Roughly 65 million Americans live in places where there are at least 2,000 potential patients for each lonely physician. No surprise, these tend to be impoverished rural regions, or depressed inner cities. We call them “underserved areas.”
If we paid medical schools to train more primary care physicians, would they migrate to these areas? Probably not. Experience shows that if we increase residency slots, physicians continue to flock to the same popular, well-served areas where most prefer to settle: Manhattan, Boston, Boca Raton. . .
It should come as no surprise that relatively few med students elect to set up a practice in rural Mississippi, Detroit, or the South Bronx—unless they are returning home. As I have written in the past, research reveals that students coming from low-income communities frequently feel a commitment to those communities.
Many—not all, but enough—want to go back. But these days, given the sky-high cost of medical school tuition, combined with the nearly perfect test scores and GPAs that med schools require, very few students who attended public school in a small town in Tennessee wind up becoming M.D.s.
Yet health care reform guarantees that waiting rooms full of formerly uninsured low-income patients will be looking for health care. According to the Harvard Medical School, an additional 17,000 primary care health professionals will be needed in underserved areas. Skeptics suggest that reformers have promised more than we can possibly afford. How will we funnel more general practitioners to areas where there already are too few physicians? How much will we have to pay to lure them there?
Most of reform’s critics have never read the Affordable Care Act, and so have no way of knowing what rich funding the legislation provides for the National Health Service Corps (NHSC)—or what that will mean for family practice. Like many Americans, they may never have heard of the Corps.
A government program created in 1970 with an eye to distributing physicians more evenly throughout the country, the NHSC offers scholarships and forgivable loans to med school graduates who agree to work in places where they are most needed for a few years after graduating from school. (If you ever watched “Northern Exposure,” the quirky television comedy/drama which tells the tale of a young doctor who lands in a very small town in rural Alaska, you’re familiar with the Corps.)
Over the years, the NHSC has proven itself in the ways that count. Very few students renege on their commitments, and more than 60 percent of NHSC clinicians have continued to devote part or all of their careers to serving the underserved, well beyond their original commitment to the Corps.
Health Care Reform Gives the NHCS a Transfusion
When the Obama administration came to D.C., it earmarked generous funding for the Corps in its initial 2009 fiscal stimulus package. The 2010 Affordable Care Act then built on that investment. All told, Washington will be putting nearly $2 billion into the NHSC over a five-year period—a sum that should create more than 12,000 additional primary care physicians, nurse practitioners, and physician assistants by 2016. (This is only one way that the Affordable Care Act swells the ranks of primary caregivers. For more, see this Fact Sheet on primary care and reform.
In 2010 alone, nearly 5,000 recent medical school graduates accepted federal grants to pay off tuition and school loans averaging $150,000 per student. The awards came with contracts that obligate the young doctors to remain in what are typically rural areas for three to five years.
The new funding for the Corps marks an extraordinary turnaround for a much-needed, but badly battered program. Ten years after the NHSC was created, the idealism of the early 1970s gave way to a political climate that was not so friendly to low-income families. As economist James Galbraith pointed out in his 2009 book, The Predator State, in the 1980s, the U.S. began to suffer from “compassion fatigue.” We started to “lose interest in the poor.”
President Reagan was elected in 1980, and, according to the National Advisory Council on the National Health Service Corps the NHSC soon “fell victim to a policy sea-change in Washington. . . driven by the twinned goals of reducing the size of the Federal government, and limiting its ‘intrusion’ into activities that could be better handled at the state and/or local level, the Administration cut the NHSC’s budget, and cut it again. It became apparent that the Program was slated for dissolution by 1990."
The indifference of the 1980s left the NHSC “a shadow of its former self.” By 1990, its “budget was $50 million – less than a third of what it had been in 1980. The primary effect of the budget cuts of the previous decade could be seen in Field Strength: as fewer scholarships were awarded (only 40 in 1988) and the pipeline dried up, the Field Strength fell by two thirds as well (from the peak of more than 3,100 in 1986, the NHSC would be able to field barely 1,000 in 1991."
In the early 1990s, funding picked up. “By 1994 the NHSC had a budget of $124 million and awarded 429 new scholarships and 536 new loan repayment contracts, Field Strength had grown by more than 80 percent to 1,867."
In the second half of the 1990s, however, the NHSC again found itself under attack. The Clinton administration was moving steadily to the right, and the Health Services Corps was not particularly popular with the base that New Liberals were wooing—suburban voters. Meanwhile, the number of uninsured grew. In 1999 the NHSC had a Field strength of 2,439—which met only about 12 percent of the need for 20,000 primary medical, oral, and mental and behavioral health clinicians in underserved areas nationwide. Of 2,439 health care workers in the field, just 1,327 were primary care physicians. Roughly half were African-American or Latino; the NHSC was attracting a more diverse group of doctors, but 1,300 just wasn’t enough.
Flash forward to the Bush years: “From 2003 through 2008 funding for the NHSC was cut by $47 million, over 27 percent of a budget that was already insufficient in FY2003."
For decades, the NHSC has been hanging on, waiting for health care reform—and finally it arrived. The $1.5 billion that the Accountable Care Act set aside for the Corps marks a final win for Ted Kennedy.
At the same time, the Obama administration realized that the NHSC would need ongoing funding. This is why, when Obama announced his fiscal 2011 budget in February 2010, the National Health Service Corps benefited from an increase in funding with the President allocating $169 million (up $27 million.)
But of course the story does not end there.
Predictably, conservatives who have launched a new war on the poor (not to be confused with a war on poverty), would like to gut the NHSC. The House Appropriations Committee has proposed eliminating $141.925 million in discretionary FY 2011 appropriations for the Corps, while maintaining $290 million in mandatory funding, which would mean that some 2,365 health professionals would no longer be able to receive NHSC dollars.
I doubt the House will succeed. More importantly, the fact the Appropriations Committee cannot whack the $290 million in mandatory funding is just one example of how difficult it would be to “de-fund” health care reform. That $300 million is part of the $1.5 billion that the Affordable Care Act promised the NHSC over five years. It appears that conservatives cannot touch it.
Money Is Just Not Enough
But money alone will not provide the recruits needed to provide continual primary care in those areas where, as the NHSC puts it, “few choose to go.” Much turns on medical school admissions committees reaching out to a larger pool of applicants.
Not long ago, the Washington Post wrote about a young doctor who had signed up to work in a small, unincorporated Virginia town just “a few miles from the real-life Walton’s mountain.” According to the Post she “embodied the traits that President Obama extolled in stump speeches about reform. She earned straight A's through Richard Montgomery High School in Rockville, Maryland, [a D.C. suburb known for its corporate headquarters] and graduated from Johns Hopkins University with a 3.7 grade-point average. She was one of two students in her graduating class at Northwestern University's Feinberg School of Medicine who chose to become a family practitioner rather than one of the high-wage specialists the school is known for producing.”
But in 2010, as she approached the end of her three-year contract, this NHSC recruit was not at all certain that she wanted to stay. She enjoyed her work, but according to the Post, she was “unprepared for the daily inconveniences of rural living: well water in the clinic's kitchen sink that smells of rotten eggs; being unable to use the iPhone's Epocrates app, which helps doctors identify and prescribe medicine; the dial-up Internet that crawls along on a single computer shared by the clinic; the 40-minute drive to a grocery store. . .”
“‘I don't think I'm a rural kind of person,’ she told reporter Darryl Fears. ‘I like having stuff around. I like the ability to go out to dinner and do cultural things.’" She added that “the National Health Service Corps should make rural offices more friendly to technologically savvy young doctors if it wants them to stay.” But the truth is that her sleek new iPhone won’t pick up a signal deep in the woods, and that is where the patients who come to her clinic live.
The Washington Post reported that as this young doctor tried to decide her future, “Deborah Anderson, an assistant administrator at Central Virginia Health Services, watched anxiously. Doctor turn-over in rural Virginia clinics creates a void in services,” the reporter explained. “Patients who develop a relationship with doctors feel rejected and are reluctant to bond with new doctors.”
No doubt, this bright and caring NHSC recruit contributed to the health of the community during the three years that she has spent there. But the town needs a family practitioner who will stick around. Before she arrived in the summer of 2008, there was no full-time doctor. “We had to let patients go," say M. Denise Williams an older doctor who works three days a week, and sees 20 patients a day, but just cannot take on a larger case-load.
As a result, “patients have been very hesitant and angry," Anderson confided. The typical question they ask new doctors is, 'How long are you going to stay?' They are very reluctant to get to know new doctors. Sadly, a revolving door undermines the trust essential for a strong doctor- patient relationship.”
Class, Income and MCATs
When I spoke at a Mayo Clinic conference on medical education two years ago, I came away with a better understanding of why so few physicians want to work in the remote Virginia town that the Post describes, even if it is “surrounded by trees as tall as skyscrapers, emerald soybean farms and vineyards.” Today, medical schools are selecting applicants from a fairly small cohort of relatively affluent students who grew up in our cities and suburbs. Little wonder that they don’t choose to settle down in the poorest section of rural America.
Speaking at Mayo’s conference, Dr. John Stobo, senior vice-president for health and health services at the University of California, was one of several speakers who suggested that if we want to correct the mal-distribution of physicians in the U.S., “we need to pick our medical students from a larger pool that does a better job of reflecting the diversity of the patient population.”
As I reported at the time, Stobo went a step further, suggesting that we might want to put less emphasis on grades and Medical College Admission Tests (MCat) scores. Relatively small differences in GPAs (say the difference between a 3.4 and a 3.9 on a four-point scale) don’t necessarily measure intelligence, he observed. As for MCATs, Stobo pointed out that we know that they discriminate against low-income students. See this study on MCats which reveals the strong correlation between MCAT scores and social class.
Moreover, while superb MCATs correlate with higher family incomes and high grades in preclinical [i.e. classroom] work, “they do not correlate with clinical performance. And to a certain extent, higher scores correlate with characteristics probably not desirable in most physicians (less interpersonal skill, empathy),” notes a reader commenting on The Future of Family Medicine. When it comes to treating patients, low-income students with lower scores do just as well or better. (For evidence, the reader points to John Delzell's blog "Education in Medicine" where Delzell reviews the literature on this topic.
Nevertheless, these days most admissions committees set the MCAT bar very high, and this helps explain why the vast majority of our doctors in training represent a small percentage of the population. Imagine a five-step income ladder. In 2005, 55 percent of those admitted to U.S. med schools came from families who had managed to arrive on the very top step.(In 2000, only 50 percent came from the top of the ladder). Another 25 percent were raised in households that lived just one step down from the top, what economists define as the statistical “upper-middle class.” Only about 3 percent grew up on the bottom step, while approximately 8 percent came from lower-middle class families doing their best to keep their balance on the fourth step—just one step up from the bottom.
Typically students who gain entrance to med school went to excellent private or public high schools in suburban or urban areas, earned impressive SAT scores, and went on to study at expensive top-tier universities. When they apply to med school, the lucky ones have the stellar grades and scores needed to be admitted to an increasingly exclusive medical elite.
Young Doctors Return To the Places They Know
When they finish their training, it is understandable that the majority of these young doctors will settle in urban and suburban areas much like the places where they grew up. This is where they want to raise their families. The idea of going to work in an underserved area might be appealing, at least in the abstract, but these young physicians are less likely to feel comfortable in an unfamiliar culture, trying to serve patients who they don’t readily understand. (Let me be clear: this does not mean that committed doctors cannot overcome cultural barriers. But it is hard. When communication is a problem—even though both the doctor and patient each speak their own versions of English—distrust can easily build on both sides of the equation.)
By the same token, research shows that medical students who choose to serve “underserved and rural populations” also pick places where they feel at home. They are “less likely to be children of professional, high income, and highly educated parents” observes Dr. Robert C. Bowman, director of Director of Rural Health Education and Research at the University of Nebraska.
In a paper titled “Comparing Physician Distribution and the MCAT” he analyzes demographic data on students who chose Family Practice after graduating sometime between 1987 to 2000. His work reveals that these students “have origins just like the regular people that they serve. They are from a broader range of people types, as a result they understand the people and their needs, and they serve the people. Service-orientation is also a part of who they are.”
“This is not a matter of choice,” Bowman adds. “It is who family physicians are and where they came from, and perhaps more importantly, what they have learned long before they were called ‘medical student.’”
Bowman argues that reliance on MCAT scores when considering students for admission undermines the goal of recruiting primary care doctors who will go where others choose not to go—and put down roots: “Basically everything that would help distribute physicians more broadly is defeated by reliance on the highest MCAT scores. . . “Students with the highest MCATs do not choose family practice or rural practice.”
“MCAT is no different than the SAT and ACT regarding income, ethnicity, and urban bias.” Bowman continues, “and the cumulative impact of ACT/SAT and MCAT is likely. The problem is not standardized testing, but over-reliance on standardized testing. The standardized tests are also the least valid on the students most likely to distribute well. Studies on those choosing primary care note a clear discrimination bias in the MCAT, likely a result of income differences.” Meanwhile “the rapid increases in admissions of those of higher income (see yearly data past decades from AAMC), also indicates that medical students are increasingly unlikely to choose family medicine and rural practice.”
“No physician would use any medical test with the specificity and sensitivity of the MCAT,” Bowman concludes. “Multi-school studies note that MCAT subscores of 8, a total of 25, and a GPA of 3.0 give maximal opportunity for diversity without increasing academic failure to a great degree.”
It’s Not the Money, It’s the Mission
We often assume that if we paid PCPs more, we could lure them to rural Mississippi or the Bronx. Certainly low-income med school applicants need scholarships and programs that will repay their loans if they wind up working where they are most needed—otherwise most could never afford to go to medical school. But according to a study physicians published in the November 2010 issue of the Journal of Public Health, money is not the key factor motivating them to go home.
On The Future of Family Medicine, a blogger who identifies himself as “Chris, a 4th year medical student entering family medicine with an interest in health care policy,” reports that “When researchers analyzed interview responses from primary care physicians in Los Angeles County, California concerning their reasons for practicing in their particular geographic location, only about one-fifth of those practicing in underserved areas in the county selected their practice location because the choice meant that they received federal aid in repaying loans, which seems to indicate that federal funding is a minor player in [attracting and retaining] primary care physicians in such areas”
“Digging deeper into the numbers of the study reveals that those physicians working in underserved areas were most likely to do so because of mission-based values,” Chris observes, defined as: a “‘sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation’ and self-identity (including ‘language, personal, family, cultural, socioeconomic, and geographic backgrounds).”
A 2003 study of a rural physician workforce in Florida confirms these findings, “noting that physicians from rural backgrounds and physicians who were exposed to rural experiences in medical school and residency were more likely to practice in underserved rural areas..” Where a student trains matters: “A 2009 study in the Annals of Family Medicine firms up the connection between training and practice: it looked at training residents in community health centers (CHCs) which serve a large number of uninsured and underinsured patients. Researchers found that family medicine residents who trained at CHCs were four times more likely than their colleagues to go on to practice at CHCs.” (It is worth noting that the Affordable Care Act provides funding to double the capacity of CHCs. More primary care residents need to be trained there, rather than in the basements of academic medical centers where, too often, they receive little support.)
“So,” Chris asks, “what does all this mean? It would appear that prior experience in an underserved community and a sense of responsibility to that community is truly the major motivator in where a primary care doc practices. It means that medical schools and residencies need to partner with CHCs to encourage graduates to work with the kinds of populations that frequent them. Even more importantly, it confirms what we should have known all along: the best medical school candidates are those who already enter with mission-based values and who self-identify with those communities that most require family physicians. . .
“Opportunities to train with an underserved population best stimulate those who already want to work in that setting. It’s up to medical school admissions committees to select medical students who fit that bill. Easier said than done, but we can’t hope to rely on loan repayment opportunities and training alone to funnel more students into family medicine.”
How Medical Schools Can Team With the NHSC
Last year Academic Medicine, the Journal of the Association of American Medical Colleges, published a paper which asked: “Do Medical Schools Have a Responsibility to Train Physicians to Meet the Needs of the Public?” The piece was subtitled The Case of Persistent Rural Physician Shortages.
“Yes,” said the author, Roger A. Rosenblatt, responding to a study published in the same journal earlier in the year: “Which Medical Schools Produce Rural Physicians? A 15-year update.”
The update, by Dr. Candice Chen, et. al, showed that the situation has not improved since the mid 1990s. Indeed, ever more affluent medical students are showing less and less interest in primary care. And here, let me submit that raising salaries by 30 percent still probably wouldn’t persuade a young physician from Greenwich Ct. to settle in Arkansas.
Some have argued that schools should address the problem by expanding class sizes, but Chen and her colleagues argue that simply admitting more students , without explicitly emphasizing primary care or rural health,” may well “result in more physicians choosing to practice in urban centers, worsening the rural–urban maldistribution.”
Rosenblatt agrees. “The convenient conclusion for the traditional academic health center is that student preferences and market forces are exerting their invisible and inexorable force on medical students, and that the ultimate choice of practice location cannot be easily affected by medical schools themselves.
“Convenient, but incorrect,” he adds. “In a series of methodologically impeccable studies across two decades, Howard Rabinowitz and his colleagues have demonstrated that a variety of medical schools across the country have been able to create rural training tracks.”
He points to Jefferson Medical College and asks “can the formula discovered be replicated?” Yes, “in actual fact, by adopting two interventions. The first is an admissions process that affirmatively encourages acceptance of qualified students from rural backgrounds . . .The second is a longitudinal curriculum that helps to protect this cohort from the siren song of the dominant medical ethos, by providing them with appropriate role models and satisfying intellectual experiences that reinforce their early predilections.”
The culture of a medical school is critical. A school where professors openly disdain primary care, while putting a premium on research, is not going to produce very many family practitioners eager to help the underserved.
Writing on the Future of Family Medicine, “Chris” goes further, suggesting that we should reward medical schools that create a culture which nourishes students with a mission:
The Robert Graham Center (RGC), which is backed by private foundation money, “is already producing objective data on how well medical schools and training centers are fulfilling their ‘social mission’ (that is to say, how well they are meeting the health care needs of the public),” he writes. “The RGC uses geographical information systems mapping tools to display these results visually.
“Knowing that, I propose a more effective use of federal money to improve the primary care services in the United States: create a national database of registered physicians and their specialties and locations of practice; then, instead of tying the majority of a medical school’s funding to the amount of research it produces, tie a large portion to the percentage of each school’s graduates who end up working as primary care physicians in underserved communities.”
This seems, to me, a compelling idea. . . Medical research is essential, and will always be the major focus at some academic medical centers. But if millions of Americans don’t have access to the fruits of that research, one can’t help but ask: why do we pour so much money into studying disease, and so little into improving the delivery of health care?
The National Health Services Corp is back on its feet. It now can make medical school affordable for a larger slice of the population—though it will continue to need additional funding. But medical schools themselves also should be reaching out to a more diverse pool of students who are likely to enter primary care, not just by admitting low-income and median-income students, but by providing them with the mentors, the curriculum, the clinical experience, and the respect that will remind some of why they wanted to go to medical school in the first place, paving the way home.