I am attempting to switch gears in a major way. Just posted a note on the
Family medicine list serve in the US regarding being castigated by the APA
(psychiatrists) for not doing better with lipids (out of Toronto). I noted
there were some basic considerations such as food, basic care, housing,
etc.

I also posted this about a researcher:

We had a conference given by a noted NIH lipid researcher, author of 1300
studies. He was an amazing speaker and made all of us older types feel at
home with his Q and A style involving the whole group. He convinced all of
us, including myself to be more aggressive with lipid medicines. However he
fumbled on my question. I asked him about the problems of family physicians
in that we care for the less advantaged, those who face significant
challenges regarding co pays and out of pocket costs. We had to work with
patients to balance all of their needs, not just a lipid medication. He
gave a curt, just present them the evidence and have them make the choice.
Actually this was just what I expected from 15 years in NIH or any of the
studies from same, but it was all the same a sad end to a very superior
presentation from a man with great knowledge, but little wisdom. Again the
needs of the 30% who control nearly all of the wealth, income, health
resources, and decisions in the nation guide the rest of the nation and are
just not in touch with this greater portion.

Now, as critical as I am about being out of touch with research and
recommendations, I am also skeptical of community-based investigations in
the area of rigor.

The qualities that make one a very good advocate, can sometimes inhibit the
absolute rigor needed in clinical, community, qualitative, and quantitative
investigations.

The balance between community and university can be essential to
maintaining the rigor, the relevance, and the quality.

It took me many years to gain the knowledge, the experience, and the
perspective needed to be rigorous. Many would say I have far to go still.
People such as Don Pathman at UNC and journal editors and mentors were
essential to this process. These are all people that are connected to
academic circles.

Perspective drives the studies and the findings. Perspective is often
strongest in community and advocacy types. But not always

For example there is a common belief that higher MCAT score means better
quality physicians or higher probability of choosing a student with a
research career. Given a completely level playing field, MCAT does predict
academic ability and may well predict quality, but the field is not level.
In fact those with lower MCAT scores also happen to be the most different,
a major reason for lower scores. Those with lower MCAT scores are also most
like the lower income and middle income and different and rural patients in
most need of care. Those most like their patients are known to have higher
quality of care or at least greater perception of quality of care by the
patient.

Studies are beginning to demonstrate that empathy, service orientation, and
basic awareness of the needs of others are all related to socioeconomics,
how medical students were raised, and their MCAT scores. The students with
the most empathy and service orientation and awareness have the lower MCAT
scores. These investigations are not yet rigorous, but they are suggestive.
They also make the most sense. Those with the most empathy are likely to
have been the most abused or had the most barriers. Those with the most
service orientation are those that had to work hardest to gain college and
medical school. They used their strengths to overcome some academic delays
that they were working on. Awareness is clearly a function of the
experiences from birth to training and being raised exclusively means
paying a price of poor awareness.

MCAT is a poor predictor of physician quality or research or medical school
performance.
      Both highest and lowest MCAT are problem areas. Above a threshold,
MCAT loses relevance
      Research types go to only 21 medical schools and are often children
of researchers and university types,
      MCAT again is limited, especially in the other 100 medical schools
      MCAT is known to be a poor predictor in medical school performance,
especially after the first 2 years.
MCAT is an excellent predictor of poor physician distribution, major
medical center location, and certain subspecialty careers.

The MCAT is well on the way to predicting characteristics that are not
likely to be flattering to the medical profession. Since MCAT and income
data on individuals is difficult to obtain, this will take time. Academics
are not likely to do such research. Community based folks will never have
the access. But both together have a shot.

Same for school teachers, public servants, public health, and other basic
infrastructure areas of society. We have long taken these for granted, but
find that we have actually been ignoring the most basic and important areas
of all.

Robert C. Bowman, M.D.
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