Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 2

The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part II: More whence, and some whither family medicine

Family medicine introduced many great things to medical education. We had non-physician faculty in our departments and residencies, psychologists and educators, unheard of then. We valued education, and realized that just being a good doctor was not the same as being a good teacher, so created faculty development programs, including fellowships, often supported by Title VII grants. Our Board required recertification from the beginning, and no one, not even those who created it, were immune, or “grandfathered in”. Many of these innovations (if not the “no grandfathering”) were adopted later by other specialties, although not always crediting the discipline family medicine. And many specialties have not adopted them yet, still to their shame.

But, in the US, family medicine is still somewhat on the margins. It never completely took over as the centerpiece of the health system, not as in Canada or the UK. Much of the opposition has been regional, especially in the NE, and in cities where there were already plenty of doctors who did not want to give up control – or money (remember that word, money, we’ll be coming back to it). Of course, then, as now, most pundits who comment on medicine – actually, on all things – are, at least relatively, well to do. Poor people often adopt such attitudes as “specialists are better”, because they assume that what the rich have is better (bigger houses, better cars, certainly better doctors), although those of us who went to medical school know that that is not necessarily true. Our classmates who wanted to become elite subspecialists caring for the rich did that, and those who wanted to serve the needy did that, and it had little or nothing to do with class rank or skill. Of course, the obstacle to poor people getting what the rich get is, well, they don’t have, and so their doctors wouldn’t make, enough money!!

The small-town white picket fence practice, of Marcus Welby and many fathers and grandfathers (less commonly mothers or grandmothers) of current FPs, such as many of those portrayed in Fitzhugh Mullan’s book ‘Big Doctoring’,[1]

may be mostly gone, but that model was long the darling of the RRC; those of us working in inner-city training settings often felt that the rules were written for someone else. 

Other issues confront us, sometimes divide us. Should the future of family medicine be about “full scope” practice, including caring for children, delivering babies, hospital work, emergency care, musculoskeletal care? Or should it be limited, specialized even (OB, geriatrics, sports medicine)?  Should we be using the term primary care or family medicine? What about general internal medicine? Pediatrics? GIM has pretty much abandoned the field, since 80% of IM graduates become subspecialists and over half the remainder become hospitalists. Should we just stop saying “primary care” and insist on “family medicine”?

Most of us recoil at the oft-heard-from-medical-students idea that GIM is family medicine without the OB and pediatrics. We think that there is a conceptual basis for our specialty that has to do with caring for the whole person and caring for them in the context of their lives, families and communities. Despite the concerns of the young Josh Freeman, this context is critical. The pediatrician cares about the health of the child she cares for, and likely that of the adult that child will become. The family physician also cares for both, but more concretely than the pediatrician experiences the health issues that adults face that often have at least part of their roots in their childhood experiences. In addition, the family doctor cares for that child’s family, and knows, for example, that the child’s mother is not just “mom” (I hate that usage!) but someone with their own problems, maybe a hard job, maybe not enough money, maybe a troubled relationship, maybe caring for her own parents, maybe with her own health issues. I have often said that if clinical sciences have associated basic sciences (like psychology for psychiatry, and anatomy for surgery) then anthropology is the basic science for family medicine because it examines people in the context of their families and communities.

Family medicine is also comprehensive, per se, by its nature. I was once able to recruit an anthropologist to our department because she wanted to work in that comprehensive context, and public health/preventive medicine didn’t really offer it. Preventive medicine is seen by some as holistic, but it segments just as medical specialties do: I do smoking, you do seat belts, she does bicycle helmets, he does violence. But the family physician has to address them all. We can’t say “wear your seat belt” but ignore “stop smoking”! Or, is that what we want FM to become? Geriatricians and sports medicine and women’s health? Hospitalists and ambulists, nocturnists and weekendists? (By the way, that anthropologist went on to help run the AAFP’s national research network.)

Sometimes the issue of how family physicians practice is formulated as a conflict between lifestyle and scope. Is that true? Maybe. Maybe it is good to not take call, or too much call, or have to round in the hospital or have to get up to deliver a baby in the middle of the night. But it may also be true that for a well-trained family doctor, 8-5 clinic patients can become drudgery. Sometimes teaching helps. And what about the issue of lifestyle vs lifestyle? People want to move to and practice in cool places to live, with a lot going on, stimulating cultural events and good educational systems. But these places may pay less money and cost more to live in. Besides your practice, do you want to be San Francisco poor or Nebraska well-to-do? That old white picket fence family doc may have had no conflict, but now young people do.

There have been lots of changes in the health system in my lifetime. Family medicine was created in the 1960s and grew to adolescence in the 1970s. In the 1980s we had lots of promise; Nixon pushed for HMOs, and in the 1990s we had gatekeepers – and different opinions about whether that was good or bad. Our best resident matches were in the late 1990s; no student wanted to be an anesthesiologist because they were afraid of not getting a job. But now ….

One study showed a student entering an anesthesiology residency can expect to make $7 million more in their lifetime than one entering family medicine. In this country. When I was in Denmark a few years ago I visited a rural family practice. In conversation, the doctor mentioned his daughter was married to an anesthesiologist. Tied to my own country’s norms I joked that at least he wouldn’t have to worry about being supported in his retirement. Oh, he replied, in Denmark family doctors make more than anesthesiologists!

Is it all about money?

We have a health system that fails to focus on the health of the people. We have almost abandoned the concept of public health. Indeed, the currency of the term “population health” is more than a semantic difference. Population health can be narrowly defined to be any population – the population of your practice, say -- and it can and does often leave people out. The people who are hard to care for, or don’t make money for us, or mess up our statistics.  Public health requires us to look at the WHOLE public. Eew! How messy!

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[1] Mullan, Fitzhugh. Big Doctoring in America: Profiles in Primary Care. Millbank. 2002.

The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.

Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.

The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.

In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]

As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.

Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

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[1] Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286

[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811

[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.

[4] Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).

[5] Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712

[6] https://www.aamc.org/data/facts/

[7] Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Why don't graduate medical education programs produce the doctors America needs?

In 2010, Fitzhugh Mullan and others from the George Washington University, with collaborators from the American Academy of Family Physicians' (AAFP) Robert Graham Policy Research Center, published the seminal article “The social mission of medical education: ranking the schools” in the Annals of Internal Medicine (discussed in this blog on June 10, 2010 in A New Way of Ranking Medical Schools: Social Mission).  This paper looked at the production of medical schools in the US in terms of whether their graduates were in 3 categories associated with social mission: practice in an underserved area, practicing a primary care specialty, and having a higher percentage of graduates who were members of underrepresented minority groups.  It was the first time such data had been published, and the results showed that most medical schools don’t do very well, and that, in general, those that do the worst are those most often identified as “top” schools by criteria such as National Institutes of Health (NIH) funding or rankings by US News. This is not surprising; enrolling students from high income families who have had top grades at the most elite private and suburban schools, training them in a setting in which the mix of doctors is heavily skewed to the most subspecialized and research-intensive, located in a densely populated urban area, is the precisely wrong formula for recruiting physicians from underserved backgrounds and training them to practice primary care in areas of need. Unfortunately, although there have been small programs implemented at many schools, this model has not seen any significant change in most medical schools, particularly those “most elite”.

This year, this group from the Graham Center and George Washington, with collaborators from the the American Board of Family Medicine (ABFM), take the next obvious step in examining the production of the nation’s doctors. In “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,[1] in Academic Medicine (not available free on-line; abstract at http://www.ncbi.nlm.nih.gov/pubmed/23752037), Candice Chen and her colleagues look at how institutions that sponsor GME (and, importantly, get very large amounts of money from Medicare and Medicaid -- $9.3 billion and $3.18 Billion, respectively, in 2009) do in producing specialists in short supply: primary care physicians (defined as family medicine, general internal medicine (GIM), general pediatrics, internal medicine–pediatrics, internal medicine geriatrics, and family medicine geriatrics), general surgeons, obstetrician - gynecologists and psychiatrists. Identifying which program produced who is quite a bit harder than when looking at medical school outcomes; while a medical school is a medical school, GME-sponsoring institutions can be consortia of a medical school and one or more hospitals, and may often sponsor more than one residency program in the same specialty.

As in all measures of primary care production, the big complication is in graduates of internal medicine programs, the majority of whose graduates go into subspecialty (e.g., cardiology, gastroenterology, pulmonary and critical care) fellowships rather than remaining in primary care/general internal medicine (GIM). Chen’s work accounts for this, but explicitly notes that they are unable to account for the percent of GIM graduates who do not go on to subspecialty training but work as hospitalists. These are clearly not in primary care, and by many accounts may represent a majority of those completing the basic internal medicine training but not going on to fellowship. The authors note that, by their calculations, the average for primary care was 25.2%,”… this overestimates primary care production, as we could not account for primary care physicians practicing as hospitalists.”

Just as with medical schools, there was a wide variation in the percent of graduates of different sponsoring institutions who entered these specialties-in-need. Of 759 sponsoring institutions, they ‘…found that 158 institutions produced no primary care graduates, and 184 institutions produced more than 80%; the latter tended to be smaller institutions.” Again no surprise; the larger, more elite and famous sponsoring institutions (most often hospitals associated with elite medical schools) did a terrible job, while the smaller sponsoring institutions -- often hospitals with one (usually family medicine) or a few residencies, in smaller cities and towns, and affiliated with Federally-Qualified Health Centers (FQHCs) or Area Health Education Centers (AHECs), based in in underserved urban and rural communities, did well. The Robert Graham Center website provides interactive tools to allow you to map the density of primary care physicians by state, county and other areas, the output of each institution producing residents in terms of location and specialty, and the footprint of graduates from each GME program.

Let me restate: 158 institutions sponsoring graduate medical education produced NO primary care graduates! Let’s add some other numbers from the study: 198 institutions (more than 25% of the total) produced NO rural physicians, while only 10 institutions had all graduates go to rural areas; the average percentage of graduates providing direct patient care in rural areas was 4.8%. 283 institutions (37%) produced NO physicians practicing in FQHCs or rural health clinics (RHCs); 479 (63%!) institutions produced no National Health Service Corps (NHSC; a program for sponsoring physicians for underserved areas) physicians. This performance can be described by a single, simple word: ABYSMAL!

Elite academic medical centers have values that lead them to attract and select students and trainees with characteristics that are the opposite of those needed for training physicians to meet the needs of the American people. They value caring for rarer and highly specialized tertiary and quarternary conditions, which both are highly reimbursed and provide the basis for research in narrow areas of disease (and almost never of health). They value receiving large sums of money from the National Institutes of Health (NIH) for research, most of which is basic laboratory research. These are not bad values; they are, in fact, necessary. We need research, including basic laboratory research and first-in-human studies, for medical science to advance (although we also need a lot more funding for population-based research into the causes of health and disease, and community-based efforts to address them). We need tertiary-care medical centers where rarer or more complex conditions can be most effectively treated by physicians and surgeons whose narrower expertise makes them more experienced and effective.

The problem is that concentrating all these subspecialists in the very places where students and residents are trained gives those learners a very skewed idea of the ratio of subspecialists to primary care doctors, and makes the teachers want to get the “best” students to go into their narrow, subspecialized areas. In addition, selection for medical school (and to a large extent for residencies that are more competitive because they have fewer slots) tend to be for students who have the characteristics that help them to do well in basic science courses, standardized tests, and possibly in laboratory research. These students tend to come from the highest income families of professionals, in the largest metropolitan areas, from elite public or suburban schools. They look a great deal like the people who have plenty of doctors to care for them, and very little like the people whose communities suffer from a dearth of physicians in inner city and rural areas. I have previously noted that, while about 20% of Americans live in rural areas, only about 9% of doctors practice in such areas; this study shows it is actually much worse, with only 4.8% of graduates in rural practice!

The situation is exacerbated by the inequity in income between primary care doctors and subspecialists, an inequity also seen (albeit at a higher level) for general surgeons vs. subspecialty surgeons, especially when hours of work are considered. Thus, students, generally selected from a population not representative of the American people, who have increasing debt (even for those from upper-middle-income, not to mention middle-income and the rare student from low income families), are attracted to specialties that pay the most; if assessments of “lifestyle” are added to the calculus, those that pay the most for the least work (or whose income/work ratios are the highest). This is a formula to continue what we have, not to make things better.

The authors of the paper say that “Primary care physician production of 25.2% and rural physician production of 4.8% will not sustain the current workforce, solve problems of maldistribution, or address acknowledged shortages. The relatively small number of physicians choosing to work in RHCs, FQHCs, HPSAs, and the NHSC will not support a doubling of the capacity of safety net services envisioned by the

Affordable Care Act.” They have that right. Medical schools and GME-sponsoring institutions have for too long been allowed to continue being self-serving, with the biggest institutions being entirely pitiful in terms of producing the doctors America needs. It needs an immediate, far-reaching, large-scale change, where the biggest training programs see themselves in the business of producing primary care doctors for underserved people.

Why would they do that? Well, there is the $9.5 billion in Medicare and $3.18 billion in Medicaid GME funding that could be withheld if they don’t, for a start…

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[1] Chen C, et al., “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,  Academic Medicine, Vol. 88, No. 9 / September 2013

Beyond Flexner: Taking the Social Mission of Medical Schools to the next level

In my blog entry for June 20, 2010, A New Way of Ranking Medical Schools: Social Mission, I discussed the article by Mullan, Chen and colleagues that had just been published in in the Annals of Internal Medicine, “The social mission of medical education: ranking the schools”. That seminal article provided concrete data on how medical schools ranked based on 3 criteria related to social mission: percent of underrepresented minority students in their classes, percent of graduates practicing in health professions shortage areas (HPSAs) and percent of their graduates actually practicing in primary care following their residency training. Unsurprisingly, the schools at the top of these rankings were a very group than those at the top than of more traditional rankings, such as US News and World Report, which are based on criteria like reputation, selectivity (what percent of applicants are rejected?) and research funding from the National Institutes of Health (NIH). Indeed, those schools that tend to rank at the top in the latter set of criteria were generally at the bottom of the list in social mission.

It didn’t make those traditional "powers" happy to be ranked at the bottom, and so they did the two things usually done by people and organizations who are found to be lacking by the data: they denied that it was true, that somehow the data was wrong, and they attacked the values of social mission, saying, in essence, that the characteristics being measured by the social mission rankings were not the important ones. The important criteria, of course, were those in which they -- the schools ranked low in social mission and high in traditional rankings – did well. Denying the truth of the study was hard, because the statistics used for measuring the 3 social mission criteria were not inaccurate. Mostly, then, their argument was “Oh, that data is old. We are better now!” But the reason the authors looked at graduates from 1999-2001 was that it allowed them to see several years after completing their primary residency training, not only whether graduates were really practicing in HPSAs, but whether they were really practicing in primary care. Medical schools like to count all students entering internal medicine residencies as “primary care”, when only a small percent do not enter subspecialty fellowships or practice as hospitalists and actually end up in primary care. And, in fact, in that 8 year interval, in the first decade of the 2000s, the numbers got worse.

So these critics mostly focused on the second defense, downgrading the importance of social mission. The measures they suggested (which they do well on) were: 1) getting a lot of money to do research (a little self-fulfilling, since the NIH panels that award research grants are largely staffed by people at the institutions that get research grants; in addition, this research is overwhelming done in the basic biomedical laboratory or early clinical trials, not in the community or the general population); 2) having a great reputation so that faculty who want to get big research grants want to come work there and students with high grades, mostly from the elite upper and upper middle class, want to attend, and 3) having a great reputation, so “peer” evaluators will say “yeah, you’re good!”

One can reasonably argue that the 3 criteria examined by Mullan and colleagues do not completely reflect the social impact of medical schools. Other criteria might include creation of community training experiences, community involvement and engagement in providing venues for training and in determining the type of research carried out by medical school investigators, the degree to which research and programs carried out by the medical school decrease health disparities, and the degree to which the health of communities and populations are increased by the activities of the medical school in practice, research, and education. However, these are not the criteria that the traditional “top” schools want to be evaluated on. The fact is that they are doing what they do, and what they do does not address diversity of the workforce, disparities in health, community involvement, or modern models of interprofessional education.

The next step in the Social Missions of Medical Education movement occurred in Tulsa, OK, May 16-18, 2012 at the “Beyond Flexner” conference. 100 years ago Abraham Flexner was commissioned by the Carnegie Foundation to look at medical education in the US. As a result of his report, more than half of US medical schools closed. Those that remained were largely the ones that had adopted a scientific basis for their medical education and were based in or tightly tied with research universities. For over a half-century, these schools grew with emphasis on the biomedical research enterprise and the training of highly skilled subspecialists, and little interest in any kind of social mission. The social movements of the 1960s and 1970s saw the first large number of new medical schools, and then quiescence until this decade, with a number of additional schools being created. Many of those in both the 1970s and 2000s groups manifested, at least initially, a social mission – that is, they had the goal of actually producing doctors and research that would improve the health of the population.

“Beyond Flexner” was co-sponsored by Mullan’s Medical Education Future Studies group from George Washington University and the new University of Oklahoma-Tulsa School of Community Medicine, led by Dr. Gerry Clancy, President of OU-Tulsa. Under Dr. Clancy, OU-Tulsa has transformed from a site for clinical training of a portion of the students from the OU School of Medicine in Oklahoma City to become the first 4-year school officially called “Community Medicine”. It was also one of the 6 schools that were part of the follow-up study of social mission, and whose leaders presented some of their innovations and successes at the conference. Three, including OU-Tulsa, Florida International University, and the AT Still College of Osteopathic Medicine in Arizona, are in the newest group, and have yet to graduate a class. Their contribution was largely in the creative and innovative methods that they are using to select and enroll and educate students, emphasizing diversity, community-based education, dispersion of educational settings, ambulatory (rather than hospital-based) training, emphasis on primary care and concern for the social determinants of health and health disparities. (A fourth new school, the University of Northern Ontario, in Canada, was also part of this group.)

The 3 other schools were part of the prior wave of new schools created in the 1970s and have had significant social impact, Morehouse University, the Southern Illinois School of Medicine, and the University of New Mexico School of Medicine. These are certainly not the only schools that have made a major commitment to social mission, and perhaps they are not in all respects the perfect exemplars, but they are certainly among the leaders in the field. They are part of an international movement of medical schools that were founded in the same period, to create physicians who would have the skills to care for people (primary care), have the knowledge to do research on community and population health, have the relationships to train and work with people in community settings, and have the intelligence to challenge traditional methods of classroom teaching by increasing clinical and interprofessional training experiences. Representatives from these and other schools described pipeline programs, interprofessional training, dispersion of training sites, innovative curricula, emphasis on primary care, and many other models and efforts.

The bottom line is that outcomes matter, and that judging a school by the impact that it has on the health of the population is the gold standard. Biomedical research contributes important knowledge that may, someday, impact human health, but this can be done in research institutes (see, for example, Karolinska, Rockefeller, Insitute Pasteur, Stowers) and certainly should not determine the core mission of schools focused on training doctors and other health professionals. The steering committee of “Beyond Flexner” is developing key principles that need metrics to assess outcomes; I would suggest the following:

·       Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?

·       Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?

·       Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?

·       Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?

Maybe by the time of the next “Beyond Flexner” conference, every one of our medical education institutions will have bought into these principles and their implementation, and be able to be examples of how it can and should be done.

A New Way of Ranking Medical Schools: Social Mission

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In the June issue of the Annals of Internal Medicine, Fitzhugh Mullan, Candice Chen, Stephen Petterson, Gretchen Kolsky, and Michael Spagnola, mostly from the Department of Health Policy at the George Washington University (and one from the Robert Graham Center) report on “The social mission of medical education: ranking the schools”. This study, sponsored by the Josiah Macy, Jr. Foundation as part of the Medical Education Futures Study (MEFS) is the first report to look at this area, and should be eye-opening to those who assume that “good” medical schools are “good” at everything. Most ranking systems, most notably those of US News and World Report, are based on NIH research funding, grades and test scores of entering students, “competitiveness” (how low a percent of applicants they accept) and reputation. Obviously, the grades and test scores are related to competitiveness and reputation is a tautology, because it reinforces itself. It should depend upon what you are looking at, of course. I addressed this in “Rankings of Medical Schools: Do they tell us anything?” (September 25, 2009), and observed that what they tell us is who does well in what is measured, and that this should only be important to us if those are the outcomes we value.

Mullan and colleagues evaluate different outcomes, the degree to which medical schools meet their “social mission”, or to put it another way, the degree to which they produce the physicians that will take care of the American people. More to the point, since it can be argued that most medical school graduates take care of some American people, physicians who will take care of those people who need it the most because they don’t already have doctors. This means largely those in poor communities, rural communities, and minority communities (and especially those communities that are two or three of these). They look at 3 characteristics of graduates: 1) what percent of their graduates are practicing primary care, 2) what percent of their graduates are practicing in designated Health Professions Shortage Areas (HPSAs), and 3) what percent of their graduates are members of underrepresented minority groups? This is pretty straightforward, and they take two other steps to try and ensure that this is an accurate reflection.

The first is that they examined students, in the graduating classes of 1999-2001, 8 years after graduation. As I have pointed out several times (Primary Care and Residency Expansion, January 7, 2010; Funding Graduate Medical Education, May 25, 2009), the “credit” medical schools claim for students entering “primary care” residencies includes all those entering internal medicine programs, the vast majority of whom will enter subspecialty training. By looking at students 8 years after graduation, after they have completed residency and subspecialty fellowship training, they are able to get a much more accurate picture of who is actually doing primary care. Similarly, it also means that those who are practicing in HPSAs have been doing it for several years. Overall, public schools did much better than private schools, and Southern, Midwestern, and Western schools better than Northeastern schools.

In terms of underrepresented minority students, the percent of graduates, for public medical schools, is compared to the percent of the underrepresented minority population for the state, while for private schools, which are presumed to draw from a more national base, it is the national percentage (26.5%). Thus, for example, the University of Iowa has a positive ratio with 8.1% minority students in a state that is only 6% minority, while the Universidad de Puerto Rico en Ponce has a negative ratio because, even though their students are 82.5% underrepresented minorities, their “state” is 98.8%. The underrepresented minority scores for the 3 historically black medical schools, Morehouse, Meharry and Howard are so high, compared to the national average (as they are all private) that they are easily the top 3 in the overall social mission score. This tends to wash out the significant differences between them on the other two areas. For example Meharry does well in producing primary care physicians (49.3%, or 2 standard deviations [SD] above the national mean) compared to Howard, which at 36.5% is only 0.19 SD above the mean; Howard, however, does better at placing students in HPSAs (33.7%, +0.78 SD) than Meharry (28.1%, +0.12 SD). Ponce, despite its negative underrepresented minority score and also a negative primary care physician score (-0.31 SD*), ranks #9 nationally in total social mission score. This is based on its high rate of physicians practicing in HPSAs (43.8%, +1.94 SD), because so much of its service area are HPSAs.

The data can be analyzed in a number of ways. Osteopathic schools have a much higher rate of producing primary care doctors, but none were in the top 20 because their percent of underrepresented minorities are low. Adding only the two dimensions of primary care and HPSA practice shows only 7 schools with a standardized score above 3, all of them public allopathic schools and 4 of them “community based” medical schools with a specific commitment to primary care (as is Wright State, the #4 ranked school in overall social mission). A few top NIH research schools (4, to be exact) “defied the trend” and were in, at least, the top quartile of social mission scores, again all public schools. Other than the historically black schools, private schools were nowhere to be seen.

The schools that traditionally do well on rankings such as that of US News tended to be at the bottom of this scale. They are overwhelmingly private (14 of the bottom 20) and generally highly NIH-funded. Comments from the leaders of those schools, unsurprisingly, tended to disparage the study and its methods, and to assert, essentially, that “our school does well on all of its missions.” If those missions include the social missions of meeting the health needs of the American people by producing minority and primary care physicians, and those that practice in underserved areas, they clearly do not. And, while some are better than others, no medical schools are doing very well at enrolling underrepresented minorities (except the historically black schools and the Puerto Rican schools) or at producing physicians for rural areas at anything approaching the percent of Americans who live in those areas (Primary Care and Rural Areas, April 28, 2010).

This is not to say that other missions of medical schools, such as biomedical research, cutting-edge medical care, and training of the future generations of academics, including the MD/PhDs who will be laboratory-based researchers, are unimportant. Lawrence G. Smith and Veronica M. Catanese emphasize this point in their accompanying editorial, “The Many Missions of Medical Schools”, as well as noting various possible ways in which the production of physicians who fulfill a social mission might have been underestimated by Mullan, et. al. They also note, as I have above, that different schools do better or worse on the different social mission measures, but also that success in the social mission needs to be pursued, as success in all other missions: “The lack of concordance among the 3 elements of Mullan and colleagues' social mission score suggests that medical schools that accept this mission—as they must—cannot define social mission narrowly. They must have multipronged initiatives and not simply 'wait' for programs aimed at recruiting and retaining underrepresented minority students, or at specifically incentivizing primary care, to bear fruit.”

The key point is that the data produced by Mullan and colleagues that shows that schools which are historically highly ranked do relatively poorly in social mission is not due to a flawed methodology. “The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas.” It is because these schools do not emphasize the characteristics that they are measuring, combined into the concept of social mission, nearly as highly as they do their other missions and do not put as much energy, time, or especially money into them. Mullan et. al. conclude that “Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform.”

The authors note that “Medical schools, however, are the only institutions in our society that can produce physicians”. It is up to the people of the US, particularly the communities in need and the policy makers who represent them, to decide how high a priority producing physicians who will meet our social need by practicing in specialties, in areas, and with populations who do not have doctors, and how to use the public coffers to achieve this. The time is long past, however, for these characteristics not to be measured. We can no longer, in self-indulgence or ignorance, assume that those schools that are the “best” on US News rankings because of NIH research funding, selectivity, and “reputation” are the best in every area. In producing the doctors most needed by this nation’s most needy, they are, with few exceptions, mostly the worst.

*Like the other Puerto Rican Schools, Ponce has a low production of family physicians, ranking 117 out of 128 medical schools for producing FPs in the 10 years from 1999-2008, as reported by the American Academy of Family Physicians (AAFP) annual analysis.
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