As a new addition I have been lurking for a bit. Couldn't resist on the
inequality area.

Washington DC may well be the most inequitable place on the planet at 28 to
1 or the highest income quintile mean divided by the lowest income
quintile. New York state is 20 to 1. Places such as Minnesota, the Dakotas,
Nebraska, are 7 - 9 to 1. The South is still in the teens.

The high ratio states have incredible rates of inefficiency in virtually
every area: welfare and prison costs per capita, auto insurance premiums,
unemployment, high school failure, and other areas.

The states that deprive the most of education also have the most crime,
social costs, and inefficiency. they have much higher ratios of kids in
prison compared to college.  For fun you might listen to the Clarence
Darrow on the Cause of Crime
http://www.historychannel.com/broadband/clipview/index.jsp?id=speech_63

“Most people think that there is no cause for crime, except the pure
cussedness of the ones they call criminals. But as a matter of fact there
is a cause for everything in this world and there is no way to remove the
evil without removing the cause. There’s a cause for all sorts of human
conduct just exactly as there is a cause for all the physical actions in
the universe. The real cause of crime is poverty, ignorance, hard luck, and
generally youth. These almost invariably combine to produce what we call a
crime. When we look at the prisoners in the jails we find that all of them
practically are poor, at least nine-tenths. And these have always been
poor. At least nine-tenths began what they call a criminal career as mere
children, eleven, twelve, thirteen. At a time in life when the ways of life
are fixed. Nine-tenths of them are ignorant. They have never had the
training that intelligent parent would think was necessary to keep their
child out of prison and make him safe in the community. All of these things
almost universally combine to put people in jail.”

Darrow defended a number of "different" types who wanted to solve problems
in America a variety of different ways, not all of them legal. It was a bit
chilling to compare this with the recent media coverage on Gangs including
the investigative reporter on Oprah and the M2 gang. Also couldn't help but
remember recent interactions with patients and recent media interviews of
street preachers in Omaha noting the rise in gangs, hopelessness, and
violence. Makes one wonder about history repeating itself since we learn so
little. Darrow's voice sounded like LBJ with a bit less Texas accent. What
struck me about the recording was how much he sounded like my grandfather.
By his own admission, Lawyer Darrow was no saint, but he did shake up the
nation.

America is failing in the major cities and the areas failing most are the
ones with the most divisions. School systems are being taken over by states
or by "private" endeavors. In Washington DC, New Orleans, Milwaukee,
Philadelphia, and similar locations, the population of the main county has
declined by 5 - 15% each decade at a time when places of over 1 million
have increased in population 38% from 1970 - 2000.

Washington DC has the "best" and the worst. Top and bottom rates for infant
mortality, longevity (50 vs 70 plus), abortion (800 per 1000 live births to
30 per 1000), and medical school admission (virtually no chance while those
only a few miles away have the highest admissions ratios in the nation)

Some claim that family medicine or primary care is a major contributor
regardug costs and quality. Although they can demonstrate strong
associations, in such research you never know whether you are measuring a
direct or indirect effect.

Family medicine is not "the solution." Family medicine itself is a symptom
of a much more major problem that impacts all of the service-oriented
professionals and the populations that they serve. Family medicine is
clearly different than other medical specialties. It is by far the more
likely choice of lower income and underserved type students. It is the
specialty that most serves the underserved types of patients. Health policy
and education policy that "concentrates" acts to destroy family medicine at
feeder end and support end
1. Maldistribution of education, quality teachers, funding, and resources
kills off the lower income types that would choose family medicine and
distributional careers at much higher levels (and nursing, and school
teaching, and counseling, and public servants). Concentrating lower income
students together only makes matters worse. Family physicians are also the
most likely to stay in a state and to return and serve the underserved.
2. Concentrational health and education policy also rewards those with
higher income and education, the ones least likely to choose family
medicine, choose rural areas, and choose underserved primary care.
Admissions probabilities, better reimbursement for subspecialty choice,
merit scholarships are just a few plums.

From the 1997 matriculants to 2004 as noted in AAMC Matriculation studies,
the medical students whose parents made over $100,000 increased from 23.5%
to 51.5% with a constant 16,000 a year admitted during this time period.
Declines in education, changes in college funding favoring the wealthy,
changes in college and medical school admissions due to legal actions, and
increased hopelessness on the part of lower income students seem to all
contribute. When you live near the bottom run in a state with such peaks
and valleys in education and income, it is very difficult to visualize
yourself ever "making it" so why try? Without changes in health and
education policy, the nation is unlikely to distribute resources such as
service-oriented professionals where they are most needed.

These who are the most privileged are also living the most isolated
academic lives and have the lowest awareness of serious problems in the
nation (AAMC Minorities in Medicine) and are the most likely to lead the
nation in health care and in other areas. (my birth origins studies) I used
to feel bad about the low income types who were denied access in so many
ways. Now I feel that some of the most tragic situations may be the
privileged kids, who are basically denied a chance to ever grow up. Of
course all of us suffer through their ill advised system breaking
decisions.

In my opinion in medicine this shows in studies such as poor physician
satisfaction in the highest paid specialties. (Leigh, Kravitz, Physician
Satisfaction Across Specialties) These are the students in my studies who
have the highest MCAT scores. They are the youngest students to enter
medical school. They are the overachievers who can master any test or any
intellectual concepts in minutes. They were born, attended college, medical
school, residency, and fellowship in the same locations and with the same
people. They chose the same careers and locations. However they are
figuring out that they are ill suited for a career that mostly involves
people, and they never had the most important training of all for such a
career. Many of them peaked out on SAT and MCAT, held on for boards, and
have been in decline ever since.

Robert C. Bowman, M.D.
University of Nebraska Medical Center
Dept of Family Medicine, Director of Rural Health Education and Research
[log in to unmask]
http://www.unmc.edu/Community/ruralmeded/physician_workforce_studies.htm -
physician distribution, birth origins, age of physicians, policy impacts