Overcoming the Perspective of Impossibility to Accomplish Needed Health Access

Robert C. Bowman, M.D.    rcbowman@atsu.edu 

Perhaps the greatest disservice to any most needed change is the perspective of impossibility. All of us are limited in our awareness. It is most difficult to move beyond our limitations to gain the necessary understanding to be able to address needed change.

It is important to trust leadership and to respect authority. However needed change is the result of moving beyond limitations in awareness to address important priority areas. This author is no smarter than any others. But this author has delivered, taught, and researched basic health access over the past 26 years.

Basic health access has been neglected for decades. Resolution of health access problems is possible, but such resolution requires a thorough understanding of the principles of health access and the multiple approaches that have worked. Understanding health access workforce involves the same scientific studies as understanding heart risk as a function of smoking, cholesterol, hypertension, and other risk factors. The probability of rural location is tripled by family medicine just as smoking or hypertension multiplies adverse cardiac event risks. The barrier regarding basic health access is not a matter of poor understanding of scientific studies. The barrier most difficult to overcome is a barrier of perspective. In many ways, the only obstacle preventing health access is lack of awareness of health access by those in leadership positions.

It difficult to understand how different physicians and physician leaders have become compared to most Americans. About 50% of those entering the workforce come from families only in the United States since 1980. Those admitted are 65% from the top 20% in income. In the top ranking schools the concentrations of most exclusive origin students are much higher with lower and middle income and rural origin physicians greatly reduced. It is not a surprise that decades of cumulative concentrations result in a limited ability to understand health workforce regarding basic health access. See Why Physician Workforce Needs New Tools and Perspectives.

It is easier to understand why such limitations exist when one understands the process involved in admission of physicians. Those most likely to gain admission, those most likely to gain admission to an exclusive medical school, and those most likely to become exclusive leaders are most likely to arise from the very top concentrations in the nation - concentrations of income, people, health resources, physicians, and specialists. It is difficult to understand most Americans and health care for most Americans when born, raised, educated, and trained in 4% of the land area immersed in top concentrations. It is also difficult to graduate physicians that will serve populations in most need of health access when physicians have the most extremely different upbringing compared to most Americans. Physicians associated with concentrations have higher probability of admission and lower probability of health access contributions.

Medical experts are captured in presentations and publications as noting that rural and urban underserved distributions of physicians are unlikely. It is also hard to understand support for policies that send the most inexperienced physicians to the most complex health care settings that take a lifetime to understand (primary care, rural health, underserved primary care).1-3 Even medical experts a century ago such as Flexner and Osler understood that such locations required the best physicians and had great respect for the experienced generalists serving in such locations. A century of separation has not added to the wisdom of the past.

This Perspective of Impossibility has not been shared by all medical leaders. Butler called on a Season of Accountability and Social Responsibility, and even outlined the medical education models that do accomplish needed distribution.4 These models exist today. Duluth model includes the Rural Physician Associate Program and Duluth graduates deliver 64 times the rural primary care of graduates of top 20 MCAT medical schools. When following the principles of health access, there is little doubt that health access can be addressed. When seen in terms of physician deficits, shortage areas, and underserved locations, the perspective is not encouraging.

When expansions are generic and not modeled after schools such as Duluth, this is a choice to avoid basic health access. When the models most associated with health access graduate the fewest, this is a choice to avoid basic health access. Terminations of the accelerated family medicine models with top rates of rural and underserved practice location are also evidence of poor decision making regarding health access. Investments of a billion of dollars in indirect primary care investments make less sense when a billion dollars a year graduates sufficient primary care to meet most of the primary care needs of the nation. 

Physicians leading billion dollar enterprises in top concentrations with all lines of health care revenue captured and the top reimbursement in each line received, it is difficult to see how health care can be delivered otherwise. Of course this is also the dilemma facing the nation, states, and businesses as the design of health care is breaking budgets. 

But the reality is quite different from the perspective. It is a quite different medical leader that understands America from the perspective of the population that is 65% outside of physician concentrations as compared to the more typical approach from the perspective of 75% of physicians in top concentrations with the highest physician concentrations in medical school zip codes.

The challenge of leadership is leading the nation in the right directions. The greatest challenge of leadership is doing the right thing for the greater good, even when this will result in fewer benefits for those in top concentrations in medical school settings.

Physicians will never distribute in a representative fashion to all populations (although some come closest). There will be substantial areas with few or no physicians. But health access is possible with physicians in relatively close proximity. By focusing on impossibilities such as impossibilities of extremes, steady movement toward resolution of health access problems is avoided. Abrupt changes are not required. A steady few percentage points more health resources distributed outside of 4% of the land area (rather than 90%), an improvement of 2 or 3 percentage points of physicians found in rural areas (9% to 11%) or in underserved areas (7% to 9%) goes a long way toward resolving health access deficits. 

The concept of experiential place is important to understand. For over 50 years workforce experts have understood that physicians tend to return to similar locations compared to previous life experiences. A common interpretation is that physicians move to slightly more urban areas compared to their origins. When seen in terms of life experiences and experiential place, it is easy to see why physicians would prefer locations and populations that are similar. Those who share the experiences, family, history, traditions, and peoples of an experiential place will desire to return to similar locations.

While this is relatively easy to understand in terms of extremes of lowest people concentrations such as rural locations or lowest income concentrations (high poverty), this does not apply just to extremes of rural or lower income origin. The same life experiential place  factors also applies to extremes of concentration. The physicians with combinations of concentration with regard to population density, income density, densities of physicians, and densities of resources consistently are the least likely to be found in rural, underserved, primary care, and family medicine careers. In a technical and biomedical sense, there is nothing wrong with exclusive origin physicians. Of course when the most exclusive gain admission, the most exclusive in practice location is a consequence.

If medical experts persist in only the most exclusive in admission, the most exclusive training, and the most exclusive career choices that mean nothing with regard to quality of care, they must understand that they are choosing not to distribute physicians and are choosing to compromise care. Leadership in health care also requires recommending health policy to the nation that will establish a health access foundation for health care. Failure to recommend policy that establishes basic health access is also a choice not to care for many if not most Americans. 

The types of graduates that do have greater probability of distribution include:

Birth origins more normal (outside of concentrations), the family medicine choice that more that doubles normal locations (outside of concentrations), and health access schools focused on everyday health needs of most Americans all have two or more times most needed distribution probability. Health access schools that admit those most likely to distribute, admit older graduates, and graduate the most family physicians craft substantially greater health access outcomes 50 - 100 times greater than the most exclusive schools with the most exclusive origins admitted and trained in the most exclusive settings with top concentrations of health resources.

Medical experts have made poor assumptions regarding rural origin being required for rural practice location or lower income origins required for underserved practice location since so many other physician characteristics, training efforts, and policy areas result in needed health access. The actual locations in need of physicians involve 30,000 zip codes spread across 96% of the land area. The only locations with saturations of physicians and primary care physicians are 3400 zip codes with 75% of physicians in 4% of the land area.

Immersed in top concentrations, it is difficult to see the needs of populations that reside only a few miles away. Even studies of infant mortality, longevity, and numerous other outcomes demonstrate substantial differences that should be understood and should be addressed by leaders of health care.

Medical experts have made statements that would be considered intolerant regarding rural or lower income populations regarding lifestyle, education, culture, and recreation. It is a wise man who realizes that there are differences, but understands that many differences are not better or worse, but are merely different. Rural areas do not have a a paucity of satisfying cultural and civic outlets.1 Such a value judgment is made from the perspective of those in top concentrations that have a different cultural and civic outlet preference. People seem to rarely have difficulty finding meaningful pursuits in life regardless of their origins, but people do have difficulty regarding what they have been programmed to understand. Overcoming this programming when it gets in the way of needed change is essential for real progress in an area such as health access.

As with all such statements and situations, they are the result of separations and segregations. An America with more physicians distributed across America would understand much more about American health care. With physicians serving in a narrow range of locations and a narrow range of populations, health access can appear quite impossible or quite undesireable. When Americans that become leaders in all walks of life are raised and educated together more and more rather than less and less, then some progress can be made in rural versus urban, lower and middle income versus most exclusive, economic divisions, and equitable design of a health care system for all Americans.

When those that are destined by birth to become leaders in health care have substantially more life experiences shared with those left behind, there can be progress toward health access resolution. When students from exclusive schools refuse to spend even a few hours in a month with poor populations and when their leaders cannot overcome their "uncertainty avoidance," leadership compounds the problem.

Eventually nations, states, and schools can begin to address not the challenge of physician distribution, but the reward of improved physician interactions with all peoples. It is just not possible to fully train physicians to be physicians without addressing the need of physicians to be able to interact with all peoples.

A considerable benefit of this effort is improved education, economics, and stability in a nation and maximization of human potential. A nation with a strong foundation in family structure, nurturing of the youngest, child development, and early education is a nation that can produce sufficient and top quality teachers, nurses, public servants, family physicians, and all who serve on the front lines of human infrastructure. A nation that concentrates its efforts efficiently and effectively in these areas will be a strong nation. It will be a nation that will distribute physicians where they are most needed. A nation with more primary care and more family physicians is not likely to have higher quality health care. But the changes in a nation that result in more primary care and more family physicians, in birth to admission, in admission, in training, and in health policy support, is also a nation that addresses the most important priorities for all nations.

A nation that steadily favors children of concentration and leaves more and more lower and middle income children behind will crumble as its foundation melts away. Optimal national performance is the result of a level playing field for all children combined with democracy and capitalism in a way that maximizes the potential of individuals and the nation. Democracy and capitalism may be the worst choices for nations that are increasingly divided with few middle income and lower income children with little opportunity. With decreasing opportunity, fewer invest in their futures or feel that their investments will make a difference. Already many if not most lower and middle income males have lower probability of higher education and half the probability of medical school admission compared to females. while this is a source of limited health access potential, it is also a marker of even greater failures such as lost productivity, prison costs, social program costs, and more.

Few understand that no less than the human infrastructure of the nation is at stake. Lower and middle income children are the future child developers, teachers, nurses, public servants, family physicians, rural physicians, and underserved physicians. They are all on the front lines serving where most needed and representing a desirable future generalist career to future lower and middle income children. They are the eyes and ears of the nation, when those who lead learn to pay attention to what is really going on in America. 

When a nation shifts steadily toward combinations of concentrations leaving more and more lower and middle income citizens behind, such a nation will have far more problems that just shortages of physicians in lower income and rural areas.

Possibilities and impossibilities are powerful. 

the task of health access is still not impossible, but it is far more difficult. The science of basic health access still indicates that physician distribution is possible or even probable, regardless of belief or disbelief.

1.         Cohen JJ. Why doctors don't always go where they're needed. Acad Med. Dec 1998;73(12):1277.

2.         Kassebaum DG, Szenas PL. Rural sources of medical students, and graduates' choice of rural practice. Acad Med. Mar 1993;68(3):232-236.

3.         Whitcomb ME. Preparing the personal physician for practice (P(4)): meeting the needs of patients: redesign of residency training in family medicine. J Am Board Fam Med. Jul-Aug 2007;20(4):356-364; discussion 329-331.

4.         Butler WT. Academic medicine's season of accountability and social responsibility. Acad Med. Feb 1992;67(2):68-73.


Experiential Place and Health Access Considerations

Nebraska: A Practical Application of Experiential Place and Workforce

Primary Care Past, Present, and Future Using the Most Important Criteria for Primary Care - Actually Remaining in Primary Care and Delivering Primary Care

Summary - Why 5000 More Family Medicine Graduates Is the Remaining Solution for Recovery of Basic Health Access in the United States

Why Physician Workforce Needs New Tools (and a health access perspective)