Saturday, June 22, 2013

Moving to Recovery By Design

The following is a guest post by Robert Bowman, MD, of the A.T. Still College of Osteopathic Medicine in Mesa, Arizona. He welcomes your comments and feedback.

Josh Freeman recently linked to the Charles Blow column in the NY Times, These Children are our future” (June 14, 2013)  about the past, present, and likely future of the HS Graduating class of 2013 - and those missing from any high school graduation. We were both up into  the wee hours as I also reacted to this with the following:

A classic story taught in most introductory public health classes is of the person who finds the body floating in the river, and pulls it out. Then there are more, and he pulls them out. Then more and more and he gets friends. Then so many that the whole town gets involved, developing a highly efficient system for removing bodies from the river, moving them up and out to the graveyard. Until someone says: "Maybe we should go upstream, and try to find out what is causing all these people to die and fall into the river. And maybe do something about it."

"Upstreamers", then, are those who try to find out why the bodies are getting into the river as compared to those who are focused on addressing problems much later; often too late. Upstreamers recognize social determinant and other barriers that can shape outcomes. For the bottom 30 to 40% of Americans, the outcomes can be shaped substantially by various determinants and not by school, teacher, physician, nurse practitioner, etc. Most of the studies regularly promoted in major journals or reports fail to understand social determinants and patient situations.

Upstream thinking is broken in our nation. Nations with effective social systems have people serving on the front line for health and other social services, who stabilize and support the people of the nation, anticipate their needs, and translate these to national leaders. The role of national leaders is to listen to the people and their translators while acting in the best interest of the nation to make the entire nation more efficient and more effective. When the stabilizing front-liners can no longer support the leadership of a nation, chaos reigns – as we should understand from numerous current examples.

Our leaders are not listening to the upstreamer family physicians, teachers, public health, military, nurses, and front line public servants. Leaders need to listen to those who have the perspectives that can help to better understand normal Americans and those facing numerous dimensions of challenges. This perspective is often shaped because front liners tend to arise from lower and middle income and upper middle income Americans, rather than the top of the socioeconomic heap. Our top leaders, on the other hand, tend to come more from the exclusive sector, and such upbringing  makes it difficult to understand the daily lives of most Americans.

Falling Behind By Design

We are clearly falling behind as a nation. A greater proportion of or nation is falling behind in ways that make recovery more difficult. How we progress as a nation (or not) is about whether we can wake ourselves up to recognize the things that are required. Nations do not recover by economic development, defense, too much spending, or too little spending. Nations recover by investing in the earliest years of life. With progress made year to year or generation to generation, we can recover.

Few want to take responsibility for poor child well being, failures of investment in child development, numerous errors in the production and retention of important health care workforce, health costs that are too high for the outcomes, and other broken designs such as school funding mechanisms. It is easier to blame teachers or physicians rather than to make the investments that can make a difference. It is hard to see how these increasing costs and distractions prevent the investments that we need to make in our children – and our future.

Our education focus is downstream and works for those who do well without any intervention. Designs for school funding and standardized testing and high school and college focus do not work for most children left behind -- almost a tautology. Investments focused downstream insure that school districts in communities with high property values have good outcomes, those with middle property value less, and that even the high performing children from lower property value school districts do less well than those in the bottom portions of the higher property value school districts. Advantages for the advantaged also may retard the needed development of the advantaged children, because they are never challenged by the majority of the population who, if offered the same advantages and opportunity, might spur real competition that pushes all of them further ahead. The result is the lack of social class mobility that worsens in our nation.

How Do Declining Opportunities for Most Americans Shape Lack of Health Access?

Resolution of health access has two multiplier factors – origin shared with the population in need of health access and family medicine choice. Frankly, as Rabinowitz[1] has demonstrated, the effect of origin to help distribute physicians is negated when rural origin candidates do not choose family medicine. This is because their practice location is dictated by their specialty rather than their origin. FM choice facilitates the influence of origin. Social determinants can greatly limit access to medical school, but FM choice is 2 to 5 times as potent a marker for rural choice than medical school training and origins. Only FM physicians, and family NP and Pas, have population-based distribution – the opposite of all other specialties which are more concentrated where health care workforce is concentrated already.

Access to health care is mostly limited by lack of front line health access family medicine. We have insufficient MD, DO, NP, and PA family practice positions supported, offered, and filled.  This is the failed health policy determinant. It fails even more when “flexible” potential sources of family providers can easily choose other specialties; this is seen in NP and PA training programs, which are adding both more specialties and more trainees in each specialty, as well as internal medicine training for physicians.

What I have learned in two decades about family physician origins confirms social determinants and social situations that shape the proportion of providers in family medicine. The same social determinants shape medical school admission and performance as a medical student. After all, those who take -- and in particular do well on -- the tests are more likely to be highest income, most urban, and children of professionals. The standard population for scoring for tests such as MCAT and board exams are the subjects that take the test. Those students whose language, culture, parents, or other origin factors are different will have different scores. Normal origins are associated with different scores because they are normal. Exclusive origin students have exclusive scores. Scores shape opportunity, type of medical school, and even subspecialty. A normal distribution of career choice types is different because it is normal. Normal origins, normal types of medical schools, normal distributions of health spending, and normal career choices such as FM are the recovery vehicles for health access. This is not what our national design dictates. Origins, training, health spending, and career choices favor the concentrated or exclusive.

FM docs arise at 1 per 100,000 people across various types of counties or types of populations. In the populations associated with lower income and other social determinants that have lesser opportunity, about 4 per 100,000 are admitted to medical school per class year (1970 county pop, AMA Masterfile with 90% birth origins). This is 25% family medicine result. In the populations of advantage, about 14 - 20 per 100,000 per class year are admitted. These are areas around DC or NYC or other major metro areas with the highest income, most urban locations with top concentrations of professionals.  When you map concentrations of physician origins it is the same as where physicists, engineers, research and development, colleges, and other concentrations of professionals are found. In these areas most associated with concentrations or combinations of concentrations of high-income professionals, about 14–20 per 100,000 become a physician – about 2 to 3 times higher than average. However, for these populations associated with such concentrations, there is still only 1 per 100,000 found in family medicine per class year. Only 1 in 14 to 1 in 20 enter family medicine (about 5 – 7%). Moreoer, this was data from 20 years ago, at the peak of FM choice. FM choice in all types of origins has declined since this time.

Access is more than FM docs. When I look at rural docs or docs for underserved locations and map them to their birth county, the same 1 per 100,000 applies. Higher proportions of FM doctors arise from locations associated with lower concentrations of people. When there are higher concentrations, the proportions of rural or underserved docs decline. Meanwhile the most subspecialized docs most dense areas (metropolitan) with higher and higher concentrations from origins associated with higher concentrations. A doctor with a sub-specialty such as gastroenterology is 6-8 times more likely to come from a county in the top tier of population concentration as compared to those with lowest quartile income or population density.

Only FM has equitable population based origins and the same 1 per 100,000 per class year distribution, or about 30 FM docs per 100,000, for the current past 30 years of FM graduates. FM will actually decline slightly with population growth as FM is locked at 90,000 due to just 3000 annual graduates dating since 1980.

Declining Middle Class and FM

Populations vary in higher education and medical school admission. In the lower income segments, few arise for admission at all. Carnevale[2]and the Century Foundation have demonstrated that only 3% from the bottom quartile were found in the top 146 colleges – the same ones that feed the same types of students to medical schools. About 74% arose from the top income quartile. In the US middle income populations are disappearing, groups that used to be able to access higher education and they also had reasonable FM probability and distribution probability. The highest income segments are lowest FM probability. For example, at the University of Nebraska Medical School, those whose hometown is Omaha and Lincoln and other metro areas have 2% family medicine while those from the rest of the state have 15 - 30% FM choice (4 years of data). Out of state and foreign born components have been increasing and are typically highest income, most urban, children of professionals.

Asian Indian choice of FM was 2% for the 1990s - the population segment most representative of highest income, most urban, children of professionals in census and in AAMC data. All such populations are 3 - 10 times more likely to gain medical school admission in the US compared to the average. Advantages of child well being from the start of life are evident.

It is not about artificial markers of race or ethnicity - it is about highest income, most urban, highest property value, and other characteristics associated with advantage (or concentrations). Those more normal and representative are falling behind of all races and ethnicities. The same is true in studies of college students. Asian and white populations are populations of advantage and as Barr[3] demonstrated at Stanford, for students who planned to go to medical school when they were freshmen, these students of advantage had 100 – 110% actually apply to medical school, while the rate for underrepresented minorities, even in a select school such as Stanford, was only 50% remaining to apply for medical school. Advantage involves concentrations or combinations of concentrations as compared to normal. Those left behind are no small segment of the United States. Most Americans do not have the concentrations or combinations of concentrations needed for better opportunity, better cost of living, better health care quality, or easy health access.

Recovering Health Care Cost, Quality, and Access

The states doing best in health care quality consistently have the best child well being, the best markers of middle class, and the least divisions between rich and poor. Health care quality, access, and to some degree costs are related to child well being as expressed birth to admission in a student or as expressed birth until health care encounter in a patient. Downstream focus, and ever more dollars invested at the high school or college downstream level will not help. Research that attempts to claim better quality without changing Upstream tends to represent distractions from real improvements.
We have models such as Southcentral Foundation in Alaska and Grand Junction that illustrate what can be done - and these are just a start. These are models that recovered from poor designs to optimal designs. As a nation we can also recover from poor designs, by designing well from the earliest months and years of life. Who would deprive a 2 year old or a 3 year old of an opportunity to rise above?

We cannot do better as a nation with so many left behind from the earliest ages by design.

Health professionals such as family physicians can do Upstream work at the community level.

We need similar professionals working entire careers like we do to improve child development.

We need primary care and public health nurses that were trained specifically for primary care and public health - and who remain in such careers.

How we invest in our children and work locally in teams will determine our future.

[1] Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. ”A program to increase the number of family physicians in rural and underserved areas: impact after 22 years.” JAMA. 1999 Jan 20;281(3):255-60.
[2] Anthony P. Carnevale and Stephen J. Rose, “Socio-economic Status, Race/Ethnicity, and Selective College
Admissions,” in Richard D. Kahlenberg, ed.,America’s Untapped Resource: Low-Income Students in Higher
Education. (New York: Century Foundation Press, 2004),
[3] Barr DA, Gonzalez ME, Wanat SF, “The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students,” Acad Med. 2008 May;83(5):503-11. doi: 10.1097/ACM.0b013e31816bda16.


johnjose said...

Very nice and succinct analysis of realities of where we have to begin as a country if we want to change the culture of medicine. Very much like the idea of normal distribution as a metaphor for how we should be working.

The only thing I would add is to recognize that low income kids are heavily influenced by their families of origin. Our 16 yo grandson who goes to school in a rural county says that his friends are already beginning to settle for less than they could achieve because, in his words, "their parents lower their expectations rather than raise them".

As family doctors and citizens in rural and urban communities, we need to work with parents of children to raise their hopes for their children, not settle for what is available. It means talking with parents from birth on, being in the community in various ways to help and support those who want more for their children, and find a way to make opportunity happen through advocacy and perseverence. Bowman beautifully outlines the issues, we need to find concrete, replicable and community by community solutions.

Glenna Martin said...

This study helps confirm your point also about the increasing concentration and exclusivity of medical students (more likely to come from educated backgrounds of higher income).

One point worth mentioning is that although many of us acknowledge these inequities we are not willing to sacrifice to make them right. I know very few physicians who would be willing to have their own child rejected from medical school in favor of another student who was more likely to practice rural family medicine, be from an underrepresented background, etc.

Furthermore, pipeline programs often don't lead to actual spots or admission to medical school, except at schools like UNM and others where once you are admitted to the undergraduate school you are guaranteed a spot at the medical school.

Other than ratifying the treaty you mentioned, I would offer universal early childhood education as a possible solution as well.

Thanks for your post!

Josh Freeman said...

Good point, Glenna.
One of the big things I have said is that, if we are to have a medical population that "looks like America" (and I think that we should) we need to NOT take faculty children (on the whole; clearly there will be applicants from the professional class who have done great work in their lives as volunteers, etc.).

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