Imagine Designs For Most Americans Not Against

Decades of highly promoted interventions have not resolved health access woes facing most Americans. All forms of training have failed as MD DO NP and PA all have the freedom to choose careers providing higher paid services that have much better support. The workforce follows the financial design and concentrates in concentrations - leaving most Americans behind in the basic generalist and general specialty services most important for basic health access.

The financial design itself has become distracting, costly, and burdensome. Attempts to improve quality and attempts to cut cost have actually worsened costs and can impact quality negatively. Most importantly, the designs are hurting health access - particularly where most Americans most need care. 

Decade after decade of failure indicates the need for a change - but it is clear that no financial design change is coming. The health dollars are even more concentrated where concentrated - even primary care dollars are going to the biggest and least distributed. Training Cannot Overcome Financial Design

Pockets of segregated populations are left behind in counties with higher concentrations of health care workforce. Even more are left behind in large regions with over 40% of the population left behind with half enough basic services. These populations are growing faster and their health access is not.

Health access proponents have two choices

Fight using all possible resources to change the financial design or create a training design specific to the needs of most Americans most behind. 

Financial Failure Continues - There is no indication of a major change despite regular claims of improvements to the financial design. Primary care is moving to a decline in the proportion of total health spending rather than an increase. Numerous substitutes undermine primary care as it gains more burdens and less support. The costly complexities of micromanagement have resulted in 8 billion fewer dollars to invest in primary care where only 38 billion existed 10 years ago. 

Freedom to Follow the Dollars Continues - There are no plans to produce graduates specific to basic health access by career and by location. In fact, the last dedicated workforce, family medicine, has declined from 90% office primary care to less than 50% and possibly even lower. The 1970s FM grads were good for 90% serving careers of 25 or more years - but this was only during a time period with much better financial support. 

Since the 1980s the financial design has taken down all sources of generalists and general specialties - and there is no obligation design. Free choice reigns and the workforce follows the financial design where it leads - procedural, technical, highly specialized, most concentrated, and best supported with the least complexity. Real complexity is about person to person interactions - the challenging interactions to help people, children, seniors, chronically ill, and others make important changes.

Making Training Specific to Outcomes

The recent celebration of another great mentor in family medicine offers the opportunity to tie in all of the various mentoring and facilitating efforts. Dr. Renee Crichlow deserves all this and more.  

And there is more that we must do to help Renee and others as well as those that they hope to mentor. It is not enough just to get students to . Even a brief examination of the Family Doctors of the Year indicate that they have done much for their communities - and yet there is much more that they can do with less effort. 

How do we replicate what they do in academic circles? Having left rural practice I thought I could bring rural practice to family practice programs. I was wrong. The context is most relevant - and is most missing in academic training. It is missed in the origins, the preparation, the selections, the medical school training, and the family medicine training. 

It is often said that the real training begins the first day of rural practice - and rural communities, people, groups, and facilities offer rich learning opportunities - for those willing to learn, and stay. But how do they build the support that they need? How can they do more with less - as per the financial design?

As it turns out the training is wrong for half of Americans. These Americans deserve better designs specific to their needs. We need more of the family physicians, nurses, teachers, social workers, child developers, youth leaders, and support professionals. We also need them to be more before, during, and after training. 

We need them to be the front lines of human infrastructure - the change agents who can do much more to change education, health, and economic outcomes. As such, they can do much more than we can do within our limited walls and resources. 

Changing Outcomes Is Predominantly Outside - Not Inside Practices

 

A few minutes with a patient is totally insufficient for the changes that we must have - and many of the changes that must be made are much earlier and are outside of health care. Primary care levels higher do not shape better outcomes; they are only associated with better outcomes. Populations with better outcomes have better health plans, better habits, better social determinants, and many factors that result in more primary care and shape better outcomes.

Primary care is half enough where concentrations of the most complex patients are found, where populations have the worst social determinants, environments, and situations. To have impact, an entirely different design is required.

So how do we improve health outcomes, health professional education, child development, and health care workforce where needed? 

The changes must be in homes, parents, children, infants, families, communities, relationships, and situations. Serving professionals themselves point the way.

Numerous past and present models are relevant - COPC, public health, asset-based community development, AHEC, AMSA-HPDP IN CHC, 4H, Extension Programs, HCOP, RPAP, post-bacc, FM accelerated, University without Walls, Invisible Faculty, Jicci, Mindinao, Northern Ontario, Project ECHO and others. Each brings important lessons. Each can also train those who mentor the next generations and so on.

But are we willing to learn these lessons - integrate, coordinate, and focus specific to health access where needed?

Most Americans need a better future. 

The economic, health, education, financial, and societal reports demonstrate this. Their futures can only be changed by interventions early and often. They need person to person contacts - change agents willing to invest time and effort and talent in others. These change agents need to be prepared with mentoring, hands-on, service-learning focus. We should stop hoping that empathy, service orientation, and services where needed will materialize after preparation and selection involving predominantly those doing well in studies - studies lacking in human interaction.

The serving professionals that we need should be selected based upon their demonstrated abilities involving interactions. These make-a-difference teaching and health care and support and development professionals need much better support and a much better pipeline focused on mentoring, facilitating, developing, and serving.  This has to occur in the places in need and involving the populations in need.

The Pipelines Have Failed - the Financial Design Facilitates Too Many Leaks

In family medicine and in medical education, we have taken what appears to be an irreversible turn in favor of centralized, formalized, and academic - a turn that has taken us away from health access and the serving professionals most Americans need most.

The Ladder Is the Design 

The ladder starts in the community and stays in the community and remains in the community. Those progressing up the ladder know where they are going and know what they need to learn and participate in the teams that work in and for the community.

Renee has established a ladder program - a mentoring program for minority youth involving health career orientation and preparation. 

 

Imagine a ladder program involving many ladders - ladders to basic health, education, development, and support careers. These ladders would be specific to 2600 counties with half enough basic health, public health, teaching, developing, and supporting professionals. 

Imagine that this ladder not only impacts teens and young adults toward serving careers, but reaches inside of homes and neighborhoods to help change parenting, nutrition, caregiver support, readmission prevention, and healthier breathing environments - adding arms and hands to these providing care to the most complex.

Imagine the next generation of nurses, teachers, and family physicians prepared and selected based on change agent ability as demonstrated by working with people in teams.

imagine training that is entirely located in 2600 counties of greatest need - populations that are growing in numbers of counties left behind and growing fastest in population, elderly, demand, and complexity - counties without any specific response that will address their needs any time in the next few decades.

Imagine trainees making a commitment based on past years of experience working with the people that you will work with and the populations that you will serve. 

Imagine a career that has a jump start as new graduates are free from orientation, recruitment, or turnover costs. This is a career of commitment with a known obligation sufficient to save 1 million dollars in primary care physician turnover losses and costs - about 8 years of such costs. Instead of losing this 1 million investment, these dollars are invested in the trainee and are kept in the community. The dollars are specific to the training - training specific to the need. The dollars, the mentors, and the mentees stay and learn and grow where most needed. The trainee levels up in the needed skills and experiences - efficiently, effectively, and specifically.

Imagine restoration of not just any workforce, but a dedicated serving professional workforce with a foundation of 10 years of service-dedicated community learning experiences plus obligation plus retention via substantial community connections. By age 44 to 50 most of these professionals will aWhy would you leave a design that was specific to your community and your support needs as you develop future colleagues and replacements?

Imagine generations before and generations to follow - with the ability to problem solve in people, community, environment, and research problem solving dimensions taking the scientific process to the ultimate level.

Imagine the assurance of necessary serving professionals to a community, to practices, to schools, and to facilities. No longer is lesser capacity the default consideration in places with increasing needs.

Imagine as a professional the ability to work with dedicated and trained team members to not only identify gaps but to plug them. Imagine generations moving up a ladder that you have shaped and have helped to improve and maintain.

Imagine real changes in outcomes because your neighbors and their neighbors are changed by people interacting with people in a process that begins as children begin to develop socially and are given the opportunity to interact in this most important dimension.

Imagine the power of gatherings of students, mentors, and project ideas at the regional level - specific to the best practices changing outcomes.

Imagine a design specific to the needs of most Americans instead of the current one collapsing toward most expensive care for the fewest.

We must do more than just imagine.

The Community Driven Approach 

Preventing Rural Workforce By Design