http://edition.cnn.com/2009/HEALTH/05/27/epperly.doctors/index.html

references an indespensible article

Baicker, K., & Chandra, A. (2009). Cooper’s Analysis Is Incorrect. Health Aff, 28(1), w116-118)

that is part of a must read scientific dialogue on the subject.

The time for kneejerk policy making is over. We must question our deepest assumptions and pay due diligence to the findings that less may in fact be more…more affordable and with more quality.

It seems that until all young doctors get a chance (and perhaps incentives) to evaluate the economic cost/benefit factors of such an important calling that the overwhelming gravitational pull of easy money in private practice will always win out.

First about 40% of the physicians entering the United States workforce are Asian or foreign born. Asians in America in the census are 90% foreign born or have a parent who is. About 90% of Americans have a realistic chance at only 60% of the physician entry positions. As Bill Gates would note to Yogi Berra - It’s Deja Vu all over again for physicians as in engineers and other professionals for America. At some point we might consider what is happening to lower and middle income children.

The probability of higher education is about 30% to 70% for lower and middle income children while 90% of the top income quartile move on.

About 74% of the college positions in the nation’s top 146 colleges go to the top income quartile children, a major boost to medical school admission. (Carnevale in Kahlenburg, Left Behind, New Century Foundation)

Then there is the United States medical school admission process. About 60 - 65% of those admitted arise from the top 20% and 80% from the top 40% according to AAMC data dating back decades. In the past decade the lower and middle income origin medical students admitted declined by 3000. Those with parents making less than $40,000 were cut in half. Those in the middle income quartiles lost 20%. The top income quartile in 1997 for matriculants was the group with parents making over $100,000. Medical students with parents making over $100,000 have increased from 3800 to 6800 from 1997 - 2004. Now you can argue that the US has widened the income gap, but the lower and middle income populations are stagnant in income changes, and are losing ground in admission. The most rapid changes were 1997 - 2001. All races, ethnicities, and geographic origins are impacted.

Matters got much worse after the nation
1. terminated 3000 by 2000 training of medical school admission committees to admit students based on who they were, rather than parent influences such as colleges or standardized test scores
2. US News and World Report rankings became more common in medical school leader and faculty conversations
3. Limited access to funding for lower and middle income children
4. Allowed colleges to start giving special funding help to highest income quartile children, seed money to bring in more of higher income levels who could pay tuition and support foundation funding
5. Continued to tolerate education funding based on property taxes, a system that sends the least funding to schools with the most complex education needs
6. Squeezed the middle class making it hard to do well economically with both working, but no one to raise the kids and relatively worthless and costly day care

While other nations doubled investments in birth to age 6, structured real no child left behind, leveled the playing field for higher education, and focused on normal health care needs in medical education.

An MCAT of 8 in each subscore is sufficient for a good quality physician with the actual quality determined by the efforts of the physician. Medical schools are competing for 11 and 12 scores. Exclusive scores only narrow the characteristics of physicians in ways that make it difficult for them to understand their patients and in ways that allow them to possess the necessary people skills that are far more important than academics and narrow science focus. Older graduates are an example as they tend to have broader origins, lower scores, and more life and health experience prior to medical school that are valuable to development of the physician.

The United States needs a lot more with 11 - 14 scores in people skills with 8 and 9 in the MCAT subtests. I don’t mind if a medical student has 11 - 14 MCAT scores, as long as they have a 9 or above in people skills scores. What we must avoid is 11 - 14 in academics and only 3 - 7 in people skills.

Of course we don’t test people skills scores prior to admission. People skills scores during medical school is the only testing in any of medical education that actually demonstrates a relationship to the quality of care delivered. As reported by McMaster in JAMA, those with bottom quartile communication skills have 70% more problems as physicians. Readers are left to their own judgment whether narrow selections, narrow training, and narrow policy help with communication skills.

If studies are not going to focus on areas other than MCAT to board score relationships, they are going to miss the most important factors for physician development and quality.

Also what the Supreme Court most needed to here in the various decisions on Affirmative Action and medical education, was the Association of American Colleges noting that the MCAT score was not a valid indicator of future quality in physicians. The MCAT score is one of many indicators. It is also most invalid in those who are not highest income, most urban, children of professionals who dominate the ranks of those that take the MCAT and set the standard for comparison. Other children are different, not better or worse, and the MCAT often fails to identify who is better or worse in medical school performance.

Even the small difference of gender a few years ago forced AAMC to shorten the verbal section 4 questions and move it to the first test section. Imagine how much bias there is for Hispanic, Native, rural, or any of lower and middle income origin when they take a test that favors the exclusive over those who are normal.

Robert C. Bowman, M.D., Professor
A T Still School of Osteopathic Medicine Arizona

Those who choose health access careers are those who share origins with the 65% of the population in the United States that are in most need of health access and only have 23% of physicians.

Logistic regression studies indicate the following about physician practice locations in rural, underserved, and less served areas (n = 316,000 grads from 1987 - 2000 class years, all medical school sources as in the 2005 Masterfile).

Birth origins shared at 2 - 3 times odds ratios of being found in a location in need of physicians.

Family practice at 2 - 4 times odds ratios from urban underserved to rural underserved locations

Older graduates, those age over age 29 at medical school graduation have 1.3 times odds ratios of optimal location.

Graduates of osteopathic, allopathic public, and lower scoring MCAT medical schools have 1.3 - 1.8 times odds ratios of optimal health access.

These are the major factors and they serve as controls for one another when included in the same logistic regression equation.

Exclusive origins result in half of the probability of distribution. Exclusive careers or all other than family practice have average to poor distribution. Exclusive age groups that are the youngest with the least life and health experience prior to medical school have 30% lower distribution. Exclusive training has half of the probability of distribution as found in allopathic private and top ranking MCAT medical schools.

In final analysis, there are failures in primary care and health access only in the physicians with exclusive origins, physicians with exclusive career choices, physicians with exclusive training, and physicians influenced by exclusive health policy that distributes 10 - 15% of resources to locations with 65% of the population spread across 96% of the land area.

These are factors that must be considered for physician career and location choices involving health access, such as primary care.

There is little chance that Title VII measures up to these factors.

Medical schools select physicians, train physicians, influence career choice, and influence national health policy. When medical schools admit more normal students, train on more normal population needs, place emphasis on normal health career choices, and work to influence normal distributions of health resources, then 65% of the American public might just have a chance at more than 23% of physicians, more than 10% of health resource distributions, and the jobs, services, economics, and leadership that come with such distributions.

The real issue is not Title VII. The issue is seeing beyond Title VII to fully fund the family practice training that will graduate the 8000 family physicians that the nation must have as soon as possible, the only shot at restoration of health access before 2050.

The real issue is making sure that the primary care that we have, stays primary care. Also the new graduates must have reasonable $170,000 plus salaries, commensurate with the most complex health care careers of all - serving the 65% of lower and middle income American that has the most complex health care needs and gets the least support.

Other forms of primary care have become flexible due to market forces and health policy. Family physicians stay in family practice and primary care and where they are most needed.

Robert C. Bowman, M.D., Professor
A T Still School of Osteopathic Medicine Arizona