Answering the Right Questions About Health Access


Robert C. Bowman, M.D.    The questions are currently listed without answers. The answers to these questions and more can be found at the web site at   If you would like to discuss the answers and post a response, please email.

Health Care: Dividing the Nation      Basic Health Access: Bringing a Divided Nation Back Together

Why must the United States assure sufficient primary care as a top priority rather than total numbers of physicians or total numbers of specialists?


Why is family medicine a best practices choice for primary care in the United States?


Why are nurse practitioners not good primary care solutions?


Is it possible to continue to allow medical school graduates, nurse practitioners, and physician assistants to have free will regarding career choice and still have sufficient primary care in a time of policy destructive toward existing primary care?


When a US medical student passes up family medicine to choose another primary care training source, what is the consequence in lost primary care delivery in the United States?


Discuss reasons for low primary care salaries in the United States.


Explain why a Duluth medical school graduate can deliver 50 – 100 times more rural primary care compared to a graduate of a top 20 medical school ranked by MCAT scores of matriculants.


Explain the futility of attempting to select students for future research careers when a medical school is not in the top 60 in National Institutes of Health annual research funding.


Explain why exclusive medical schools have the lowest health access contributions.


Explain why certain workforce experts and even the US Civil Rights Commission can “believe” that underrepresented minority students fail to choose careers serving the underserved or rural origin students fail to choose careers serving rural populations.


Estimate the percentage of graduates found in a predominantly black rural county in the United States when the birth origin county of the physician is a predominantly black rural county. What is the rate of return when the specialty choice is family medicine?


How many 2009 nurse practitioner graduates will it take to deliver the same primary care as a single 2009 family medicine residency graduate?


Discuss why internal medicine should no longer be considered a primary care training form.


Why do flexible primary care training forms appear to collapse in their delivery of primary care during worsening primary care policy periods?


If the United States began to produce enough primary care by 2020 and had in place incentives and protection such that 90% would remain in primary care for an entire career and they remained 90% active and delivered 90% of the volume of a current family physician (gold standard for top volume) for a full 35 year career, how many annual graduates of this primary care source would be required. Also how long would it be in years before the United States could expect sufficient primary care.


Discuss the factors that indicate that the United States has already made the changes to move it toward sufficient specialty care. Also note how primary care workforce has been impacted.



Discuss alternatives to the expansion of physicians with regarding to delivering more health care in the United States.


Basic health access primary care demands facilities, health care team members, practitioner support, sufficient primary care practitioners, and sufficient funding for lower and middle income people. Discuss the current US attempts to meet each of these areas. Discuss the impact of moving toward universal financial access without sufficient practitioner workforce.

Discuss why the elderly, with the closest to universal access, fail to have access. Discuss also the special needs for local or adjacent zip code primary care for the elderly and their particular pattern of residence away from concentrations of physicians, stroke centers, and heart attack centers.


Discuss the reasons for states to have top health care quality.


Why do states that have the top concentrations of physicians have lower quality, highest costs, and still limited access to care?


About 4% of the land area in 3400 zip codes captures the most physicians, health resources, and more. For this 4% of the land area, what is your estimate of the % of US physicians?  the % of total US health funding associated with US physicians? The % of the US population in this 4% of the land area? The % of total internal medicine or pediatric primary care physicians? The percent of family physicians? The percent of specialist nurse practitioners and physician assistants? The percent of nurse practitioners and physician assistants practicing in the family practice mode? The % of NIH research funding? The % of graduate medical education funding?


If the United States continues to increase the share of health funding going to 4% of the land area with top concentrations of health resources at one-third to one-half of a percentage point of health funding per year, what will be the result in 10 years? 20 years?

What is the percentage of rural origin physicians entering the US workforce?

African American and rural origin medical school admissions are half of the national average while Hispanic admissions and admissions from lower income rural counties are only 20 – 30% of the national average. African American males and rural males have half of the rate of medical school admission of African American females or rural females. Hispanic and lower income rural origin admissions are not so stacked by gender. Discuss genderDoes this involve higher levels of lower and middle income origins? If so discuss Hispanic medical school admissions or lower income rural county admissions to medical school

During the 1970 to 1980 medical school expansion with a doubling of total medical students, did rural origin admissions benefit with a higher percentage admitted?

Discuss the timing of African American and Hispanic medical school admission increases. Was this related to the doubling of medical students or was this before expansion?

Discuss a method of admission that minimally increases the risk of academic difficulty while maximally preserving admission of students most likely to choose careers serving the 65% of the US population left behind.

Discuss the folly of a plan for a geriatric physician specialty serving the geriatric needs of the entire age 55 and above population including health policy support, locations of geriatricians, production of geriatricians, and locations of the elderly.

The University of Nebraska Medical Center is the source of about half of the physicians for the state of Nebraska. Discuss admission, career choice, training, and US policy reasons why UNMC will no longer be able to supply this workforce.

Explain why primary care did not dissolve in rural Nebraska in the past decade while primary care in metropolitan Nebraska was cut in half.

Alaskan practice locations, particularly those serving the most complex populations, are spending over 10 million dollars a year on recruitment, retention, bonuses, locum tenens, medical education, state, and federal costs and the end result is still insufficient workforce for Alaska. Discuss why 20 – 25 family physicians a year produced by Alaska will cost less and will meet Alaka’s health access needs.


List and discuss the factors that are related to health care quality particularly with regard to the lack of primary care interventions changing the quality of care in many populations.


Discuss why physicians serving the underserved might be unfairly rated as lower in quality.


Discuss the loss of local influence in rural communities in Wisconsin as large systems slice up the state territory.


Discuss the consequences of twice as many nurse practitioners and physician assistants by percentage compared to physicians with increasing control by large systems, with lower costs of delivering specialty care for non-physicians, and with more controls on highest paid specialty procedures.


Discuss abuse or misuse patterns in each of the following federal programs that result in physicians supported even in locations with concentrations of physicians – National Health Service Corps, J-1 Visa Waiver, rural health clinic, Community Health Center or Look Alike programs,


Discuss how movements to urgent care, emergent care, hospitalist care, locum tenens, and the rise of health care brokers and for-profit health access has helped to destroy continuity primary care in the United States.


Discuss why the Continuity Medical Home or a place for medical care does not deliver primary care and the reasons why a continuity home or place will fail to deliver continuity care.


Discuss reasons why 1 billion more in graduate medical education that includes internal medicine as a primary care source, fails to result in primary care recovery in the United States.


Discuss the reasons why expansions of pediatric residency graduates cannot address primary care and health access in America.


Discuss the outcomes of the Duluth model with regard to all of the most pressing physician workforce needs in the United States.


Discuss the declines of osteopathic family practice choice from 80% to 60% to 40% in the 1990s to 20% by 2004 to the likely level of 15% or below in coming years and the impact on primary care, family medicine, and osteopathic influence, even with a doubling of osteopathic graduates from 2004 to 2017.


The Standard Primary Care year is a measurement from 1 to 35 with 35 Standard Primary Care years being 35 years of a career with 100% remaining in primary care, 100% active, and 100% of the primary care volume of a family physician. The simple primary care year calculation multiplies these 4 factors such as 35 years (age 30 – 65) times 90% primary care retention times 90% remaining active times 90% of the volume of a family physician for 25 standard primary care years. Calculate the standard primary care years for nurse practitioners that graduate about age 38, remain in primary care with 33%, remain active at 60%, and deliver 60% of the volume of a family physician. Calculate the standard primary care years for a foreign origin (not a US citizen) international medical graduate internal medicine graduate also entering at age 38 with 10% primary care retention with 60% active (departures from the US, higher chronic unemployment),  and 80% of the primary care volume of a family physician.

Discuss the overestimation of primary care delivery using the Standard Primary Care measuring tool when graduates depart primary care (as in 30,000 leaving primary care internal medicine for hospitalist careers in the last 6 or 7 years).


Discuss the assertion that the current administration (or any administration from 1990 to 2030) will result in a health care plan that will result in inability of senior citizens to be able to find a physician to care for them. For the 1960 through 2050  class years, discuss the primary care needs of seniors, the location patterns of physicians in the current design, and the production of physicians most likely to care for seniors and their location pattern.

Discuss regional variation in health care costs as a function of a health care design for each region that involves a more vertical top concentration of physicians such as a medical school or a large system.


Discuss the situation facing other nations that have permanent primary care with regard to determining how many generalist primary care physicians to produce each year for the next 50 or 100 years as compared to the US situation with a design that involves flexible primary care (that departs primary care during training, at graduation, and each year after graduation) for 22,000 of the 28,000 annual graduates arising from the 5 sources of primary care.


Discuss why Asians have relatively higher MCAT compared to board scores while whites have relatively higher board scores compared to MCAT with regard to different origins, parents, and distribution.


Discuss reasons why courts or even the Supreme Court may not be able to grasp the basic concepts regarding standardized testing as in the MCAT test where higher scores are going to be assigned to student types according to their background such as more urban, higher income, children of professionals or physicians.


Discuss the deterioration of ACT, SAT, or MCAT to predict performance in college students or medical students in the 3, 4, or 5 years after taking the test.


How are current attitudes regarding intelligence testing similar to the 1920s attitudes?


Discuss the theme: those with lower probability of medical school admission when admitted have a higher probability of being found in a most needed health access primary care career years later with regard to birth origins, opportunities for medical school, types of medical schools attended, career choice, and practice location.


Discuss at least 5 factors that can be addressed to help improve most needed health access in the United States in birth to admission, admission, training, career choice, and policy.


Discuss the bizarre situation where medical leaders with top scientific training can understand odds ratios related to adverse cardiac events but fail to understand the odds ratios related to most needed health access in the United States or even assert that factors known to increase the odds ratios of most needed health access do not work.


Discuss the accelerated family medicine program model with regard to

·         Lowest cost of medical education

·         Rapid spread across the nation without special federal or state funding

·         Criteria of selection of accelerated graduates with regard to health access

·         Reasons why accelerated FM models will have top instate primary care contributions

·         Optimal rural location without rural bias in selection or training

·         Optimal underserved location without underserved bias in selection and training

·         Success of the model in health access outcomes regarding the three directions of medical school admission in the past 20 years (female, foreign born, urban origin)

·         Reasons why the model was allowed to be terminated

·         How the model represents the principles of health access (origins, age, family practice, training)

·         The major limitation of the model regarding location and career tendencies of accelerated graduates over time and the way to turn this limitation into even better health access outcomes

Discuss the likely reasons why Mercer decreased from over 32% to less than 8% family medicine and the impact this will have on Mercer regarding declines in primary care, rural primary care, and underserved primary care contributions.


Name the number one medical school with regard to primary care production for the United States workforce and the reasons why this medical school also has over 20% family medicine graduation rates.


Discuss the role of exclusion with regard to rural and underserved workforce.


Discuss the use of 600 million dollars directly to fund medical students to become family physicians compared to 600 million dollars spent in grant funding.


Recently 18 billion dollars was committed to improving information technology for health care. The potential for increasing primary care delivery is minimal in this investment. If this 18 billion dollars was spent directly on primary care production using a family physician cost of $250,000 per graduate for training and an increase from 3000 to 8000 family medicine graduates a year (5000 increase), how many class years of much greater primary care delivery (near sufficient) does this represent?

18 billion divided by 5000 more FM grads a year divided by $250,000 for the production of each family medicine graduate for 14.4 class years of sufficient primary care (even with continued movements away from primary care in other forms)


Explain the flaws in Institute of Medicine reasoning regarding the physician role in iatrogenic morbidity and mortality, the role of uninsurance in health outcomes, and other studies where the major variable is a physician variable as compared to patient, system, health care team, or other variables.


Explain why internal medicine and pediatric primary care levels are not associated with higher quality in state correlations using United Health Care or Project hope state health quality rankings, while family practice and generalist levels are associated with higher quality