Health Access Professional Training Should Avoid Medical Schools

As long as we continue to focus 70% of spending upon clinical interventions that can only influence 10% of health outcomes, we will fail to focus attention on the 70% of health outcomes that can be addressed via people factors. Situations, environments, behaviors, relationships, and other people factors are the dominant influence in health care outcomes (and education outcomes, and economics...). Health access professional training needs people change focus far more and clinical intervention focus far less. The reality of true health reform awaits discovery. True health reform must have health professionals with people and people factor focus. The preparation and training and payment designs fail to support the cognitive or person to person interactions that can best change health outcomes.

Health access professionals should understand the people that they serve. This seems obvious, but what is not obvious is substantial movement away from people understanding.

Health access professionals are not likely to pick up people focus or people skills during training. They should have people awareness and people skills focus before, during, and after training. It should not be surprising that it is difficult to change health professional attitudes, behaviors, and actions after a first 30 or 40 years of immersion in something quite different. 

The Flexnerian design is widely praised as the foundation of modern medical education. Unfortunately this design was implemented by zealots that wanted to extinguish anything that looked like the past such as preceptorships and apprenticeships. The zealots were so focused on academic, university, science, and technology that they removed local, people, and health access focus.

Physicians arose from the people and distributed where people needed physicians prior to 1910. Yes, there remains a need for formal training, but formal training should not result in compromise of local people focus and health access. Zealots have added new characteristics such as subspecialized, centralized, high volume, and quality measures focus. Sadly these have moved health care further away from what really matters in health outcomes.

It will take redesign to re-establish a priority of local, people, and health access focus.

The 30 or more years prior to a health access career should be immersed in local situations, patients, families, and community. There are people skills, background fit, and geographic arguments to explore. Payment designs should reward careers involving people interactions (cognitive), experience, team focus, and continuity.

It is safe to say that we have the wrong designs for preparation, selection, training, and payment with regard to solving health access woes. 

People Investing in People for Outcome Improvements

Preparation for medical school rewards those who invest in themselves rather than those who invest time and effort in people and people change. Changes in behaviors, situations, relationships, and environments have far greater potential for outcomes improvements as compared to clinical interventions. Preparation, selection, training, and support of health professionals should be re-oriented to maximal influence rather than minimal.

College-based preparation for health access professional education has all the wrong influences
The colleges that shape future medical students are over 70% from the top income quartile and have most urban origins. These are only a few of the social determinants, environments, upbringing, and multiple other dimensions that separate the elite from the entirely different patients they will see.

Future physicians have exclusive parents, schools, and other environments.  Immersions in exclusive environments and exclusive groups are not conducive to the attitudes, behaviors, and skills needed for health access. Those raised by the school of hard knocks have a chance to grow in awareness regarding the condition of most people. Those protected from hard knocks by their parents and others in their environment do not. This may be one reason for physician suicide rates to be so high.

Medical school training and testing focuses physicians to focus on basic sciences while avoiding people skills training. Studies of empathy and service orientation demonstrate the resistance of medical students to such training unless these existed previously (O'Connor). These are linked to primary care, mental health, and behavioral changes (Newton, Madison).

Medical school and residency training sites illustrate the disconnect between most Americans and their physicians. Training is stacked over 60% in 1100 zip codes in 1% of the land area where 10% of Americans are found (shrinking atypical populations at that). Highest income, most urban origin, children of professionals are trained in similar most exclusive settings by faculty with the same origins. The problems of past medical school environments have not completely been worked out.

Less than constructive attitudes and behaviors shaped in training persist in medical careers and in the groups and associations that involve physicians.  Top academic bodies and journals continue to overemphasize clinical interventions while minimizing people factors – behaviors, attitudes, environments, situations, social determinants, etc. For example, To Err is Human is widely regarded as a major influence toward quality focus and reduction of medical errors. However nearly 20 years later the outcomes have not substantially changed and the costs of administration and quality focus have accelerated - eroding support for the team members to deliver the care. The impacts may be greatest on the small hospitals and small practices most in need of support - support that is less likely under past designs and made worse by the new innovative penalties.

True health reforms require different thinking and different thinkers. 

Solving health problems in the United States is a task that requires entirely different solutions. The current political, economic, and health leadership is far too immersed in the exclusive. Ideas and innovations are implemented without prior testing and even despite known consequences.

Geographic Inequities By Designs of Preparation, Selection, and Training

Medical schools fail for health access across many areas. The easiest argument to address is geographic. Medical students in the US are an extremely poor fit with the health care needs of most Americans. Most urban, highest income, most educated parents and similar influences before, during, and after training is a poor fit with 2621 lowest physician concentration counties where 40% of Americans most need care. Medical school and the most important influence of residency training location shape physicians away from these counties. Only 6% of training is found where these 40% need care. Concentrations of preparation and training shape future concentrations of physicians. 
  • Concentrations by design may also shape overutilization. As physicians pack in to highly concentrated areas, more health spending is required to support them. In counties lowest in physicians, current cuts and costly regulations are a poor fit with the need for more services and more workforce – especially in these counties with more rapid growth of population, elderly, and complexity.


Specific Career Choices - Generalist and General Specialties

The US produces the wrong specialties.  The US needs broadest generalists and general specialties. This is the result of demographic shifts to more elderly, more complex care, and more people interactions such as integration, outreach, coordination, navigation, and facilitation. Many patient care needs could be met by less expensive generalists and general specialties – but only if we can produce and support these careers. For an entire generation (30 – 35 class years), we have not done so. Now we face substantial deficits getting worse.

The US specifically needs more family practice positions filled by MD DO NP and PA. The designs of payment and training and regulation insure that these careers are avoided or are temporary. Payment is least for cognitive or people focused interactions. Training minimizes these areas. Regulations allow graduates to depart family practice for numerous other careers. This is particularly seen in NP and PA graduates as “success” is seen as more specialized graduates. Clearly those with specialty and subspecialty positions have the most support and the most salary. For those who enter primary care, turnover to other primary care practices or away from primary care is substantial at 11 – 13% a year or twice the primary care physician turnover. Turnover in all sources is facilitated by poor support and greater burdens with designers, payers, and employers failing in support and adding greater burdens.

Training designers seem to have a poor understanding of the consequences of their actions. Because they do not understand that outcomes are about people factors (not training), they are surprised when clinical interventions fail to demonstrate results. They expected resident work hours limitations to improve the quality in teaching hospitals. No such expectation should have existed for those who understand what shapes outcomes (patient factors before, during, after). Unfortunately actions have consequences. What did happen is that about 20,000 to 30,000 NP and PA graduates moved over to fill the teaching hospital workforce gap created by resident work hours limitations.

The innovative designers continue to implement without regard to the consequences. DRGs or bundling payments by diagnosis was chosen for cost cutting in 1983 after very little testing. The drive to get patients out of the hospital faster was bad enough but higher cost personnel such as nursing was marginalized. Lower quality may have been facilitated by DRG design. These are not the only consequences. Hospitalists were promoted as solutions for getting patients out of the hospital at least a half day sooner. The promotions have so far diverted 50,000 primary care trained physicians to hospitalist positions. As is common, the designs were a good fit for some who promoted the idea with their studies. This hospitalist design was ideal for academic centers short of workforce and faculty. NP and PA hospitalists have also increased. The studies arising out of such academic centers resulted in distribution nationwide, including distribution to settings that may not benefit. 

Generalists have consistently been diverted to new specialties that often have hospital, disease, technical focus – the wrong directions from health access. Now hospitalists train substantial portions of primary care physicians - the wrong faculty for health access.

Family physicians have been resistant to departure from family practice positions until recently. As family physicians increased, other sources flexible for primary care have declined (IM, PD, NP, PA) with fewer entering and fewer remaining in primary care over their careers. Eventually family physicians reached saturation after 35 class years of 3000 annual graduates. The numbers overall for primary care were too much for the limited support for primary care positions. Even a relatively permanent workforce will respond to insufficient payment. Workforce follows the dollars and payment design shapes the workforce.

Previously a physician departure to another career required retraining in another field or a fellowship. Over 20% of family physicians have found ways to depart family practice positions. Now about 12% of family physicians practice full service emergency medicine with another 4% in urgent care and another 4% as hospitalists. Care where needed may suffer most. Rural family physician careers lose out to those leaving for rural hospitalist and emergency room careers. FM grads in office based care are 20% rural in location. This rises to 26% for hospital based FM docs in the AMA Masterfile 2013.
Family medicine remains most important in counties in counties lowest in physician concentrations. 

About 24% of physicians in 2621 counties lowest in physician workforce are family physicians. About 13% were general internists but this is moving to 7% or less as few IM trained physicians remain generalists. Pediatrics is about 6%. General surgical specialties contribute 3 – 5% each across surgery, ob-gyn, orthopedics, urology, ENT – but are rapidly decreasing nationwide at about 2 percentage points a year. The older physicians are found in these counties – another indication of too few remaining in these general specialty careers after residency training. Payment design dictates one or more fellowships – training that insures locations in highest concentration counties rather than lowest. FM remains the top specialty in demand but fewer choose FM. Medical students are well aware of the poor support, especially with higher medical education debt. The 8 times expansion of PA graduates and the 10 times expansion since 1980 is also evidence of the failure of training to overcome payment design.

Counties without a hospital or losing their only hospital are particularly dependent upon family medicine. But payments for office services are lowest in these counties. These gaps are often in states and settings with the most concentrations of Medicaid, Medicare, and other lowest paying plan patients. The threats to small practices and small hospitals include the designs for training and the designs for payment.

Very specific career choices are required for resolution of health access. Only family medicine has 36% of its physicians found in 2621 counties with 40% of the US population for a 0.9 ratio – a population based fit. These counties include 32% of the urban population and 75% of the rural population. Family physicians remain at about 26 to 34 family physicians per 100,000 across the wide range of populations. FM is over 1.0 for rural locations or 20% found where 18% of the population is found.

Nurse practitioners and physician assistants have limited distribution. Those departing family practice to more specialties also depart population based distribution. Psychiatrists, geriatricians, and internists tend to avoid these lowest concentration counties. This is not surprising given lowest payment for cognitive services and higher complexity with increased cost of delivery. The payment model fails most where care is needed most. These are counties with the most population growth over recent decades and they have greater proportions of near elderly, elderly, and oldest of the elderly.

Most Failure for the Most Americans

The US designs for payment and for training fail most where needed most and at the worst time in history given demographic changes. More cuts specific to these populations, more consolidations, and more attention paid to the largest and most organized almost guarantee widespread deficits during this time of no increases in payment, rapidly increasing administrative and other costs of delivery due to regulation, and declines in productivity forced by regulation. The small practices and small hospitals are facing the most problems but continue to receive the least attention and the least payment.



Recent Posts and References 
The Ultimate Government Health Care Paradox - Government must facilitate better EHRs and better health access, not prevent them.
No Positive Spin for the Innovator Tailspin - more claims for innovation successes are apparently attempts to hide failure
Stop the Promotion To Restore Mental Health Access - claims of mental health care reforms or improvements are a stark contrast from the reality of lowest payment, highest complexity of care, unreliable payment, and poor support other than lots of rhetoric


Primary care can be recovered and should be recovered, 
but cannot be recovered when moving the wrong directions

Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.
Copyright 2016




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