Inequality and Medical Education – A Tribute to Martin Luther King, Jr.

Robert C. Bowman, M.D.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. Martin Luther King, Jr.

One of the greatest problems of history is that the concepts of love and power are usually contrasted as polar opposites. Love is identified with a resignation of power and power with a denial of love....What is needed is a realization that power without love is reckless and abusive and that love without power is sentimental and anemic. Power at its best is love implementing the demands of justice. Justice at its best is love correcting everything that stands against love. Martin Luther King, Jr.

Those who deliver health care are among a privileged few that access the opportunity to develop relationships with all types of Americans. Health care careers represent the chance to become aware of the hopes and dreams of the American people and the reality of their daily living.

Physicians and those who train physicians must open their eyes to the opportunities, the realities, and the responsibilities. Vision is a common word used to express a unique ability to see the direction of the future, but a more basic interpretation is needed. The United States needs more than just vision from those who delivery health care. The United States needs physicians and physician leaders to experience, perceive, and put themselves in a position to improve the daily lives of most Americans. This is a focus that is best shaped long before medical school admission and continues throughout life. With a focus on selecting and training those who see, many of the problems of health care delivery can be solved. Until physicians and those who lead the nation in health care can see better and better with each generation of physicians, even basic problems cannot be solved. 

The State of the Union in health care leadership can be summed up in visual terms as the legally blind leading the legally blind. Vision is possible, but it is not well focused. United States health care leaders have stated that physicians will not go where needed, that primary care is not marketable to the American people, that medical education is good for the economy, and that more physicians are good for the economy.

·         Those who are aware are familiar with multiple ways to double, triple, and quadruple the probability that physicians will go where needed. Those who see can best facilitate health access recovery, but those in charge fail to see health access solutions or perhaps their vision is clouded by other priorities.

·         Primary care is not a commodity that is marketable. Primary care is essential at nearly the same priority as nurturing, child development, early education, local public security, and public health. Primary care should never be considered marketable or market driven. Even family medicine made a mistake attempting to market their “brand.” How can a priority focus on unique continuity relationship to patient and family and community be marketed or branded? A health care foundation demands that the American people establish a relationship with doctors and nurses that they call their own. Primary care as currently designed is challenging because of the design set up by health care leaders who have become blind. They fail to see the essential role for primary care as a foundation for health care in America. Primary care is also the major beneficial local economic benefit from health care for most Americans. Most of the American population resides in locations dominated by primary care. Specialty and hospital care is reserved for exclusive locations with far less than a majority of the American people. To see primary care, medical leaders must be in entirely different locations and must have entirely different backgrounds. This makes vision difficult regarding basic health access.

·         Finally, the contribution of medical education to the health and economic well being of most Americans is limited, especially compared to claims by medical education. 

Medical education has played the dominant role in shaping American health care for nearly a century. The programs, policies, legislation, politicians, and health care businesses have been shaped by medical education. Medical education mainly sees what its concentrations of physicians see and medical education represents the top concentrations of physicians, specialists, and health resources in America. The same concentrations are found in medical associations and also in physician assistant and nurse practitioner associations. This is inevitable when 90% of training and 75% of graduates are found in zip codes with 75 to 5000 physicians that have 80 – 92% of the specialists in the United States and less than 20% of physicians in primary care. The limitation of experience is complete as the predominant medical student admitted shares origin in this 4% of the land area as defined by top concentrations. Beyond this 4% of the land area is a very different nation that waits to be re-discovered by a medical education that has spent the last century moving away under a different design.

The Flexnerian centralization, academization, and concentration of health care established an important framework for admission, training, and discipline but it has generated a number of serious consequences in health care cost, quality, and access. From the start, health access schools and programs were among the first terminated under Flexnerian reforms (Ludmerer, Time to Heal)    The design has had consequences in economics and government as well as in health. The case can be made that the United States is spending so much on health care that all Americans are impaired by a design that impairs all government budgets from school districts to state to federal and a design that impacts all businesses.

Do we have such a short range of vision that we have forgotten that the recession of two decades ago was shaped by health care costs and was resolved by addressing health care costs such that the economy could catch up and take off?

This resulted in a climate that took America (and the world) on one of the longest periods of economic progression in recent history. Perhaps our vision is clouded by foreign defense, energy costs, and health care costs rising up together once again. And since we still have health care issues unaddressed dating back for 30 years, we still have three main problems rather than two.

The consequences of poor vision in physician leadership have never been higher. At stake is the very role of physicians in health care and in society. Do patients trust physicians? Do medical schools focus on the needs of the nation or do they focus on their own needs? Do physicians focus on the future of their patients and the nation or do they focus on their own future? Do medical schools understand that a medical education that better met state and national workforce needs would be more likely to attract state and federal funds for medical education? Do they understand the gathering frustration of the majority of states left behind by the design? Do they even gather much information from these states since so little of medical education occurs there?

Do physician associations serve as they say they should? The Association of American Medical Colleges (AAMC) lists its mission to improve the nation's health by enhancing the effectiveness of academic medicine, but has the focus on the nation's health been lost? Is the nation as healthy as it should be in health outcomes as well as economic outcomes? Are American children stronger in mind, body, and spirit leading to better personal health, economic health, and national health? Does academic medicine lead the nation to stronger children by exposing the process that leads to lower levels of development, health, and potential for most American children? Physicians commonly complain about populations dependent upon social programs, but do they see NIH and graduate medical education as the same dependency? Would the elderly support billions more dollars taken from their health care to go to graduate more residents that will still be in the wrong places and careers to care for 70% of those age 65 and above, or even those 55 and above? Would they vote for or against the recent losses of 25,000 taken away from internal medicine primary care for hospitalist care – a move that depletes adult primary care and geriatric care at a time when the US population over age 65 is increasing from 35 million to over 70 million?

Will medical educators reflectively self-assess the health care situation in the same way that medical students are supposed to be taught? It is time for medical leaders to adopt reflection in action and reflection on action that are the mainstays of the reflective practitioner – one who contributes and communicates much more than simple health care solutions. We teach our students to be reflective, but do we practice reflective self-assessment in the areas that determine the future of our profession and the health of the United States?

Will medical education finally enter the time of accountability and social responsibility proposed by Butler in 1991 or will medical educators continue to react reflexively in a counterproductive way? Do medical schools and teaching hospitals truly impact their surrounding zip code populations that have had some of the highest rates of poverty and poor health in the nation for past decades and more decades to come?

AAMC reports have been compiled to demonstrate the economic impact of medical education. It is important to understand that medical education is clearly the major beneficiary of the current health design. Medical schools and teaching hospitals have continually placed themselves at the center of all of the major lines of health revenue and receive the top reimbursement in each line. Million dollar state and national reports do demonstrate the economic impact in dollar amounts far above the experience of most Americans, but most Americans do not experience the economic benefits of medical education. US allopathic medical schools and teaching hospitals pump over 512 billion dollars into the US in economic impact, but half of this goes to a few dozen zip codes in 6 states and only 10% goes to 25 states.1 Each federal medical education dollar gathers 19 more dollars to concentrate the economic impact in a few locations, but outside of a limited 2000 zip codes receiving top concentrations, locations have few or no federal dollars.

The primary products of medical education are supposed to be physicians, but this primary function is more and more obscured by other emphasis areas. The economic impact of this physician product is also limited. About 75% of physicians are found in zip codes with 75 or more physicians that are found in 3400 zip codes in 4% of the land area. These zip codes are clustered together in a small portion of the largest cities and contain a favored 35% of the population. These zip codes inside of concentration have 70% of internal medicine and pediatric primary care, 80 - 92% of specialists, and over 90% of researchers, residents, faculty, and medical students. Given this pattern of concentration of the physicians associated with top funding and resources, about 80 – 85% of total health spending in the United States is likely to be associated with these 3400 zip codes. It is hard to design a distribution of physicians, economic impact, and health spending with less benefit to the nation as a whole.

Whose economy is impacted by the designs of health care and medical education?  The economy impacted is not the economy of most Americans. Over 65% of Americans are left behind in one or more dimensions regarding access to services, economic impact, basic health care coverage, secondary services, and the local leadership benefit of highly educated professionals.

Health care has more than enough funding for consistently the best outcomes for all Americans at 2.4 trillion dollars, but the design of spending fails in efficient return on investment. Disturbing dependencies are seen with substantial and increasing portions of health spending going to those that are not delivering health care.

Again those who “see” understand that Alaska and dozens of states are spending 2 million dollars more each year to maintain the same insufficient level of workforce for much higher cost. Each year state reports indicate that Alaska’s health access locations pay more for costly temporary locums workforce and pay more just to replace departing primary care and to retain existing primary care. More and more in locums, recruitment, and retention payouts to get insufficient care is the result of design failure in health workforce training and design failure in primary care delivery. Expansions of safety net programs fail without sufficient primary care nurses and physicians. The building of a new facility or yet another incremental adjustment in primary care reimbursement is an easy task compared to the 50 years required to reconstruct the primary care training design and restore basic health access. Real health access primary care to meet 80% of Alaskan primary care costs about 10 million per year, but the state continues to pay 8 million, 10 million, 12 million, 14 million, and increasing amounts to get the same grossly deficient primary care workforce. Alaska has had to craft different mental health, different local health care, and different oral health already. It will also need to craft medical education that does fit the needs of the state and at least 25 other states with the fewest physicians and the least workforce coming from the typical sources will need to follow suit.

Real health access primary care delivery requires sufficient and specific primary care workforce to be produced so that 65% of Americans residing in 28,000 zip codes in 96% of the land area can move from 30 – 50 primary care physicians per 100,000 to 100 or above primary care physicians per 100,000 (Data compiled using the Physician Distribution By Concentration Coding System ). This is a level sufficient for the higher concentrations of elderly, underserved, and otherwise most complex patients who reside beyond zip codes with concentrations of physicians. Few understand that those on fixed budgets or lower salaries can ill afford to live in top concentrations of physicians and health care. They must depart for locations where the cost of living and the cost of health care is more reasonable. Of course the distribution of physicians and health resources can make it more difficult for health care to be found outside of concentrations. And the aging of the population, poor Medicare and Medicaid reimbursement levels for primary care, and the rapidly rising cost of all health care will make it more difficult to find care at all.  

United States medical schools have not been the best possible partner in the nation’s quest for better health care. Medical schools favor admission of the students with highest scores, highest grades, most prestigious schools, and most prestigious parents during a selection process that screens out those more normal. Even when children arising from top concentrations or combinations of concentration fail to gain admission in United States schools they have second, third, and fourth chances in other paths to medical practice. Those from other nations that gain entry to the United States workforce have the same exclusive characteristics. Those most exclusive make career and location decisions that take them away from care of lower and middle income, elderly, lower and middle population density, poor, near poor, and Community Health Center populations. Most consistently those born, raised, educated, and trained in top concentrations for the first 30 years of life choose schools, programs, careers, and locations associated with top concentrations. They are more likely to arise from about 3400 zip codes in top concentrations and they are found 80% in 3400 zip codes clustered together in top concentrations of physicians, specialists, people, income, and health resources. Currently top concentrations are promoted as a benefit to all but a design that favors top concentrations is a design that ignores much more than a majority of Americans left behind.

No studies demonstrate that exclusive medical student selection results in better physicians and there are consequences of the exclusive focus in admission. Those most exclusive have half of the probability of serving the populations and locations and ages in need of care.2, 3 A narrow focus has consequences regarding what can be seen and what can be done. A focus on top scores, grades, schools, academic focus, and science focus shaped by exclusive parents has consequences. Studies do demonstrate lower levels of service orientation, empathy, and basic awareness of "others" (their future patients) in those most likely to gain admission that also choose the most exclusive careers. Those choosing primary care, family medicine, and women’s health have the same more normal and less exclusive origins that have more normal scores and higher service orientation.4-6  Such origins may be an advantage in areas such as empathy, awareness, and health access careers.

Studies clearly indicate better encounters or at least the perception of better encounters when physicians share common ground with patients, but US physicians entering the workforce have rapidly moved away from common ground. Physicians move steadily toward most exclusive in a number of dimensions. Nearly half of the physicians entering the US workforce are new to the United States or have a parent who is foreign born. Over 30% of United States medical school graduates have foreign origins or a parent who is foreign born. The foreign born populations yielding the most physicians are concentrated in the most urban and highest income locations sharing characteristics of the US origin medical students with top status. The United States medical schools have consistently admitted 60 – 65% from the top 20% in income, but more dimensions of concentration have been added to this simple income dimension. Each year new record parent income levels indicate changes in those admitted. Each year more are admitted from the top income quartile with fewer admitted from the lower and middle quartiles. Those most likely to serve the nation where needed have steadily been replaced by those least likely. The Medical College Admission Test was standardized in 1993. Increasing scores are a reflection of students that have origins associated with concentration. Over the past decade the scores have increased steadily especially in areas such as the biological sciences.7  A comparison of the health access career outcomes to MCAT scores is also revealing. (MCAT Central)

What is the response of academic medicine to the changes in student origins and to departures from primary care? Of course it must be the debt so we should inject even more funding to cover the debt and pay higher tuition rates. Once again this sounds like a solution for medical education rather than a solution that fits health access needs and medical student needs.

More students are better prepared to past the MCAT test, but they may be less well prepared to become physicians. Children arising from concentrations and combinations of concentration have always had advantages in admission but never have they so dominated entry to the physician workforce. Never have United States physicians and future leaders of healthcare been so unlike the American people that they are supposed to serve. A state of being ever more apart from the American people is not a good trend.

It is important to understand that physicians were once selected with attention to awareness and people skills in addition to science ability at much higher levels. Students were even tested by earlier versions of the MCAT on their general awareness. Interviews, admission testing, and those proceeding to interviews have moved steadily to a more narrow group. 8 The elite with top scores and top grades are very few unique individuals compared to the US population. Even worse there is no voice calling for a re-examination of this narrowing process as was common periodically over the past 100 years. The ability to perceive in a wider range of dimensions, the ability to communicate, and the ability to relate can be impaired when there is a narrow focus on top scores and sciences.

Physicians are familiar with risk to benefit ratios. The current narrowing has little benefit and greater risk. Top scores have not been associated with higher quality physicians, however there are consequences of narrow admission and potential consequences of narrow admission. Also there are alternatives to most exclusive in admission that decrease the risk and may well result in some benefits. Albanese and others have documented the threshold method of admission and graphics indicate the plateau where increasing in MCAT scores do not decrease academic difficulty or result in more academic distinction. Recognizing that there is little point to excessive test scores, the focus in the threshold admission method is sufficient academics.

With a normal standardized test score just above the median for applicants, sufficient performance is assured. The focus then becomes characteristics most important for physicians. Scores, grades, colleges, and parents are set aside to examine the individual applicant. What did the applicant do with their life so far? What indicates service, communication ability, people skills, and the ability to defer self when needed? Without scores, grades, and prestigious college shaped by parents, what is the true nature of the applicant with regard to the most important characteristics of physicians and physician leaders? Who is already a great person – a versatile, self-assessing, mature servant? Such a choice is not a risk in admission. A great person has a greater chance to become a great physician. A less than mature medical student facing medical education may progress, but such a student may also regress – a sad but all too common consequence of medical education. Few understand that the most exclusive types of students with exclusive scores choose exclusive careers. These careers also have low physician satisfaction levels despite highest salaries and support personnel (Leigh, Physician Career Satisfaction Within Specialties). As is common, the characteristics were compared to specialty choice rather than to scores and other exclusive measures, but at some point exclusive characteristics may be examined as a factor in dissatisfaction. Or perhaps exclusive children were pushed into careers that were not necessarily a good fit. Are Asian Indian children with 1 in 20 now admitted to medical school all as good a fit as the 1 in 200 for the national average or the 1 in 1000 for students of Hispanic background? Is the 25% of the US workforce that entered from other countries a best fit, especially for those left behind? What about the nearly 50% of physicians entering the US workforce that are only first or second generation to America that are raised and educated differently that most Americans? Do the physicians raised and trained in nations with extreme divisions between rich and poor exhibit behaviors that may not be as acceptable in US health care? Higher physician discipline rates are seen in some specialties such as internal medicine. Closer to home the same could apply to US origin physicians born, raised, and trained in New York City or Washington DC where divisions between rich and poor are 30 to 1 using income quintile measures. They also are the most likely to be concentrated in 4% of the land area at levels nearing 80%, the same preferences as non-citizen international medical graduates that are raised in similar settings and train mostly in NYC, DC, or similar top concentrations in the US.

There are potential risks associated with narrow admissions. Although studies have not yet attempted to compare lower levels of communication skills to student test scores, there is little doubt that those focused narrowly on academics and sciences have made life choices to facilitate these areas. Just as obvious is that those focused on service have made decisions that can impair their ability to gain admission should they fail to focus on academics and sciences to the necessary degree. Studies demonstrate that the bottom quartile of medical students as assessed by communication skills observations have multiple times more reported adverse events. Attempting to find medical student applicants that can meet the academic, science, people skills, and communication abilities needed for today’s physicians is a challenge. Perhaps the most difficult task of all is for admission committees to see past scores to see the future physician with the most potential for patients, medicine, and the nation. 

Cost, quality, and access are key elements of health care and all are impaired by the current designs and implementations in American health care. These are perhaps best represented in the process of selecting and training of physicians. Those admitted are immersed in academics, sciences, standardized test scores, and looking good on paper, but does good on paper translate to good in person or in interpersonal skills?

The current design insures inequities in physician distribution at the critical starting and ending points. Those least aware or in other words those least able to “see” are the students that gain admission and it appears that leadership shaped by the process of medical education results in even lower levels of awareness and the ability to “see” in medical leadership positions. The current designs of health care, medicine, and medical education implemented over the past century allow no other conclusions. The consistent opposition to proposals to improve health access, increase health care coverage, and redistribute health spending to the care of those left behind also demonstrates lack of awareness and the promotion of agendas other than better health for Americans. (History of Social Security)

Marginalized along with most Americans are the rural physicians, underserved physicians, and family physicians that distribute where needed. These physicians can be traced to origins and ages that are more normal and less exclusive than those that gain admission at top levels who choose more exclusive careers and locations.

Marginalized are the medical schools and programs that have attempted to embrace health access and a primary focus on the education of medical students. They have faced a design so thoroughly immersed in the reward of narrow specialties and practice locations that choices become compromise or closure. The Flexnerian design that favors top levels of financial support also assures that medical schools will pursue such support to a greater degree than the education of medical students. Most commonly health access schools or programs receive brief academic attention (as in “how quaint”) but these departures from the traditional fail to gain recognition, replication, widespread replication, and then much needed integration into the basic designs for health care and health professional education. Top health access medical schools birthed in the 1970s reform period are merely average now after decades of 30% greater family medicine choice and top contributions to rural and to underserved workforce. Rural training tracks and smaller family medicine programs are downsized or closed. The accelerated family medicine residency training programs that contributed the maximum rural and underserved outcomes and added a year to the workforce achieved the most yield of primary care for the lowest cost –was terminated. Family medicine leaders noted that the model was under study but the studies never materialized.  Other leaders noted that the program had poor local support and yet this model spread rapidly to 15 locations that obviously did provide some support. Imagine what some level of state or federal funding would have done to facilitate a model with best health access outcomes. Over 150 graduates in a partial data capture from only 11 sites was enough to demonstrate the value of the approach in a wide variety of locations. By whatever measure the failure to recognize the best health access model in the nation in cost per yield of primary care, in yield of instate primary care, in years of primary care delivered per graduate, in rural workforce, and in underserved workforce was a major error. Also the model maximized needed health access even when the training was not specifically rural or underserved. It stands testament to candidates selected and trained for permanent health access primary care at lowest cost – something that the nation will require as a top priority for the next 50 or more years. Frankly the original family medicine training model was a two year model. Such a model costs less and delivers even more primary care, rural primary care, and underserved primary care than the 3 year model. But we focus on formal training in a set few years rather than a lifetime of training shaped by the physician and the patient interactions and the community life experiences after graduation. We also tolerated dysfunctional academic primary care training likely to have side effects, such as departures of medical students and residents from primary care.(Keirns, Academic Medicine)

Marginalized are those most closely associated with needed health access in multiple dimensions. Family physicians exist because of decades of efforts to bring awareness of the decline of the broad generalist. Family physicians exist because of decades of effort before and after the creation of family medicine to re-establish a physician for the entire United States population.

Family physicians (and choice of family medicine) should be understood as the product of a nation that thinks and acts in the long term best interest of direct patient care, health access, families, communities, and the full range of ages and stages in life. Family physicians are the result of a nation that prioritizes children, education, higher education, and medical education with a focus on health access. Family physicians are the remaining permanent primary care form with top primary care delivered per graduate and lowest cost for the yield of primary care.9, 10 Even the medical students choosing the most expensive routes to family medicine with costs of 1 million dollars in college, medical school, residency, and cost of living that also tend to deliver slightly less primary care at 20 Standard Primary Care years still cost only $50,000 per SPC year as compared to $70,000 for pediatric, nurse practitioner, and physician assistant graduates. The average family physician cost per Standard Primary Care year is about $35,000 or half of the cost of the nearest primary care training sources. The accelerated training programs and the health access schools reduce the cost of training, increase the workforce yield, and substantially improve the rural primary care delivery and underserved primary care delivery during and after training.

Family physicians are more likely to arise from more normal origins including origins among the 65% left behind.11 Family physicians are more likely to serve lower and middle income, elderly, lower and middle population density, poor, near poor, whole county shortage area, and Community Health Center populations.12, 13 One in four physicians born in predominantly black rural counties can be found in practice in the same counties and this increases to one in two family physicians born in such locations. Of course too few born and raised in predominantly black rural counties manage to gain admission, resulting in a number of disparities in physicians, health access, health outcomes, and economic outcomes. Origins, training, and health policy that facilitates health access facilitates family physicians and vice versa.

Family physicians deliver 3 to 8 times the primary care as compared to all other sources of primary care. Family physicians serve where needed at multiple times the level of other physicians. They are even twice as likely to be listed as medical teachers in the Masterfile compared to other specialties even though they are one-third as likely to be employed by United States allopathic medical schools (only 4% of full time faculty).14 Family physicians now face more challenges than ever before. Clearly the nation needs more but medical student trust in a permanent primary care career is the lowest of all time as indicated by their lowest choice of family medicine.15 The nation needs more family physicians. The nation needs family physicians and all remaining in primary care to be protected from conversion away from primary care. The nation must insure that family physicians remain permanently in the broad scope generalist family practice mode that universally results in optimal health access in physicians and non-physicians. The United States must have basic access to health care through coverage (not all health care coverage, but access to basic coverage), and family physicians must insure that the US supports basic primary care delivery in local or adjacent zip code locations - facilities, health care team members, physician support.

I am proud of family physician leaders that have spoken up for these principles in national meetings and those that have opposed the pursuit of further inequities by organized medical education. But family medicine also has far to go. As with most physicians and physician associations, family medicine faculty and leaders are too quick to claim credit for success and fail to understand the most basic and important role of family medicine – helping others to see such as patients, fellow physicians, those we teach, our institutions, and our nation. In many ways we serve with teachers, nurses, and public servants as the eyes and ears of the nation serving on the front lines. Even when the nation fails the human infrastructure that binds the nation together, we must not fail the nation as our role is the most important one connecting those who lead to those that are led.

There is much to see for those who are able. It does not take a brilliant mind to capture these concepts. It does not take sophisticated technology or analysis. It takes awareness. Unlike medical skills that take much less time, a certain level of awareness must be built in prior to medical school and honed during decades of teaching, research, and health care delivery focused on health access accompanied by immersion in the data. It takes a number of mentors who have similarly devoted their lives to health access. Mostly it takes a focus on basic health access primary care from the perspective of those in need of such care. It is the lack of this perspective that makes it very difficult for the United States to enter a process that will truly lead to the recovery of primary care and basic health access in America. No complex disease process has been conquered without decades of dedicated effort by any number of researchers immersed in all aspects related to understanding and solution. Yet the United States spends a minimal time and effort attempting to understand the health care design itself even though it is a major reason for impaired health and other outcomes in most Americans.

There is great disappointment with regard to national leaders that have chosen to support policies that take physicians away from needed locations. Not uncommonly those needed for basic health access in America are diverted to work for medical schools and large systems. The process of specialization is important to meet the health care needs of the nation, but overspecialization is a major factor that has resulted in insufficient physicians and the need for more and more physicians. The current support of generic expansion is poorly planned and deceptive in nomenclature and implementation as has been pointed out by family medicine leaders. The effort is a poorly concealed plan to send more federal dollars where they will do the least good for any except those with top concentrations of health dollars already. The current political climate does provide the desperate Congressional leaders that might vote for such funding, but the reflective approach is to bring forth a design that truly does focus on the needs of most Americans, the true restoration of primary care, and specific rather than generic funding.

There is really only one expansion that can meet the health care needs of most Americans left behind and this is an expansion of permanent primary care in design, implementation, and support. Until the nation has 14,000 to 16,000 annual graduates that remain permanently in primary care for 35 year careers in a broad generalist role, the basic health care needs of most Americans and particularly those left behind will not be met. The soonest that the nation can expect resolution of health access woes is 45 years from the beginning of restoration of sufficient annual graduates.

Organized medicine has been a great disappointment with decades of opposition to reform proposals that will redistribute health care funding to facilitate better health care for the nation at a reasonable price tag. It is also easy to see that more patchwork programs get in the way of needed reforms as they prevent progress toward a real design for health access workforce and a real design for the support of primary care delivery.

We do not need a million people to march on Washington for all to see and hear but we do need half a million physicians in permanent primary care so that Americans can have the health access that improves their health, improves their costs of health, improves their cost of living, and improves their prosperity compared to other nations.

The work of Deming screams quality in the matrix of relationships. A process that focuses on relationships has recovered businesses, economies, nations, and people. During the next 100 years Americans must be restored to nurturing relationships with their infants and young children. Americans must be restored to optimal relationships with teachers across child development and early education. Americans must be restored to quality relationships with primary care nurses and physicians. This requires a reorientation of priorities that facilitates relationship building. The nation must support and promote better relationships between parents and their children especially in the earliest months and years of life. The nation must support enough teachers and support personnel to result in a better teacher-child relationship. The nation must produce and protect enough primary care nurses and physicians with a priority focus on the development of relationship. A nation that steadily compromises lower and middle income families and children that supply the human infrastructure of the nation and that complicates the most important relationships for trust, security, opportunity, and health simply cannot recover.

Substantial levels of greater understanding are required in a nation that promotes No Child Left Behind when most are left behind, when continuity health care delivery is far different than what is promoted by Continuity or Medical or Home, and when current primary care training from five sources results in primary care graduates less than 30% of the time. At a time when people in health care try to substitute places and technology for relationships, it is important to clarify matters. Relationship is not a place, it is a state of being. A home is a place where relationships can take place, but it is not the relationship. Technology can be used to introduce or develop relationships but the relationships developed are limited. Technology can also distance people or result in much higher costs for lower yield of actual health care delivery thus impairing health care for more Americans. Medical education is great about concepts but lax about contributions. The concepts are about primary care delivery but they do not result in primary care delivery.

Medical education must decide to keep a focus on producing the best physicians and must avoid distractions of technology, places, personality traits, controllable lifestyle, or other topics suitable for the popular press but not relevant to the attitudes, skills, and behaviors needed for basic health care delivery.

Americans once excelled at problem solving. Americans have integrating the best of other nations into the fabric of the nation. American medical education integrated the best of Europe into the training of physicians and developed the teaching and research to improve upon the best. But now Americans are commonly taught that solutions working for other nations do not work for Americans. Do we think of ourselves as having such little ability to comprehend the differences and similarities and potential outcomes and consequences? Even our primary care proponents err in their studies. While other nations with more primary care do have better outcomes, the other nations also rank far ahead of the United States in child well being. The United States and the United Kingdom finish 21 and 22 in child well being in developed nations. What does this mean? Better children make better students, employees, citizens, and health care decisions. Cost, quality, and health access are all shaped in the earliest years. The correlations between child well being and health care quality at the state level are 0.7 to 0.9 depending upon which quality ranking (Project Hope, United Health Care) and which child well being rank is used. Family medicine, primary care, and generalist measures are the best correlations at 0.4, but internal medicine and pediatric primary care are not correlated with better quality. There is nothing wrong with such care, but these physicians are found in top concentrations where the population is divided into rich and poor, as are the outcomes in health care. Correlations with top quality using a hybrid of Project Hope and United Health care include

0.88        Kids Count 2007 ranking (child well being measures)

0.8          Child Well Being Rank (multiple measures)

0.824     Employment Ratio 2005

-0.735    Child Poverty % 2005

-0.709   Poverty % 2005

0.695     Married Both Work 2005 (middle class distributional measure)

0.686     HS Graduates % 2000 (better start)

 0.667   Gini House Income 1999 (divisions of income rich poor)

0.538     Voting Rates (also similar for auto insurance, welfare, prison rates)

0.516     Bachelors Degree % 2004

-0.515    Underserved physician %       (note: Pay for Performance is a questionable concept as physicians skilled and experienced enough to care for the underserved are penalized for doing so as they associate with populations that naturally have lower health care quality – and then get paid less.

0.43        Generalists Area Resource File (much lower correlation)

0.41        FM per 100,000 people in the state

0.112     IM and Pediatric PC per 100,000 – not a significant correlation.

As long as we are dominated by thinking from a narrow physician perspective, we will not see some of the most important relationships and a major role for physicians. Even though Flexnerian changes had consequences, those desiring to become physicians had to greatly increase their academic focus. The resulting changes in secondary education and higher education were important changes for the entire nation. What physicians can do is much more than medicine or health care. Physicians can lead the nation to see the most important concepts. The lack of physician vision and understanding can devastate a nation.

Why should be afraid to examine the efforts of other nations? What is wrong with some delay in specialty care if the reward is more equitable basic health care delivered to all of the population?

Why should we fear tripling or quadrupling or 0.5% of Gross Domestic Product to a more reasonable 1.5% or 2% spent on children age 0 to age 6 to reach the levels of countries that are kicking our tails in science, math, verbal, and other areas. How They Do It Better illustrates important differences in other nations that are relevant to the United States. Scores of examples can be found. But of course this US News and World Report article about other nations is not a best seller compared to issues that contain top ranking prestige colleges and medical schools that are largely ranked according to prestige shaped by standardized test scores.

Resolution of problems does not mean conversion to social welfare state status. We are talking about investing in children and improving the potential for relationships that can impact the entire life span after age 6. The nations with the best children win regardless of political system. Capitalism and democracy work best when most children have a reasonable chance to invest their lives individually for best outcome. Capitalism may be at its worst with a limited few able to participate in opportunity as guided by birth to age 6 factors. Efforts to improve children are not socialist or too expensive, they are essential in a nation that hopes to do well in the future. For the centuries that have had civilized existence, the consistent focus has been better children.

Those who lead nations raise the children who will be leaders, but if they raise children that are not aware of the daily lives of most children in their nation, they are uniquely impairing them for leadership. Landmark studies such as Meaningful Differences in the Everyday Experience of Young American Children illustrate the earliest differences that mean so much in future health, education, medical education, and other outcomes. With regard to physicians who must understand their patients and their situations to be able to act in their best interest and help them deal with uncertainty and help them deal with impossible situations, parents who protect their children from adversity and uncertainty and awareness are planting seeds that will lead to dissatisfaction with careers in medicine and poor leadership in health care.

The consistent direction of physician workforce in the United States has been away from physicians who are aware of the health needs of most Americans. Each of these moves runs contrary to the designs of education, higher education, and medical education and in some cases the designs of the law of the land as interpreted by the Supreme Court and leaders in higher education. Is it so surprising that lawyers from basically one most exclusive law school would fail to grasp the benefits and consequences of standardized testing as Supreme Court justices? Or perhaps was there missing testimony not provided by AAMC that failed to indicate the lack of a correlation of standardized testing with physician quality. Do lawyers even believe that standardized testing is correlated with the best lawyers? Meanwhile the matriculants of 1997 to 2001 just after court decisions had the most rapid rise of admission of the top income quartile and the most rapid decline in lower and middle income admissions. Those most exclusive and least likely to serve where most needed rapidly replaced those most likely to be found in the careers and locations needed.

It is not difficult to understand the pathway required to reduce disparities in health costs, health access, and health care quality. Every move across birth to admission, admission, and training that results in a more normal child advancing in the United States, every move that results in admissions more closely representative of the US population, every move more normal in training specific to the most needed health care of Americans, and every move toward more normal distributions of health care funding is a step in the right direction. These choices work to admit physicians who are likely to have improved abilities to relate to patients and physicians with advantages with regard to shaping health care in the right directions for better health for all. Such a move clearly results in the graduation of physicians that serve people in America in most need of health care - rural physicians, physicians in the most underserved areas, and physicians found in locations with less than the average level of physicians and primary care physicians. Choice of family practice multiplies distribution to areas of most need in physicians. These studies involve complete populations of physicians for over a decade of class years using birth origins (approximately 1970), 1990s medical school graduates, and 2005 practice careers and locations in the Masterfile.2, 3  Surveys by physician assistant and nurse practitioner associations also document choice of family practice as most important in health access for non-physician clinicians as well.

There will be no bomb that blows up young children in a church to raise awareness and bring focus to needed changes, but Americans are dying needless deaths with regard to the decision to access health care. Americans are having arguments over whether to even go to get health care across the nation. I know this because I have had these arguments with my family members and I have had numerous conversations with patients in the office and outside. Morbidity and mortality cases that I have reviewed are often blamed on physicians (or the physicians blame themselves), but the unfortunate ones clearly did not access health care in a timely fashion. In a different family or social setting they would not have died when family, community, and health care plan works for instead of against health access.

Studies document disparities in outcomes for those lower and middle income, just as they document lesser access to higher education (30 - 70% versus over 90% for the top quartile) and lesser access to the prestigious universities with over 70% from the top quartile and most medical schools with over 70% from the top quartile. These are only one dimension of inequity as those left behind also have dimensions of geographic origins, parent origins, property value origins, and other measures of association with lesser concentration. How do medical schools expect children that are 90% born, raised, educated, and trained in counties with medical schools in top concentrations to distribute outside of these counties where physicians are needed?

The same forces that shape higher probability of medical school admission appear to shape lower probability of physicians found where needed. The same forces that result in lower probability of admission for those less associated with concentrations of income, education, physicians, and social organization also result in greater probability of choice of health care for those in most need of health care.

Martin Luther King, Jr. believed in people ability. He believed that people could change the situations that existed if they could just see. We do have the ability to change our course personally, professionally, and as a people. We must focus not on the people left behind, but on the health care needs of people. As always, the task of seeing the people is the task of removing our own barriers that keep us from seeing others. The task of health care may be even more difficult when our “advances” allow us to “see” so many others and yet have meaningful relationships with so few. Health care careers represent a great advantage in that we do “see” others and more types of others and how others live. When we focus on the health care of others we are able to “see.” Ophthalmologists cannot restore this vision. Only those who see much like people such as Martin Luther King, Jr. can do so. 

Medical education focused on scores, facts, disease, and evidence cannot result in better health for more Americans if the process is implemented and shaped by those that cannot see. Selecting those who see better, rejecting those that cannot see, training medical students and residents to see better, and selecting health care leaders that have a passion for vision can result in better health care. Such a process cannot fail to result in better health for people, academic medicine, physicians, and the nation.

1.            Association of American Medical Colleges. The Economic Impact of AAMC-Member Medical Schools and Teaching Hospitals. Washington DC 2008.

2.            Bowman RC. They really do go. Rural Remote Health. Jul-Sep 2008;8(3):1035.

3.            Bowman RC. Basic Health Access Logistic Regression Tables: Taxonomy, Themes, Theories of Experiential Place.

4.            Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XI Available at Accessed April, 2003. Washington DC 1998.      Tables from this work relevant to awareness

5.            Newton BW, Barber L, Clardy J, Cleveland E, O'Sullivan P. Is there hardening of the heart during medical school? Acad Med. Mar 2008;83(3):244-249.

6.            Madison DL. Medical school admission and generalist physicians: a study of the class of 1985. Acad Med. Oct 1994;69(10):825-831.

7.            Association of American Medical Colleges. AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers. Washington, D.C. 2009.

8.            McGaghie WC. Assessing readiness for medical education: evolution of the medical college admission test. Jama. Sep 4 2002;288(9):1085-1090.

9.            Bowman RC. Measuring Primary Care: The Standard Primary Care Year. Rural Remote Health. Jul-Sep 2008;8(3).

10.          Bowman RC. The Standard Primary Care Year Web Site. .

11.          Bowman RC. Birth Origins and Distribution. .

12.          Ferrer RL. Pursuing equity: contact with primary care and specialist clinicians by demographics, insurance, and health status. Ann Fam Med. Nov-Dec 2007;5(6):492-502.

13.          Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.

14.          Barzansky B, Etzel SI. Medical schools in the United States, 2007-2008. JAMA. Sep 10 2008;300(10):1221-1227.

15.          Bowman RC. Five Periods of Health Policy and Physician Career Choice. .       The works of this site do not represent the work of any medical institution or organization.


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