The literature says that it may be too late for some.

Consistent in serving the underserved: Those who were born or raised in
underserved locations, who somehow manage to overcome the obstacles to gain
admission

Experiential place or the Life-course perspective study these concepts.
Diametrically opposite to these is major medical center origins, major
medical center training, and major medical center health policy - all
driving students away from geographically and socially isolated locations
and populations.


Parents, role models and mentors all appear to influence these areas. Brief
training resources may be less than adequate. In evaluations of service
orientation, a similar concept, service orientation can be taught, but
rapidly fades. For those with service orientation prior to training, the
effect remains (O'Connor)

For those of lower and middle class origins, their awareness of such
situations is markedly greater. They have the background that can
facilitate the training or even give the training.  AAMC Minorities in
Medicine Studies, AAMC Matriculant and Graduation Questionnaires



Who serves the underserved? Predictors of physician care to medically
indigent patients
Heidi Taylor Chirayath
Bates College, USA
http://hea.sagepub.com/cgi/reprint/10/3/259
Chirayath H. Who serves the underserved? Predictors of physician care to
medically indigent patients. Health: An Interdisciplinary Journal
for the Social Study of Health,
Illness and Medicine. 2006;

O'Connor SJ, Trinh HQ, Shewchuk RM. Determinants of Service Orientation
Among Medical Students. Available at
www.sba.muohio.edu/management/mwAcademy/2000/38c.pdf. Oxford, OH: Miami
University Farmer School of Business; 2000.
Vol 10
(3):259–282.

My own research

Family physicians are the most likely to be lower and middle income and
rural in origin, are most likely to train in medical schools with slightly
less major medical center focus, and are actually driven away from major
medical centers by current health policy. Under current health policy,
there are few other options for family physicians who remain in primary
care at 90% levels and distribute to rural and to underserved locations at
2 - 3 times all other physicians. NPs and PAs once had these distributions,
but no longer.

Physician assistants and nurse practitioners were created to be "outside"
of major medical centers, started their training "outside" and had health
policy that facilitated their training and distribution, however NPs and
PAs are more and more likely to be inside in origins and training and
current health policy drives them away from primary care, rural, and
underserved areas and into major medical center careers and locations.
About 1 - 2% fewer are found in primary care, rural, and underserved
locations each year for the past decade under current health policy and
training program development. About 1 - 3 new subspecialties a year are
created.

Under current health policy the following can be expected in years of
primary care per graduate in NP, PA, FP, IM, and PD


      PC    FTE   Per FP
      Yrs   Total Index
NP    3     0.15  5.6
PA    7.2   0.24  3.3
FP    25    0.84  1.0
IM    7.2   0.24  3.5
PD    16    0.53  1.6
MPD – disappears into IM and PD

Nurse practitioner graduates of 2007 are expected to serve an average of 3
years in primary care for the 7000 graduates (21,000 work years of primary
care adjusted for primary care %, volume, and activity, but not other
reductions). Nurse practitioners have 0.15 FTE of primary care for their
expected 20 year average work career. It will take 5.6 NP graduates in 2007
to provide the same primary care as a single family physician.

Nurse practitioner losses from primary care and potential to serve the
underserved include 11 years spent as an RN prior to NP training, losses
due to NP training (from nursing capacity and from primary care capacity)
less than half found in primary care, half of the volume of primary care
patients seen compared to FP, significantly higher levels of part time
work, 10 hours a week less primary care than FPs or other physicians, and
60% levels of activity as an NP after training.

PA losses include less than 40% in primary care, 15 - 20% levels of
inactivity (2 - 3 times physician levels), part time work, little call, 10
hours a week less primary care work than FPs or other physicians, and about
75% of the volume of family physicians.

Physicians graduating in primary care (1960 AMA Longitudinal study)
remained in primary care til the end in 57% for 0.7 FTE of primary care
(using survival curve calculations). Only family physicians at 0.84 exceed
this. Over 47 years of health policy involving billions of dollars have
found only one improvement since 1960 for primary care retention that is
relatively immune to adverse health policy. Sadly family medicine is also
known as a permanent form of primary care by medical students and has
reached its lowest choice. The low levels of family medicine choice are the
only accurate reflection of primary care in the match. Only 60% of
pediatric residents and 25% of internal medicine residents that remain in a
pediatric or internal medicine career will be found in generalist primary
care. About 90% of family physicians in the match will be found in
permanent primary care and will be joined by about 10% more after the
match. The match in family medicine, poor as it currently is, is an
accurate reflection of future primary care from family physicians. These
figures apply best to the 1975 - 2000 graduates. The deterioration in
primary care policy and in the health resource support for lower and middle
income populations (outside of major medical centers) makes it less and
less likely that medical students or other residents will move to family
medicine over time.

There is no disrespect meant for those who follow health policy and
certainly not for the hardy NP, PA, IM, and PD folks who remain serving in
primary care, rural, and underserved areas by the tens of thousands. Just a
realistic view of the future for those who most need health care and the
economics, jobs, and shaping forces of health professionals.


those who are excluded will serve the underserved, including origins,
training, and health policy

those who are exclusive or follow exclusive health policy will not serve
the underserved, including origins, training, and health policy

Robert C. Bowman, M.D.
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