A response to those complimenting family medicine leadership for a job well
done on funding retention

Yes this is important, but...   Why should we have the same battle next
year?
Why should we spend our political capital all on one narrow area when
reimbursement is the key?

It is time to draw a line in the sand.  On one side of the line are those
who serve all the nation, including those who arise from lower and middle
income populations and those who return and serve such populations. On the
other side of the line is the nation's leadership and those who enjoy the
benefits of being in the top status in the wealthiest and most powerful
nation on earth.

We have made our choice. It is time for you to make a choice. This is what
FP stands for, do you want in, or not?  We are not jumping on the
bandwagon, we are the band, the wagon, and the vehicle for primary care in
the nation.
99% of residency graduates stay active
98% stay in family medicine
90% of residency grads stay in office primary care
50% remain in major medical centers of 75 or more physicians at a zip code
where 75% of US physicians are found and where 100% are trained
50% leave major medical centers to serve the 70% of the US population
outside of major medical centers
24.4% are in rural locations and 22 - 30% for each class year dating back
to our creation
12% are in underserved locations and 10 - 15% dating back for class years
back to our creation

We begin with 8% of physicians in major medical centers. Because so many
physicians are crowded into these locations, this 8% is half of us, but it
is our lowest concentration. We are 22% of the physicians in urban
underserved locations. We are 30 - 100% of physicians in rural locations.
We increase in concentration with decreases in income, health care
coverage, education, physicians, facilities, and people.

We are not just where we want to be. We are where the nation wants us and
they have selected us in open competitions involving all physicians and
practitioners in the most important elections. We are only 12 - 14% of
physicians but we are 50% of the physicians in Community Health Centers and
increase to 61% for those in rural areas. (Rosenblatt, Jama)

The nation could not ask for a purer form of primary care and physician
distribution, even in the worst health policy in 40 years, policy that has
driven away all of the less committed forms of primary care even though
they were created for primary care. By neglect of basic understanding of
distributions of education and health at a crucial time in history, the
nation has wasted billions in federal investments for decades with many
more billions in inefficiencies to come.

The investments in family medicine have paid off, big time.  We are the
ones who contribute to the important economies in middle income, lower
income, and rural areas, the areas ignored at greater and greater levels.
When we are not supplied to these areas, hospitals close, clinics close,
jobs dry up, and the most fragile Americans die sooner than they should.

We are the ones invested in by local and state efforts in education, who
actually stay around to contribute. We are the least likely to be the brain
drain component that leaves for exotic locations. We maintain connections
and relationships. We are those who took advantage of the pipeline
programs. We are not as likely to be the children of professionals who paid
their children's way through all the steps. We are a direct reflection of
American investments in American people, especially those in lower and
middle income populations.

When the nation does not graduate family physicians, there is something
terribly wrong with the nation. Sadly enough, when few choose to become
family physicians, we even try to figure it out and blame ourselves. What
is happening now is not a problem with family medicine. What is happening
in family medicine is a reflection of what is happening in the nation.
Fixing family medicine requires fixing the nation, so we better get
started.

Family medicine does not change. It has existed since the beginning of
medicine. It was the first form of medicine. It remains the purest form of
doctor-patient interaction. It is what those who desire such a relationship
pursue, even from birth, even if they have never seen family physicians.

For those born in the most difficult circumstances, about 1 FP arises each
year out of 100,000 and another 3 - 4 gain admission but do not choose FP
For those born in the most elite origins, about 1 FP arises out of 100,000
and another 8 - 10 gain admission, but do not choose FP

What is clear from these studies: A maximum of 25% choice of family
medicine is possible and is seen in studies of counties, states, and
population groups. A minimum 6 - 7% choice of family medicine is also seen
in the same studies. However there are medical schools that graduate 40 -
50% into family medicine and they get there by prioritizing the qualities
of family physicians. There are also medical schools that graduate no
family physicians. They also clearly must do a great amount of work that
manages to exclude family physicians. Factors arising from birth to parents
to education to standardized tests to admissions to training are all
involved.

Regardless of the difficulties, family physicians seem to find a way. They
may not have the income, urban origins, professional parents, private
schools, or top colleges of the 70% of US MD grads admitted from the top
30% of the nation, but they find a way. They find a way to gain admission
even with scores that are not quite as high as those most likely to gain
admission to the top colleges and professional schools. They gain admission
despite a standardized test that remains speeded or biased by the speed of
processing test material because it cannot predict first year medical
student performance without retaining this bias (Ellen Julian, VP of AAMC).
The MCAT test discriminates against those with different language, culture,
and background who process multiple choice test questions at slightly
slower rates. This is also a group that is not able to buy better scores
and better test taking strategies as many are lower in income, married,
have children, and work 2 or more jobs to get the chance to become
physicians and family physicians. The family medicine group also has
slightly lower board scores for the same reasons, not related to
performance as a physician, but just because they are different.

How many top notch family physicians we would lose if board scores
reflected actual physician performance, we will never know.  What we have
known for over 80 years is that intelligence testing fails to predict
complex areas such as physician performance. The initial designers such as
Thorndike told us this. (McGaghie, Hx MCAT, Jama)

As allopathic US schools fail to admit lower income, middle income, rural,
different, diverse, and older types, the ones with slightly lower scores,
those destined to become FPs find a way. Most of those going to osteopathic
schools plan to become family physicians and the concentrated segment
(higher percentage of FP) rejected by allopathic medical schools joins
them. Others leave the United States to Caribbean and international schools
and a higher percentage of this group also become family physicians.

Rural interested medical students have 68% FP choice, the highest levels of
interest (60% vs 10.5%) in serving the underserved, and they deliver in
actual practice. Inner city origin medical students have 40% interest in
serving the underserved, and they deliver in actual practice, but only when
they choose FP. Only family medicine choice has demonstrated the ability to
turn the highest income, most urban, or children of professionals into
rural or into urban underserved physicians at higher levels than the
national averages. Graduating more physicians with less choice of family
medicine and admitting lower concentrations of lower income and rural
origin students only dilutes rural and underserved workforce.

Family medicine choice doubles urban underserved location, triples rural
location, and results in 3.5 times greater location for rural underserved
choice. Family medicine contributes more to rural distribution than rural
origins. Family medicine contributes the same doubling effect for
underserved distributions even when loading multiple underserved origin
characteristics in the equation. Family physicians are retained in the
state that supported them for education and medical education at the
highest levels, particularly when we link medical education to graduate
training in the same location.

In other words we go where we are most needed and we stay. We don't make
promises about primary care. We keep them. Our only mistake is that we
choose to serve, not promote ourselves (outside of this author).

In fact as bad as we need support, there are those who need it more than we
do. Without massive improvements in the investments in children age 0 - 6
in the United States, even having more family physicians will not help. The
United States was a nation charged with responsibility for current people,
but also future generations of children. (Preamble to the Constitution)
Even more than supporting us is making our job better and more effective.
As it turns out, you can make life better for all on the front lines of
infrastructure, those who serve the people of the nation.

You as leaders of the nation can choose to reward the service oriented
professionals like us, and that we all depend upon, or you can remain where
you are. The line in the sand is drawn. It is your choice. Teachers, public
servants, nurses, counselors, and family physicians have long ago crossed
to the other side, in fact we really never left. The child development
profession that would complement us and the nation waits for you to birth
it.

After you get cleaned up from the delivery and congratulate the parents, we
would love to have you join us again. You just can't beat being part of the
family and the front line team of serving professionals in the most
important moments in life: births, graduations, new jobs, healing ups, new
directions, contributions, society getting more and more efficient, and new
generations getting better and better.

Robert C. Bowman, M.D.
[log in to unmask]
www.ruralmedicaleducation.org

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