Thank you Robert and Michael,
Some of us, chose to be physicians for the committment to population
health, altruism, humanism, and true patient care....at the expense of
yes, putting family on hold, risking loosing our lives in the process,
and of course, ending with over $100,000 in debt.
You see, I fit the category of Hispanic/Latino student, foreign born,
who did very well in college and always dream with attending medical
school. It took me three tries to get in, partly due to the lack of
understanding of a system that included standarized test to "place you"
in a certain rank order, naiveness regarding the system that expects you
to pay private organizations to "get you ready" to compete (Kaplan
etc,), and of course lack of social capital: no one in my family had
gone to college, no one to advise me on the perils of competing to get
into medical school.
But I was blessed. Public programs such as Title VII grants, funding
Centers of Excellence in medical schools intended to increase the number
of minorities who will potentially take care of our own population made
it possible for me to gain entrance demonstrating my ability, and
excellent grades.
So at the age of 26, I entered medical school. Graduated in 1996, and
for the last ten years, chose to practice in an academic institution
catering to the urban poor population, many without health insurance.
I met the criteria of the Title VII programs.
As Dr. Bowman properly pointed out, my class mates did not look like
me....most of them White, Indian, Asian....many highly committed and
humanisitic, had a hard time relating to the people we were caring for
at the hospital (the urban poor minority)....they had no connection.
At the end, the majority chose either a subspecialty field, a private
practice or administration....Only a few went on to practice in rural
areas, or poor urban areas. For those of us who practice in those
areas, we do it with the acceptance that they pay is less, the so call
"prestige" of medicine is non existant, but the regard is priceless.
Today, funding for those programs has been eliminated, so the
possibility of those at the bottoom of the scale getting into medical
school will become even more pathetic than it is now....those who can
afford it will continue to get in....some will truly do it for the sake
of the population, but most will continue to propagate the medicine
status many of you dislike.
The problem is in the system, not the people that get into it. It is
the system that continues to set the differences between the haves and
have-not.
ANA
Ana Natale-Pereira, MD, MPH
Assistant Professor of Medicine
Division of Academic Medicine, Geriatrics, and Community Programs
Director---Community Based Networks
30 Bergen Street ADMC-6-614
Newark, New Jersey 07102
Office: 973-972-8994 or 1744
Fax: 973-972-8799
[log in to unmask]
"We the willing, led by the unknowing, are doing the impossible for the
ungrateful. We have done so much, with so little, for so long, we are
now qualified to do anything, with nothing."
~ Mother Teresa ~
>>> [log in to unmask] 02/16/07 5:32 PM >>>
Diana,
You touch on an important point: physicians are not the only method
by
which population health needs can be met.
However, the medico-legal system does place significant value on the
decisions and conclusions drawn by physicians and lawyers.
I think the inclusion of Nurse Practitioners is one strategy that can
help
remedy the issues.
Ultimately though - it remains that there is a disproportionately high
percentage of "privileged" persons being drawn to the professions.
While
I've not researched this statistically, Dr. Bowman's observations and
insights can be found throughout the professions (teachers, lawyers,
psychologists, nurses, etc.). Bledstein talks about this phenomenon in
the
book (Culture of Professionalism) published in the 1970's.
Your suggestion of increased support (free education in exchange for
service
contract in remote areas) is a good one. But the trick is to convince
the
policy makers that there is a need to support such an investment. As
Dr.
Bowman has effectively pointed out - the decision-makers (not just
physicians) tend to be affluent urban-origin people, who may tend to
overlook the importance of rural communities and the associated needs.
Looking at it from a pure business perspective - consider the "rate of
return on investment". If you can invest money in urban-centric
medical
education programming where there are significant congestions of
population,
you can create the illusion of greater efficacy of spending (each
dollar
spent covers more "souls" per square mile). However, with the remote
rural
locations - the dollar investment covers fewer souls per square mile.
With
this thinking - funding initiatives would be biased to urban areas.
This
applies to general education - if education dollars are focused on
city-dwellers, and rural education systems suffer for lack of funding
-- who
is more "competitively" positioned to gain entry to medical (or any
professional) schools? Thus, this reinforces the cycle in Dr.
Bowman's
discussion.
Ultimately - this cycle does need to be interrupted, or at least
widened
with some flexibility. Another positive opportunity is to create a
part
time study opportunity. This will allow potentially gifted students to
gain
access to medical education while also attending to family/personal
commitments. Many very good people miss the opportunity to attend
medical
school simply because they cannot afford to place their lives on hold
for
7-9 years! While I understand that the total immersion in "medical
school
culture" is part of the training - it is something that limits the
professions capacity to grow.
Dr. Bowman - thank you for inspiring some great reflection!
Michael
On 16/02/07, Diana Liw <[log in to unmask]> wrote:
>
> Well, we seem to be going round and round about Asian being admitted
to
> medical school more as if entering into the profession of medicine is
so
> much more superior than any other professions. There are a lot of
other
> honorable professions such as nursing (which we have a shortage as
> well), social work, psychiatry, manial, engineering, farming,
> homemaking, trades etc, and etc. May be we ought to just treat
medicine
> as any other professions. I digress. I think the real question is
not
> how many get admitted to medical school and why (although it is
> important if we have the shortage), but how many of those admitted
> practice in rural or low income areas. And the next question is how
do
> we change this perception of the superiority of the medical field.
One
> way as an incentive which many had talked about with shortage of
> physicians in low income and rural areas is to provide scholarship
or
> free medical education with graduates practicing in these areas in
> return. I think that totally make sense and can help solve the
issues
> of only higher income families can afford sending their children to
> medical schools. Last time that I checked, going to medical school
is
> not cheap, and the enormous debt that physicians have from their
> educations may also be one of the reason why our health care cost is
so
> high.
>
>
> >>> Robert C Bowman <[log in to unmask]> 02/16/07 11:05 AM >>>
> My apologies about the wonderful protection provided by encryption
of
> sensitive patient information, which is never enclosed of course.
>
> It is uncanny how multiplier effects work all the way from the
extremes
> of
> concentrations, the worst health stats to the best, and the worst
> behavioral or education outcomes to the "best"
>
> Those most likely to gain admission to medical schools in the US are
> Asian
> with 3 times higher levels of admission (higher now with 23%
admitted
> and
> 4.3% Asian). Asian Indian admissions are actually 10 times higher
(not
> quite 1% of the US pop, 7% of admissions), a reflection of even
> greater
> concentration of status factors for this particular group in
America.
> Averages for whites, urban origin, and other foreign born not Asian
> are
> about 1 in 200 who are medical school age. Averages for whites or
any
> group
> with the same elite status factors are as high as Asian populations.
> Since
> we fail to distribute information about social class and income
well,
> ethnicity and race ends up being the marker used.
>
> Progressively lower levels of admission: rural born 1 in 360, Black
1
> in
> 400, low income rural 1 in 750, Hispanic 1 in 700 - 1200, and lowest
> income
> of all at 1 in 2000. again these are comparisons to medical school
age
> populations. The range is 10 times higher to 10 times lower, but for
> most
> purposes, 3 times higher to 4 times lower is the range - about 7
times
>
> Another calculation based on entire population (not just medical
> school
> age) by state or county finds Florida near the bottom again, with
very
> little chance of those most socially distant or those most
> geographically
> distant gaining admission. The company kept at the bottom reflects
> serious
> problems for a state that has relatively great wealth.
>
> Family medicine appears to be a relative constant in admissions
dating
> back
> to the class years of 1975. Once the nation had established
Medicare,
> Medicaid, and family medicine, the levels found in family medicine
> have
> stabilized and remained. Clearly the rates of FP choice have
increased
> and
> decreased with health policy, but using a relatively neutral period
can
> be
> helpful. Using Masterfile data and census data on birth county of
> physicians with US birth and med school graduation 1987 - 1996:
>
> About 1 born to each 100,000 gain admission from normally
distributed
> populations and eventually become family physicians. This is no mean
> task
> for those born in lower income or rural areas as only about 4 per
> 100,000
> gain admission. It is rare to see less than this level.
>
> Total admissions from a county or group for 1987 - 1996 class years
*
> 100000 / population of county or group in 1970 / 10 (ten class
> years)
> Repeat for those choosing FM to get FM per 100000 per year
>
> In the highest status populations the single future family physician
> is
> joined by about 8 - 10 others. The average for the nation for those
> born in
> the US is about 6 - 7 per 100,000 per year and this does not include
> foreign born. Including foreign born increases the level to 9 per
> 100,000
> for US MD Grads.
>
> For the US born population alone, this translates to a maximum of
about
> 1
> in 4 or 25% choosing family medicine for the most disadvantaged or
> distant
> (usually both) populations. The minimum is about 6 or 7% or about 1
in
> 12 -
> 14.
>
> To get more than 25% choice of family medicine it appears that you
have
> to
> do work, you have to select very carefully beyond rural origins or
> lower
> income origins. One result from these findings: Generic approaches
for
> just
> rural origin or for just lower income origin are not likely to work
to
> increase FP, since those admitted are more likely not to choose FP.
>
> To get specific concentrations of FPs beyond 25% you have to
> identify
> characteristics that are specific for FP and not just rural or low
> income.
> Those who have done so have focused on areas such as people skills,
> service
> orientation, specific focus on family medicine. In the schools that
> specifically select for family medicine and rural interest and
> background,
> the maximum appears to be 50% as in Duluth, using a variety of areas
> such
> as overcoming obstacles, time spent in rural areas, specific FP
> interest,
> service orientation, but higher may be possible since there is still
a
> generic push for rural involved. The rural push is good for rural
> specialists by the way, which are needed perhaps more than FP in
many
> areas, so no problem here.
>
> To get less than 6% FP in a medical school or state, you have to
work
> very
> hard to exclude those who are trying very hard to become physicians
> and
> family physicians. Remember that they manage to gain admission even
> from
> the most difficult origins, even if they have to leave the country
to
> become a physician. Currently about 3 medical schools each year
> graduate no
> family physicians and this will likely grow. Of course 1 - 2
> eventually
> become family physicians (their exclusion comes after medical school
> instead of before) Still this is less than 6%. Now to be fair, we
have
> entered a new era in health policy where FP choice for all
populations
> is
> dimenishing. Seems that a certain level of primary care support,
> support
> for those outside of major medical centers is required and we have
> sunk
> below 1965 levels. (five periods of health policy)
>
> Somehow the process of preparation, admission, and training manages
to
> extinguish family medicine in the narrowing process in some areas,
> schools,
> and states.
>
> Anyway it is very hard to suppress family medicine. In recent
decades
> US
> born types have even escaped to Caribbean schools and higher
> percentages
> become FPs than about 60% of US medical schools.
>
> These are the areas of the nation that have been excluded so much
that
> they
> have the lowest levels of admission. In the most severe cases, they
> have
> even managed to inhibit family physician production.
>
> counties Admit Admit FM FM ratio
> 1987-96 87t96
>
> Commuting Counties 381 1.28 0.29 22.6%
>
> 4 Adjacent Less Than 123 1.71 0.32 18.8%
> 10000
>
> Whole County PC Shortage 784 2.03 0.43 21.1%
>
> 6 Adj Small Metro < 10000 626 2.08 0.46 22.2%
>
> 9 Not Adj Less Than 2500 511 2.16 0.59 27.1%
>
> Retirement Counties 189 2.32 0.40 17.4%
>
> Federal Fund Counties 381 2.62 0.56 21.4%
>
> Over 20% Over Age 65 388 2.71 0.59 21.6%
>
> Poverty Counties 535 2.84 0.59 20.9%
>
> Manufacturing County 506 2.91 0.60 20.8%
>
> Farming Dependent County 555 3.09 0.80 25.9%
>
> Predominantly Black Rural 88 3.10 0.54 17.4%
>
> NH - no public school 10 3.12 0.39 12.6%
>
> 8 Not Adjacent 2500 - 547 3.19 0.79 24.9%
> 10000
>
> ME - no public school 16 3.25 0.46 14.3%
>
> FL 67 3.45 0.40 11.5%
>
>
>
>
> Numbers with descriptions are parker and ghelfi Urban Influence code
> groupings from 1993, 8 and 9 are most distant, 4 and 6 are adjacent
> and
> lower income
>
> The most distant and dependent counties have the most difficulty
with
> admissions. Some are "sucked dry" by adjacent areas. Whole county
> primary
> care shortage areas are concentrations of poverty, low education,
and
> poor
> economics and often involve socially distant populations or those
> where
> patients are sucked into larger nearby urban areas. Not all of the
> counties
> are linked to high levels of minorities. The most rural and distant
> ones
> geographically are 85 - 90% white as are certain states. About 6
> million
> live in predominantly Black, Native, or Hispanic rural counties.
>
> New Hampshire and Maine are rare states that have no public medical
> school,
> clearly impacting admissions. Dartmouth is private. Maine has only
> recently
> had an osteopathic school, but not one of the 6 public osteopathic
> schools
> that have the highest rates of FP, primary care, rural, and
underserved
> in
> the nation.
>
> Florida does have public medical schools and has created a new one
and
> more
> may be on the way, but graduating family physicians, geriatric
> physicians,
> and physicians for Black and Hispanic populations will be a problem
> for
> Florida State which has promised to deliver in these areas. The
fault
> may
> not entirely be FSU, given the environment. Retirement counties and
a
> retirement state may not be the best location for children - a lesson
I
> was
> barely able to get across to my daughter and her grandchild. Of
course
> Nebraska responded with one of the longest coldest periods in recent
> history.
>
> It is very, very hard to suppress FM choice, but some manage to do
so.
> FM
> as represented here does not appear to be a specialty so much as it
is
> a
> collection of those different, diverse, older at admission, inner
> city,
> rural born, middle income, not born to professionals, and excluded.
> they
> are the most likely to arise from areas outside of major medical
> centers
> and the most likely to be found outside MMCs in practice.
>
> We make decisions at the local, state, and federal level that result
> in
> these situations and exclusions.
>
> For a review of what is coming, or not coming so to speak,
Educational
> Testing Service did a report on America's Perfect Storm at
>
http://www.ets.org/Media/Education_Topics/pdf/AmericasPerfectStorm.pdf
>
> there are nice tables about various differences in student
performance.
> The
> interesting thing about the report is that it never mentions rural
or
> nonmetropolitan once, nada. If they divided out the rural white
> population
> or the lower income white population, the distances would be even
more
> remarkable, even among different types of whites. By my calculations
> the
> levels of urban whites at the highest levels of literacy (4 and 5)
> would
> increase from 17 to 19 or 20% for urban whites compared to rural.
This
> is a
> major omission since 50 million are white and rural, since 69% of
the
> poverty population of the nation is white, since child poverty rates
> are
> rising rapidly in most lower and middle class groups, and since the
> major
> points involved divisions and interactions between education and
> class,
> race, and ethnicity. The literacy data does not treat Asians well
since
> 90%
> of Asians are foreign born or have a parent who is and various
science
> and
> math measurements would have had different results.
>
> Rural areas being forgotten is also in the Wall Street Journal,
where
> loopholes allow foreign born physicians to bypass rural areas for
the
> urban
> and academic locations that they most desire. Seems like someone
would
> figure out that 24% rural location from family physicians looks
better
> than
> special legislation.
>
> Quotes from this ETS report and from the education pipeline and
useful
> references at http://www.unmc.edu/Community/ruralmeded/education.htm
If
> you
> have suggestions for additions or publication, please send.
>
> Most total admissions in the nation - hope this works in email, last
> one
> did
>
>
> County (City) | | Number in | Total | %
> Family
> | | Family | Graduates |
> Medicine
> | | Medicine | |
>
>
>
-------------------------------+------+-----------+------------+----------
>
> San Francisco | CA | 133 | 1046 |
> 12.7%
>
>
-------------------------------+------+-----------+------------+----------
>
> Hamilton (Cincinnati) | OH | 151 | 1056 |
> 14.3%
>
>
-------------------------------+------+-----------+------------+----------
>
> Hennepin (Minneapolis) | MN | 190 | 1144 |
> 16.6%
>
>
-------------------------------+------+-----------+------------+----------
>
> Erie (Buffalo) | NY | 112 | 1159 |
> 9.7%
>
>
-------------------------------+------+-----------+------------+----------
>
> Milwaukee | WI | 154 | 1160 |
> 13.3%
>
>
-------------------------------+------+-----------+------------+----------
>
> Orleans (New Orleans) | LA | 75 | 1169 |
> 6.4%
>
>
-------------------------------+------+-----------+------------+----------
>
> Harris (Houston) | TX | 168 | 1181 |
> 14.2%
>
>
-------------------------------+------+-----------+------------+----------
>
> Essex (Newark) | NJ | 106 | 1201 |
> 8.8%
>
>
-------------------------------+------+-----------+------------+----------
>
> Baltimore City and County | MD | 128 | 1294 |
> 9.9%
>
>
-------------------------------+------+-----------+------------+----------
>
> San Juan Municipio | PR | 110 | 1276 |
> 8.6%
>
>
-------------------------------+------+-----------+------------+----------
>
> St. Louis City and County | MO | 179 | 1524 |
> 11.7%
>
>
-------------------------------+------+-----------+------------+----------
>
> Allegheny (Pittsburgh) | PA | 201 | 1670 |
> 12.0%
>
>
-------------------------------+------+-----------+------------+----------
>
> Suffolk (Boston) | MA | 168 | 1902 |
> 8.8%
>
>
-------------------------------+------+-----------+------------+----------
>
> Cuyahoga (Cleveland) | OH | 252 | 2019 |
> 12.5%
>
>
-------------------------------+------+-----------+------------+----------
>
> District Of Columbia | DC | 207 | 2129 |
> 9.7%
>
>
-------------------------------+------+-----------+------------+----------
>
> Philadelphia | PA | 367 | 3005 |
> 12.2%
>
>
-------------------------------+------+-----------+------------+----------
>
> Wayne (Detroit) | MI | 406 | 3109 |
> 13.1%
>
>
-------------------------------+------+-----------+------------+----------
>
> Los Angeles | CA | 751 | 5369 |
> 14.0%
>
>
-------------------------------+------+-----------+------------+----------
>
> Cook (Chicago) | IL | 713 | 5546 |
> 12.9%
>
>
-------------------------------+------+-----------+------------+----------
>
> New York (11 Counties) | NY | 1404 | 18690 |
> 7.5%
>
>
>
> Numerous variations in the nomenclature for birth city and state for
> New
> York City in the Masterfile (NY, NYC, New York, boroughs, spelling
> errors)
> make this city the most difficult to code. The 11 county area used
> minimizes error and maintains similar admissions ratios and family
> medicine
> choice. What is found in the Masterfile as Washington DC birth could
> also
> be subject to actual birth in nearby counties. Considering DC and
> surrounding counties as an area does dilute admissions ratios, but
not
> by a
> great margin. Birth in Washington DC is an entirely different world
> with 2
> FPs and 22 admits per 100,000, both the highest in the nation and
> complete
> outliers. Those born in Washington DC becoming FPs did not stay in
the
> area
> diffusing across then nation with college, medical school, training,
> and
> practice. They go to places with fewer in major medical centers and
> better
> distributions of education and income.
>
> Readers are left to their own impressions as to whether variations
in
> FP
> choice using birth origins are related to locations that distribute
> income,
> education, and opportunity at higher levels. Certain areas such as
MN
> continue to do well. CA, FL, NY, and other areas continue to do less
> well.
> This also includes the foreign born physicians in the US in % in
> family
> medicine, but my inexperience does not allow me to assess other
nation
> inequities and individual physician data would be needed and
adjusted
> for
> status levels in previous nations.
>
> For FM in the US, you will find consistently high correlations with
> Gini
> Indexes, income quintile ratios, and FP choice at all levels from
> county,
> to state, to medical schools. They also share the same correlations
> with
> MCAT scores, although again the individual MCAT scores, parent
income,
> and
> parent occupation data are highly protected. They are consistently
the
> opposite from the top status populations and funding mechanisms.
>
> Family medicine choice increases with broad measures such as high
> school
> graduation rates, and has less increase or even decrease with
> increased
> rates of college educated or professionals.
>
> Given the doubling or tripling rate for distribution for family
> physicians
> for all areas outside of major medical centers, given the admissions
> relationships, given the origins and locations, family medicine
appears
> to
> be an excellent marker for further study regarding distributions.
>
> It is also nice to have birth to practice data on US physicians and
> career
> choices using these markers for 93% of US MD Grads.
>
> Robert C. Bowman, M.D.
> [log in to unmask]
> www.ruralmedicaleducation.org
>
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