned off by traditional medical education approaches that do not emphasize service.
What if more rural candidates were selected? What if more rural and inner city training were available?
In this situation, there would be enhanced access. There is the possibility that practitioners might stay in practice longer. Even a few months longer goes a long way toward meeting shortage area needs and greatly improves access (Christ – Title VII).
In a worst case scenario, these physicians who were trained for underserved areas would not be able to find shortage area jobs. Some would choose primary care jobs. Others might choose to return to training. Even this is not a loss for the health system. Such physicians are more likely to work better in health systems, having trained in primary care, then having practiced primary care, and then practicing in a subspecialty. Communication and patient care would most likely be improved.
In the current scenario that we have now with too many specialists, each one adds hundreds of thousands of dollars a year to US health care costs. All physicians, those serving the overserved and the underserved suffer under the restrictive practices necessitated by overspending on health care. Those in underserved situations face the most difficult choices. Clinics and physicians in underserved areas can ill afford to deal with even the current 5% cuts in Medicare, the escalating cost of maintaining a high standard of care, the rising costs of equipment, and the skyrocketing costs of liability insurance.
Underserved - Overview and Models