Robert C. Bowman, M.D.
This packet is for admissions committee members who want medical schools to strike a balance between research and service, between the needs of the institution and the needs of the community.. This information is for those who want to understand more about selecting students to meet specific needs in a region or state or even an entire nation. This work is a collection of information from academic publications and those who have done research on specific selection issues. It is clear that selections can have a great impact on the numbers choosing eventually to practice in urban underserved and rural locations. Nearly every medical leader notes that this is a major problem, but few of these leaders acknowledge the body of literature that clearly indicates the importance of selections in addressing these problems. This package will target admissions that are more likely to impact on increasing the numbers choosing small towns. The concepts are also applicable to other underserved locations.
Nearly every medical school has a mission and incentives to serve underserved populations, as a public institution, through state or federal funding, or as a private institution devoted in some part to a Christian or public service mission. How this mission is implemented is a day to day function of leadership at these medical schools. The decisions that are made at medical schools have impact on the entire nation.
Physicians are leaders in communities and the nation. They help shape the fabric of environments, especially in education and health. The unique relationship between physicians and their patients gives physicians an opportunity to improve neighborhoods and communities. Medicine as a discipline must work constantly to discover and apply new knowledge, but it must not focus on the simple intellectual pursuit of such knowledge to the exclusion of other endeavors. Medicine must be able to interpret such knowledge and apply it to an increasingly diverse population.
There are two major errors that can occur in medicine.
In the past century, medical education has come far in understanding medicine, but it has not made much progress in understanding people. The case can be made that success with the pursuit of knowledge has magnified the second major error. Current efforts to reduce medical errors that focus on the medical instead of people aspects, are likely to result in more mistakes and higher health care costs.
Physicians increasingly are failing to translate and apply their knowledge through service. In recent decades the public has demanded more work in this area, but medical schools have been slow to respond. This is where medicine is failing the nation and the world currently. To really make a difference in health care, physicians must be involved. They must work in and among people and apply their understanding about disease and infirmity with the wisdom acquired from experience in patient care. Being involved is becoming more and more difficult in a world that continues to worship at the technology shrine. Technology Character and Family Medicine
Most of this is from other and more respected and experienced authors. Your problem will not be in the amount of information. We have had this information available to us and to the nation for a long time. When medical schools pursue a strategy across the years of education and college and medical training and when this strategy involves communities and governments and educators, the strategies are highly successful.
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
When loan forgiveness programs have been instituted without any other strategies, the results have been dismal. But when they have been combined with other efforts, such as careful selection of candidates who are motivated to work in the areas of need, specially designed teaching experiences, and counseling and placement services, they have been quite successful. Southern Regional Education Board 1983
Tom Bruce's book Improving Rural Health in 1984 and Rosenblatt and Moscovice's in 1982 had most of the things that we continually rediscover:
It is a basic consideration that the Rural Medical Development Program could have achieved on or both of the following, recruitment and/or retention in rural communities. It is the considered judgment of the program staff members after several years of work in this field that recruitment represents about 20% … and retention 80%… if all of the communities who had recruited physicians over the past years had been able to keep them, there would be no problem of access to rural medical care today. Improving Rural Health P 162
These efforts have been most helpful: AHEC, expansion of primary care residencies, move of rural preceptorship to earlier position, development of Office of Community Medical Affairs with its host of outreach and bridging activities. Improving Rural Health P 165
Even in the early years federal programs that focused on the end stages rather than the beginning, those in charge knew that there would be problems:
We began to realize very recently that we have been doing something which ……may be destined to failure. As far as physicians, we have had limited success… What can we do that maintains that person there? … what can you do to change the pattern of isolation, low status, and lack of consultation that occurs in most of the places we are talking about? We feel that the present time, that without changing those three things, one will not retain a physician, or any other health professional, beyond that 5 or 7 year limit when most of the statistics say they leave. Particularly the young ones. Robert Shannon, M.D. National Health Service Corps: Overview and New Directions. Report of Regional Workshops on Health Manpower Distribution, National Health Council, New York, 1975 more at Obligations and the Potential for Indifference and Increased Health Costs
The problem with medical leaders such as the above is a matter of perspective. Admitting students who prefer rural lifestyle resolves not only the problem of retention, but also getting enough rural physicians. Other national leaders have the same problem with assumptions and lack of perspective Why Doctor's Don't Go Where They Are Needed.
The problem will not be with expense, for programs like RHOP cost pennies and are probably the best economic return for a state dollar ever. While it is true that we can steal physicians from other countries or even other states, it is a better policy to grow our own. Obligations vs Grow Your Own
As always with any change, the problem will be with acceptance and implementation.
Change is always more troublesome than sitting still. Change is most easily accomplished at the medical school-college interface or in the first two years of medical school. Innovation at this level will never have much effect on the educational program, because the majority of a doctor's education comes after that period of time. Any significant change will have to affect the clinical years of medical school, internship, residency, and postgraduate education. Eugene A. Stead, Jr., M.D.
