Don't despair regarding admissions or choice of family medicine or lack of
support. Those fighting uphill are tougher than the obstacles. Family
medicine is also a stronger breed capable of surviving, as long as a
certain minimal level of primary care support and support for health care
outside of major medical centers continues. The US is dangerously close to
this threshold, but not yet beyond it. Of course the US is also dangerously
close in health systems, education systems, and economic systems. Family
medicine is a reflection of these changes. The state level correlations,
especially with efficiency measures are strong and significant.

The issues of social distance, geographic distance, ethnicity, race, and
gender are fascinating.

I divided the US into 4 birth origin county types by per capita income for
the purpose of categorizing the birth origins of US born medical students.
Each category had 50 million people in 1969. I then categorized the county
by presence of a medical school or not for 8 different types. (or a medical
school in the same city if multiple counties in city).

There were 51 counties in the top income grouping with one or more medical
schools. These counties represent the top 20 – 25% by income level,
education level, percentages of professionals, admissions rates, and more.
Only a few percent of the population in the top income quartile had no
medical school. These 51 counties have only 1% of the land area of the
United States. In the 2000 census these 51 counties held 57 million people,
20% of the total US population, 17% of the White population, 47% of the
Asian population, 23% of the Black population, 11% of the Native
population, and 31% of the Hispanic population.

For these counties about 8.5% of the total population is Asian, 13.8% is
Black, 0.5% is Native American, 64.6% is White, and 19% is Hispanic
Normal distributions across the nation are 4.2% Asian, 71% White, 12%
Black, 1% Native, 11% foreign born, and 11% Hispanic.

These 51 counties are still growing in population largely due to foreign
born immigration and populations with the highest fertility rates, but
populations within these counties also have the lowest rates of
reproduction. Also overall these counties are losing population share (1 -
3 percentage points per decade) relative to all other types of locations
with lower income levels that are growing at faster rates.

These 51 counties include the birth locations with the highest rates of
medical school admission, but subpopulations within these counties also
have little or no chance of admission to medical school or college. Some
populations in these counties only graduate 30% to 60% from high school.

Although some see such locations as great opportunity, this requires
significant levels of education and organization to be able to take
advantage of these opportunities. Those living in such locations sometimes
do not see that others in the nation desire a different place to live for a
wide variety of reasons.

Medical students and all types of professionals often have little choice
since nearly 80 - 100% of the colleges and professional schools have
similar location and pre-requisites. For those raised "outside" they must
adapt to the requirements long before admission. For those planning to
distribute "outside," they must adapt to the setting and then de-adapt to
distribute to the most needed locations.

Fewer and fewer appear to be capable of making this adaptation. National
policies also complicate distribution.

What is becoming more and more clear to me is how little all of us
understand about geography, income, and education distributions. We
understand far too little about concentrations of resources that impact so
much now and that will continue to impact future generations.

Then there is the matter of parent expectations. If your parents were at
the top, I strongly suspect that they will not be satisfied with anything
than the top status. This creates interesting dilemmas for those who are
accustomed to being on top in any nation, and for a variety of reasons,
find themselves no longer on top.

Then finally there is the increasing development of a sense of global
status perhaps more apparent in the corporate world, but moving steadily
onward. Status measures are less and less defined by status within a nation
or city. The World is Flat as Friedman points out, and then intentionally
contradicts himself by showing that it is also not Flat.

Since the United States has some of the least awareness of what is going on
within the US and also outside in the world, the next decades will largely
be a series of surprises for America.

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

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