THE DISTRIBUTION OF AMERICA’S MEDICAL SCHOOLS AND
THE PERSISTENT PROBLEM OF
PHYSICIAN ACCESS
______
A Thesis
Presented
to the Faculty of
California State University, Chico
______
In Partial Fulfillment
of the Requirements for the Degree
Master of Arts
in
Political Science
______
by
© Ginger M. Alonso
Spring 2018
PUBLICATION RIGHTS
No portion of this thesis may be reprinted or reproduced in any manner unacceptable to the usual copyright restrictions without the written permission of the author.
iii
DEDICATION
For Ben, Chloe, and Bethany. I believe in you.
iv
ACKNOWLEDGEMENTS
I wish to acknowledge
My family for their patience and understanding as I became absorbed in this project.
Ms. Susanna Boxall for welcoming me to her fascinating Health Ethics class at Chico State;
having that experience certainly helped me write my first chapter.
Ms. Katy Sylvia for giving me such a great introduction to the department that I was able to
connect and grow through the program after years out of academia.
Dr. Alan Gibson for being confident in me from day one in the master’s program. His generous investment of time, energy, and expertise has helped me complete this research and
has given me assurance for future academic adventures.
Ms. Pam Nelson for her inspiring hands-on dedication to physicians, community, and the
democratic process.
Dr. Becky White for her support, advice and feedback, and most of all for being my role model - like me in some ways, and yet simultaneously epitomizing everything I strive to be.
Dr. Matt Thomas for understanding my approach to research not only in the academic context, but in the context of a life’s work. His contributions to this thesis were many, but it
is Dr. Thomas’ example of living a life rooted in the local academic community while
actively growing as an individual scholar that left the greatest impression on me.
Dr. Diana Dwyre for her kindness and unwavering dedication to excellence demonstrated by
the quality time and attention she always gave to me and my multiple drafts.
v Dr. Andy Potter for being that enthusiastic thesis chair who students inevitably
recommend to their peers. His support through the writing process - from chaotic abstract
ideas to organized chapters - draft after draft, kept me focused and paced. Dr. Potter shared knowledge that was always several steps ahead, and last but certainly not least, motivated me
to do my best.
vi
TABLE OF CONTENTS
PAGE
Publication Rights ...... iii
Dedication ...... iv
Acknowledgements ...... v
List of Tables ...... ix
List of Figures ...... x
Abstract ...... xi
CHAPTER
I. Introduction to the Study ...... 1
Theoretical Background ...... 1 The Enduring Significance of Medical School Location ...... 2 The Essential Physician ...... 3 In-State Competition and Unequal Access ...... 5 Theoretical Framework ...... 7 Libertarian Approach: Health Care as a Service...... 8 Utilitarian Approach: Maximizing Happiness Over Burden ...... 11 Egalitarian Approach: Healthcare as a Positive Right ...... 13 “Fair Equality of Opportunity”: Norman Daniels ...... 16 Conclusion ...... 21
II. Historical Background ...... 23
Introduction ...... 23 Early Stages of Medical Education ...... 23 Industrialization and Urbanization ...... 30 Medical School Reputation and University Affiliation ...... 33 John Hopkins Model ...... 37 Flexner Report ...... 39 1920s to Today ...... 45 The Physician Shortage and Medical Schools in the United States Today ...... 53
vii CHAPTER PAGE
III. Data and Methodology ...... 59
Introduction ...... 59 Research Approach ...... 59 Data and Methodology ...... 60
IV. Results and Discussion ...... 63
Hypothesis...... 63 Discussion ...... 66 Conclusion ...... 68
V. Conclusion and Recommendations for Future Research ...... 69
Aims of Research ...... 69 Summary of Findings ...... 69 Theoretical Implications ...... 79 The Dual Health Care System in a Theoretical Context ...... 71 New Medical Schools - A Misguided Solution?...... 73 The Role of Graduate Medical Education ...... 77 PCPs, GME, Medical Schools and Institutional Priorities ...... 78 Limitations ...... 80 Recommendations for Future Research ...... 81 Conclusion ...... 82
Bibliography ...... 84
viii
LIST OF TABLES
TABLE PAGE
1. U.S. Medical School Growth, 1960-1961 to 2008-2009 ...... 52
2. Predictors of Physician Access (Physicians Per Capita) in States ...... 65
ix
LIST OF FIGURES
FIGURE PAGE
1. Medical Schools: The United States ...... 2
2. Number of Medical Schools and Physician Access Per Capita ...... 64
x
ABSTRACT
THE DISTRIBUTION OF AMERICA’S MEDICAL SCHOOLS AND
THE PERSISTENT PROBLEM OF
PHYSICIAN ACCESS
by
© Ginger M. Alonso
Master of Arts in Political Science
California State University, Chico
Spring 2018
This thesis is a study of the relationship between the number of medical schools in a state and physician access, and the implications of this for rural and poor Americans.
Access to care is a growing concern in the United States today. Research confirms that health status indicators including rates of life expectancy, timely treatment, and preventative care all increase with physician access. Access disparities have led the federal government to provide funding and incentives for physicians practicing in regions known as designated Health
Professional Shortage Areas (HPSAs). One possible explanation for the persistence of this problem is that medical schools have been historically located in urban centers on the East
Coast in geographically smaller states. By examining the relationship of the number of medical schools in each state to the ratio of physicians to population in each state, I hope to shed light on the phenomenon of the rural physician shortage, including the sources of this problem and how it might be addressed. Research on this topic is particularly relevant today
xi because the “Silver Tsunami” brought about by the aging of the American population promises to significantly increase demands for health care in the United States. Increasing demands will be difficult to meet through the existing rate of expansion of the physician workforce. In this context, physician access and state medical schools are worth examining.
xii 1
CHAPTER I
INTRODUCTION TO THE STUDY
Theoretical Background
If healthcare research is sharply divided on various matters, it unambiguously points in one direction with regard to physician access: more is better.1 Research suggests that health status indicators including rates of life expectancy, timely treatment, and preventative care all increase with physician access (Abrams et al. 2010; Macinko and Shih
2007).2 In this thesis, I examine the questions surrounding access and test the hypothesis that the number of medical schools in a state is directly correlated with a high physician-to- population ratio. My premise, highly intuitive but not tested here, is that high physician-to- population ratios, in turn, provide a rough proxy variable for access and that underserved populations may be assumed to have more access in states that have high ratios.
In particular, there are 181 accredited medical schools in the United States today
(American Association of Colleges of Osteopathic Medicine 2017; American Board of
Medical Specialties 2018). The federal government spends billions of dollars annually on research and training conducted in these schools (National Institutes of Health 2017).
Centralized, institutional coordination of medical education programs and activities has been lacking or non-existent throughout American history. Furthermore, as Figure 1 demonstrates,
1 Some scholars such as Pincus and Esther et al. (1998) disagree. They argue that that demographics and individual choices are more significant factors behind health status than access to physicians. It is most likely that all of these factors are interrelated, though the importance of physicians is empirically supported. 2 Both of these studies specifically focused on primary care physicians.
2
Figure 1. Medical schools: The United States Source: American Association of Colleges of Osteopathic Medicine. 2017. “U.S. Colleges of Osteopathic Medicine” https://www.aacom.org/become-a-doctor/us-coms); American Board of Medical Specialties. 2012. “Accredited Medical Schools” https://www.abmsdirectory.com/pdf/Resources_directory_MedSchools.pdf
America’s medical schools are unevenly distributed across the United States. In large part because of the east-to-west settlement patterns, the geographic size of the United States, and fluctuating population densities, the lion’s share of America’s medical schools are located in urban centers on the East Coast.3 This fact is particularly relevant if the physician-to- population ratio is higher in states with a lot of medical schools, and if the number of in-state medical schools is a health care access determinant.
The Enduring Significance of Medical School Location
Uneven medical school distribution can be best understood from a post-behavioral perspective. Both medical students and patients are subject to the effects of a serpentine,
3 In the book New Directions for Medical Education the impact of western expansion in early America on medical school location is briefly discussed (1989, 477).
3 decentralized history of America’s medical education system. As a result, the recurring theme in American medical education is that opportunity, expertise, quality, and efficiency are most easily secured in metropolitan areas because of the abundance of institutional and financial support (Markowitz and Rosner 1973). Lack of coordination is a common thread through history and persists today (O'Brien, Cooke and Irby 2010). In the place of central coordination or patient need, market capitalism and physician autonomy (freedom from government interference or control) have dominated medical education policy decisions
(including location of medical schools). Unequal access to a medical school education
(required for licensing and practice) may be a barrier to equal health care access for some
U.S. citizens and residents (Council on Graduate Medical Education 1998) and the uneven geographic distribution of medical schools may contribute to the inability to meet rising demands for medical care (O'Brien, Cooke and Irby 2010). This fact is evidenced by today’s federal Health Professional Shortage Areas (HPSAs) which are used to identify regional disparities - particularly areas of need - across the United States (HRSA 2008).4 In summary, based on Figure
1, a health care system in which medical schools are highly concentrated and uncoordinated is unlikely to provide equitable physician access across a geographically large country.
The Essential Physician
Around 20% of the nation’s gross domestic product (GDP) is spent on health care
(Centers for Medicare and Medicaid Services 2018), but health care spending alone is not enough to guarantee health. In fact, the United States spends more, yet is plagued by a higher maternal and infant mortality rates than most industrialized nations (The World Factbook
4 Federal funding is available to physicians who serve designated HPSAs, which have a physician-to-population ratio of 1:3500 or higher, in the form of bonus payments, reimbursements, and scholarships (HRSA 2008).
4
2017). Health and well-being are affected by genetics, individual choices, and a number of demonstrable environment factors. They are also affected by access to modern hospitals and advanced medical technology. Access to physicians is doubtlessly only one factor in overall patient well-being (Blum 1983; Pincus and Esther et al. 1998). Nevertheless, it is clear that good health is profoundly affected by the services that physicians provide. Physicians are a health determinant since modern medicine gives physicians authority to make decisions regarding mortality and morbidity. In fact, dramatic changes in society and health care have rendered physicians indispensable as a part of the health care delivery system (Starr 1982).
Physician access is essential because it ensures continuity of care and promotes prevention; patient confidence and overall sense of well-being are also improved with access (Shi and
Singh 2015).
Further, scientific and technological advancements have led to specialization and expertise, securing the physician’s niche in society. Not only is health care a large portion of the national budget, a physician’s role is increasingly complex and requires rigorous and lengthy training. Physicians today go through up to eleven years of post-undergraduate training. The average student loan debt for physicians when they begin to practice is approximately $200,000. Lengthy training and expensive training has its benefits; training enables physicians to contribute to good health in significant ways including: care that cures, ameliorates, and prevents disease, gatekeeping, technological expertise, and leadership.
Physicians, primary care in particular, contribute so much more than face-to-face treatment
(Schmidt et al. 1989, 27). They supervise other providers and coordinate medications and specialist consultations. Physician assistants, pharmacists, and nurse practitioners, for example, provide health care services but physician supervision is required for full
5 functioning of these professions. For the purposes of this study, I will focus on physicians as the central health care provider. As I have shown, physicians are essential. Health care costs, however, continue to rise, and physician access has become a complex issue both ethically and economically.
In-State Competition and Unequal Access
Access begins with education. Aspiring doctors face intense competition for
United States medical school seats, and this is evidenced by the fact that sixty percent of medical school applicants were rejected in the 2015-2016 academic year (Association of
American Medical Colleges 2016, 18).5 Student relocation is often necessary given the competition and the geographic location of schools, and this is an accepted part of medical training. Western states with large geographic areas and few schools struggle with more competitive conditions for in-state students.
Because of competition and the potential to utilize medical education to increase physician access, the number of schools in a state may matter. Studies show that early experiences, such as background and undergraduate education, influence where physicians practice. A Canadian study of rural family physicians found that rural background is associated with rural practice (Chan and Degani et al. 2005). In a systematic review of twelve analyses, rural background correlated with rural practice for 10 out of the 12 studies (Laven and Wilkinson 2003). A 2016 study of 1,168 practicing physicians found that a higher percentage practiced in Michigan when their pre-residency training was also in Michigan
(Koehler et al. 2016). Research on New York yielded similar results, finding that in-state
5 Only 21,647 were accepted out of 52,550 applicants.
6 high school and medical school were significant for retention (Armstrong et al. 2014).
Scholars have followed medical school programs designed to encourage rural practice in states like Michigan and Pennsylvania, and they are largely successful (Rabinowitz,
Diamond, Markham et al. 2008; Wendling et al. 2016; Rabinowitz and Paynter 2000).
Medical school training is a part of physician background and this training could be linked to physician retention and, therefore, access disparities. In short, there may be a causal relationship between the locations of medical schools and levels of physician access within a state.
To my knowledge, the topic of the impact of in-state medical schools on in-state physician access has not been previously studied. Therefore, I plan to address the following questions: Does the physician/population ratio decrease as the the number of medical schools in a state increases? Do rural state populations have comparatively less access to physicians than their urban counterparts? Is there a similar trend in terms of socioeconomic status? I expect that areas with high poverty levels will have reduced physician access.
Given the predominantly eastern and urban location of medical schools in the
United States, and the distinctly smaller geographic area of older eastern states, populations in eastern states and urban areas may have greater physician access because of institutional advantages and smaller land areas. In other words, more proximate medical schools may indicate more physicians per capita.
My hypothesis is that the more medical schools a state has, the more physicians per capita there will be in that state.
I will further analyze the data by adding two controls: state population density and state federal poverty level rates. I will do this because state population density is an indicator
7 of the proportion of rural/urban dwellers and appears to be an access factor based on history.
Poverty impacts the health status of populations and is associated with rural areas, which experience reduced access to primary care physicians.
Theoretical Framework
Competition for power and influence in health care policy is inevitable since the stakes are high, there are many stakeholders, and resources are limited. To add to the complexity, debates over the distribution of social goods (health care access, in this case) involve conflicting claims that cross multiple lines of society: geographic, social class, physician, patient, and risk-level (Daniels 2008; Stone 2001).6 Some attribute the lack of progress in improving access to the fact that safety net policies are not compatible with the
American ethos (Starr 1985; Shi and Singh 2015). Because equal access relates to justice, however, I will seek to show that there is a theoretical basis for equal access to health care consistent with American values.
There are multiple approaches to the government/healthcare interaction, and I will highlight four theories of distributive justice in the section below. Each one seeks to answer this question: What should the role of the national government be in distributing physician- provided health care in terms of rights?7 If medical school distribution is causing systematic exclusion in terms of physician access, then market forces are not a sufficient solution, and perhaps principles of justice can provide an alternative theoretical approach.
6 See “Origins of American Health Insurance: A History of Industrial Sickness Funds” (Yale Series in Economic and Financial History) written by John E. Murray (2007). While insurance coverage is central to access, for the sake of clarity and brevity, I will not address insurance in this study, and will instead recommend it for future research. 7 The concept of rights is a part of American founding tradition as indicated by the Bill of Rights and Declaration of Independence.
8
Libertarian Approach: Health Care as a Service
According to libertarians, rights are defined only in negative terms.8 For example, a negative right that most Americans are familiar with is the right to non-interference; that is, regarding personas and institutions, and especially the government. Libertarians seek freedom from taxation and virtually all unnecessary government regulation. From the libertarian perspective, health care access is not a right, and thus requires minimal or no government involvement.
Using this approach, physician services should be earned based on income; the ability to pay makes a person eligible for the service. Just as one should not own a car if he or she cannot pay, a person should not have health care if they cannot pay. The idea is that if the government stays out of the way, Americans will have room to succeed independently and ensure their own physician access (including transportation if there is a long distance between a patient’s home and the physician office or hospital).
The justification of physician access based on socioeconomic status is much easier to accept when one has the means to pay, and may reflect hints of meritocracy such as those promoted by the “American Dream.” For those who are financially comfortable, it is easier to believe that a person who works hard will succeed financially and deserve all the services they can pay for. American society has favored health care as a service, and this is evidenced by the market attributes of the healthcare system (Shi and Singh 2015).
Dr. Robert M. Sade (1971) is one of many advocates for the libertarian approach to health care in response to the Kennedy-Griffiths bill which was debated in Congress in
8 There is much confusion surrounding the concept of rights. The controversy revolves around whether rights have to be given or not. See literature on Rights Theory.
9
1971. The Kennedy-Griffiths bill was a proposal to replace private insurance with government-funded insurance for all Americans. Dr. Sade published an essay attacking the proposed bill by exclusively defining health care as a service. He argued that freedom from government interference, including the freedom to choose your own actions and beliefs, is the most effective approach (Sade 1971). Healthcare as a right is a mistaken concept, according to Sade, since individual freedom is threatened by positive rights (otherwise known as entitlements). I will briefly identify a few of his arguments and their weaknesses.
Sade’s first point was that one of the most powerful determinants of health is personal behavior.9 Community, or in this case, government, intervention is peripheral at best, and is therefore not necessary. He suggested that because individual choices have relatively greater influence on health, the government cannot be blamed for negative health outcomes. Individual ability to pay and control one’s own life parallels the assumptions behind the American Dream. However, Sade overlooked a significant portion of the population for whom health care and/or physician access cannot always be gained by individual effort. For example, hard work and financial success are not always linked, and assuming such a link leads to an unfair generalization that the poor are lazy and do not deserve assistance. There are barriers beyond an individual’s control that must be considered.
For example, Alzheimer’s disease, Autism Spectrum Disorders, and many congenital conditions are not currently linked to behaviors. Since there are other government-based factors that contribute to individual success (such as investment and opportunity) that are outside the realm of personal effort, and the government is responsible for welfare of the people, it is not absolved of the responsibility to care for citizens and residents in need (Stone
9 He is not alone. Pincus and Esther et al. 1998 and Blum 1983, 137 “Force-Field and Well-Being Paradigms of Health” also concur.
10
2001). Since, in the market economy, some cannot pay even though they need medical care, a pure market system fails to set a minimum of access and access disparities grow (Daniels
1985). The argument that individuals should pay on their own is weak because, in terms of government policy, the individual, micro-level provides no safety net and renders macro decision-making and a minimum level of access reasonable.
Sade’s second point was that medical care is a market provision and so it should not transcend market forces. Cost-effectiveness is vital in the context of limited resources especially to those concerned with excessive taxation. In a capitalist system, supply and demand are inevitably a part of health care and distribution. It is important to note that effective health care, however, maximizes health by effectively getting care to those in need.
Efficient and effective health care systems, then, are not structured around the ability to pay - yet cost is a persistent issue. Out-of-control health care budgets are a reality, and health care as a commodity may appeal to some as more cost-effective and feasible than health care as a right or entitlement (Sade 1971). If it is a mistake for medical care to transcend market forces, why do we have an established Medicare program, for example?
In fact, the government has already set a precedent for health being a unique social good to the benefit of many Americans, but there are contradictions in existing policies. Sade’s argument is contested by policies such as the Social Security Act
Amendments, which established Medicare and Medicaid, and the United States Healthcare
Act of 1974. Medicare and Medicaid have eligibility requirements which are based on assumptions of who needs help and who does not - a clear departure from the merit-based market system. In addition, the Emergency Medical Treatment and Active Labor Act
(EMTALA) mandates that hospitals that accept Medicare must treat patients regardless of
11 their ability to pay (Courtland 2017). More recently, The Patient Protection and Affordable
Care Act of 2010 (H.R. 3590) provided insurance coverage for all Americans and sought to address physician shortage areas. There have been many examples of rights-based legislation failing in Congress as well. The American Medical Association opposed President Harry S.
Truman’s 1949 public health plan proposal, for example, calling it socialized medicine
(Merkel 2014). Sade would argue that all of these policies were egregious mistakes.
Third, Sade argues that the liberty of physicians is threatened by government regulation. He asserts physician and patient autonomy are preserved in the market system by checking government force and control (Sade 1971). If Sade is correct (and perhaps he is), physicians will lose liberties if and when the government intervenes to secure equal access to their services. However, physicians themselves do not agree with Sade’s view. The 2016
American Medical Association Code of Medical Ethics states that justice and professionalism require them to uphold equal access to health care (AMA 2017).
Utilitarian Approach: Maximizing Happiness Over Burden
The utilitarian approach seeks to achieve the greatest benefit for the greatest number of people. In the context of limited resources, not all goods can be provided (Vaughn
2010). The main objective with this approach is to accomplish the most good when constrained by limitations that require rationing. This approach is appealing in the context of rising health care costs. As was previously mentioned, the United States spends more, yet is plagued by higher Maternal and Infant Mortality Rates than most industrialized nations (The
World Factbook 2017). Utilitarians would prioritize younger generations, for example, since they benefit the most from access to care. For example prenatal care would be easily
12 justified, while organ transplants for adults would not. In terms of health care, utilitarians would argue that cost-effectiveness is vital. Efficiency should be maximized. The more patients physicians are able to treat, the better.
Since, according to utilitarianism, the best allocations give a longer and higher quality life to as many persons as possible, rights are simply those that will maximize utility.
With utilitarianism, the more “quality” years a person will live as a result of their health care, the more deserving they are of access. Likewise, the greater the societal impact that results from restoring optimal function or preventing/minimizing dysfunction, the more deserving a patient is. Utilitarianism is unique in that it focuses wholly on outcomes. According to this theory, there are positive health care rights, or entitlements, but the process of determining who deserves those entitlements is quantifiable (Vaughn 2010).
Applying the utilitarian approach to health care access disparities, the greater the population of an area, and the greater the need, the more deserving that area is of health care access. Greater numbers of people will benefit from physician services in the urban setting.
Urban centers should be areas of increased access because health care can be effectively distributed. The higher population density will allow for a focus on those who will live a maximum number of healthy years.10 In addition, more patients can be seen in a shorter amount of time, because the high population supports efficient physician practice.
Quantifying health and the value of life is arguably morally objectionable. Critics argue that utilitarian health care would lead to only caring for those who need health care the least and giving them more resources. The concern is that utilitarian approaches discriminate
10 Quality Adjusted Life Years (QALYs) are utilitarian units of measurement to determine maximum benefit. They have been criticized for ageism, and discrimination against the sickest patients (Vaughn 2010).
13 against the elderly and terminally ill. The underlying dilemma of how to measure the value of a life with no consideration of morality is clear in the following example: Health care provided to a young medical student is justified with utilitarianism because she has many years of life left, and will save other lives in her profession. In contrast, an older paraplegic would not qualify for care because of her age and her assumed lack of usefulness to society.
Likewise, utilitarians would argue that physician practice in rural areas is inefficient, given limited resources. In summary, requiring the greatest good for the greatest number of people leads to the marginalization of the elderly and, particularly significant in this study, to rural residents.
Egalitarian Approach: Healthcare as a Positive Right
According to egalitarians, the primary value, in terms of access, is equality. By definition, positive rights entitle citizens or residents to something and obligate someone (for our purposes, the government) to provide it. For example, a citizen or resident facing direct threats to life or health should be given equal access to physicians to meet that need. In addition, it must be distributed in an equal or fair way because it is a right. From this perspective, a system is flawed if it denies certain people access, because all citizens and residents are equally members of society.11
Applying the egalitarian approach to health care, the government is the solution to equal access disparities. Society has a duty to provide access to health care, because individuals are inherently entitled to equal access to health care. Instead of resisting government intrusion, egalitarians argue that the government is instrumental to and
11 Concurring with the famous phrase in the Declaration of Independence “We hold these Truths to be self- evident, that all Men are created equal…”
14 responsible for providing access to health care. All other developed countries and international organizations have already adopted this approach.
The World Health Organization (WHO) constitutional definition of a just society is a society where healthcare rights are protections and entitlements (Constitution of the
World Health Organization 1946). According to the WHO, all citizens or residents are entitled to quality health care in addition to having the right to authority over their own health-related decisions (1946). The World Health Organization Constitution asserts that health care access is a part of international human rights law (1946).12 The United Nations presents a similar view in the Universal Declaration of Human Rights (1948). These documents assert that adequate health care is a rights-based entitlement, provided and protected by the government.
This approach is conceptually opposed to libertarianism, and has been labeled a
“socialist ideal” (Fried 1976, 32). The Kennedy-Griffiths bill and Truman’s failed legislation both proposed universal health insurance based on the rights approach and were classified as socialist. Market forces are seen in a completely different light in the two approaches.
One major weakness in the egalitarian approach is that it does not consider cost.
How can there be entitlements provided by the government when facing limited resources and skyrocketing costs? Shane Courtland uses Hobbes’ Leviathan and Laws of Nature and the social contract theory to argue that stability is worth the cost. He asserts that according to
Hobbesian principles, health inequities will cause societal destabilization (Courtland 2017).
The idea is that everyone is affected by a lack of care, even the healthy or rich will have friends and family that suffer when there is no safety net for sick and poor. If the government
12The definition of health is as follows: “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” (WHO Constitution 1948).
15 does not fulfill its duty to provide the necessities, there is a high risk for rebellion among the people in general terms, according to Courtland. There is little incentive for subjects to obey authority when protection is lacking. Because health care protects life, it is a necessity like food. This idea is further supported by disparities in health among social class. Poor health is associated with poverty, and so the weakest in society are the least protected (Ibid.). This argument is simply that everyone is happier and less prone to object to government when all members of society are taken care of in terms of their healthcare needs.
While egalitarianism in health care is popular, cost in not the only flaw (Daniels
2008; Sade 1971; Fried 1976). First, there has to be a scope and boundary to the right of health care, given the exorbitant costs (Daniels 2008). This suggests micro or macro rationing. In addition, to argue that there is a right to health care may not be the same as arguing for equal access (Fried 1976). The question remains, a right to what? Is every citizen or resident entitled to the best care available, or a minimum baseline? Health care costs are seemingly limitless, but there has to be a limit when there are limited resources. In addition, there is no way to guarantee equality of health if equality is the goal because of the multiple factors involved.
The egalitarian position is central to this study because societal injustice and a concern for fairness imply government responsibility in terms of equalizing health care access. Medical schools produce physicians with each graduating class, and yet the physician shortage and malapportionment of doctors persists and grows. The egalitarian approach can be applied to this unfair situation, raising the question of justice as fairness and societal obligations. Today’s Health Professional Shortage Areas (HPSAs) provide accessible data on disparities across the United States (Health Resources and Services Administration 2008). It
16 is clear that physician access is reduced for certain populations. If this approach is followed, than the government is under an obligation to equalize access.
“Fair Equality of Opportunity”: Norman Daniels
Justice is a foundational American principle according to the Federalist interpretation of Article VI of the Constitution (Cooke 1961). The government’s role in providing access to health care can be examined through the lense of justice, given the principles of the founding documents. In Federalist No. 51, Publius penned, “Justice is the end of government. It is the end of civil society” (Ibid.). The link between justice and health care can be explained this way,“...if it is a requirement of justice that basic social institutions guarantee fair equality of opportunity, then health care institutions should be among those regulated by the equal opportunity principle” (Daniels 1985, 117).
The Declaration of Independence lists three rights that the government should protect: Life, liberty, and the pursuit of happiness. Norman Daniels establishes a moral basis for the right to health care access based on these three rights. He argues that life, liberty, and the pursuit of happiness make up “equality of opportunity” (Daniels 1985, 39). Rights, simply put, are what enable equal opportunity. Disease and disability threaten opportunity because they take away independence - especially the ability to work and acquire income and wages. So, according to Daniels, the government has a responsibility to eliminate threats to opportunity that could have been prevented. In a sense, he is advocating for a safety net in health care that provides a minimum level of functional and productive activity (Daniels
1985). The government only has a responsibility to restore an individual’s health to bring them back to a level playing field of normal functioning (Ibid.).
17
Daniels argues that if inadequate access is resulting in poor health and reduced function for certain populations, then Rawls’ theory of justice as fairness is applicable (Rawls
1971). Inadequate physician access is well documented in the literature. Certain populations are more likely to be unhealthy and some populations use services less than others (Bayer,
Caplan and Daniels 1983). The system is identified as unjust when services differ based on social status or other exogenous characteristics (Daniels 1985, 17).13 It follows, then, that if government has the ability to contribute to equity, then the solution is a societal obligation.
But, Daniels cautions, the obligation is limited. The government is only responsible to ensure that there are no obstacles to access at the basic level - the level of function and opportunity.
Daniels uses the fact that health care is “special” (quasi-market) as a central piece of his argument, and this approach aligns with certain federal policies already mentioned such as Medicare and federally designated HPSAs (2008). health care is a social good, because it contributes to the health of citizens and residents, but what kind of social good?
Daniels says the government has already indicated that health care is not a commodity.
Resources are limited, individual opportunity, so the market system cannot be relied on for equal access (1985). The passage of The Patient Protection and Affordable Care Act of 2010
(ACA) also indicates strong support for the position that health care is unique, not to be left to laissez-faire capitalism, and primary care physician access is highly important. The ACA contained provisions for approximately $3.5 billion for primary care providers from 2011-
2016 (Congressional Budget Office 2010).
Because some health care institutions and practices contribute to “fair equality of opportunity,” Daniels argues for an adequate minimum for all as a social responsibility.
13 Sloan and Bentkover (1979) also concur with Daniels.
18
Access, he argues, should be based on need. There should be a basic minimum. The minimum is defined as the amount that restores opportunity for the patient. For Daniels, the concept of need replaces the concept of service. The government should be involved in health care at the need level and not the service level. Daniels’ response to the rights-based approach to health care is that the government is not responsible for happiness or overall well-being. It is only responsible for “normal functioning” simply because it relates to opportunity. Libertarians disagree, arguing that a minimum will always be elusive because it is in the context of the technology and services available at the time.
Equal access to physicians is a contested issue. Sade argues that a physician’s right to free choice of where to live and work cannot be undermined by patient need. Daniels argues that in order to ensure justice, a basic number of physicians need to be available no matter the socioeconomic status or geographic location of the population (2008). Those physicians who choose not to practice in areas of need ultimately deny patients health care access. Because of this, Daniels’ rebuttal to Sade is that physician autonomy and health care as “special”. Medicaid policy, which is not purely market-based, indicates this, yet even today physicians do not have to see Medicaid patients, and this also reduces access. Daniels argues that physician obligations are individual level when dealing with their patient, but centralized planning is vital for equitable access. In other words, it is not an individual physician’s responsibility to alleviate access disparities (Daniels 2008). Physicians will fulfill societal responsibilities when centralized planning and macro level decisions are in place.
The obligation to ensure access is on all citizens or residents, and not just on physicians.
Daniels argues that physicians have enjoyed more autonomy than most professionals in other
19 fields. Daniels advocates physician incentives to reduce disparities including financial means
(2008).
Purpose
To frame my hypothesis, my research focuses on the state level and is deductive, deriving from the “justice as fairness” theoretical approach established by Rawls (1971) and articulated for health care by Norman Daniels. “...if it is a requirement of justice that basic social institutions guarantee fair equality of opportunity, then health care institutions should be among those regulated by the equal opportunity principle” (Daniels 1985, 117). Since it cannot be assumed that uncoordinated placement of medical schools promotes principles of justice, the relationship between placement and access should be analyzed at the medical school stage of physician training.
Norman Daniels asserts that the three American rights life, liberty, and the pursuit of happiness are applicable to health care because government protection against disease and disability help guarantee individual independence and wages, promote opportunity. So, according to Daniels, the government has a responsibility to eliminate threats to opportunity that could have been prevented, and part of that responsibility is access to health care provided by a physician. Daniels argues that if inadequate access is resulting in poor health and reduced function for certain populations, then Rawls’ theory of justice as fairness is applicable (Rawls 1971).
As the United States faces a growing physician shortage and aging Baby Boomer population, the uneven distribution of medical schools becomes potentially relevant in terms of justice as described by Daniels. There may be a connection between access to medical education and the number doctors in a geographic area, and this is a particular concern in
20 rural and poor states. Not only does unequal access to medical education affect younger generations, elderly populations in areas of reduced access would potentially benefit from increased access to physicians trained and working in their region as well.
The purpose of this quantitative study is to examine the relationship between medical school density and physician-to-population ratio. The underlying question is whether or not medical schools impact physician access within states. While I am not examining
Graduate Medical Education training, insurance reimbursements or coverage, pre-medical school experiences, or student characteristics, the study is intended to initiate a discussion regarding how effective or ineffective state funding, in particular, is on in-state physician retention, and therefore what role the federal government has in reducing barriers to access.
It is a fact that medical schools produce physicians, and, based on my research, I am assuming that physician location is influenced by medical school location. Public opinion has also been influenced by media accounts indicating that lawmakers believe physician numbers will increase in-state with the opening of new medical schools. My hypothesis is also based on the map in Figure 1 which shows that medical schools are more densely scattered in the eastern half of the United States, while the national population center has been steadily moving west (Henderson 2016).14 In short, the purpose of this study is to question the importance of the distribution of medical schools in contributing to physician access disparities. I predict that as the number of medical schools in a state increases, the likelihood that there will be more physicians per capita increases.
14 Pew Charitable Trusts research used census population estimates to show that Americans are tending to move South and West for economic self interest.
21
Conclusion
The geographic location of medical schools may have a significant impact on in- state retention of doctors, as is suggested in Koehler et al. (2016). The theoretical framework
I have presented sheds light on contrasting views surrounding physician access disparities.
When viewed through the lens of libertarianism, the variability of physician access among states is a non-issue. Access based on ability to pay reduces geographic importance because with financial success comes mobility. In terms of utilitarianism, medical schools should be located in large metropolitan centers where there are more people. With a large population, it will be easier to select out patients who will maximize the collective good with the least amount of resources. Neither of these approaches is satisfactory based on the principles of justice and equality, and that leads to the egalitarian approach and justice as fairness. In this context, state variation is worth examining. For example, if a large percentage of medical students in California are forced out of state for medical school, how does that impact retention rates in California? Perhaps levels of physician access within a state may be influenced by the number of medical schools in that state.
In summary, I have provided a theoretical “access” framework by exploring the philosophical and ethical justifications for establishing government responsibility to ensure physician access as a part of access to health care. Because egalitarianism complements the principles of equality and justice outlined in the American founding documents, there is societal value in examining the factors.15 Using egalitarianism, I will consider the factors that would equalize access to physicians, but first I will examine factors underlying disparities in physician access.
15 The rights-based philosophies of Locke, Burke, and Hobbes influenced the American founding.
22
This thesis is organized as follows: employing the theoretical lens of egalitarianism as a justification for equal access to physicians, I examine the impact of medical school location on physician access. In chapter two, I provide a historical account of
American medical schools from colonial times to the present. In chapter three I describe research methods that involve using secondary, publicly available data to calculate physician/population ratios by state. In chapter four I present results and findings. In chapter five I provide a conclusion including reflections and potential future research and policy such as focusing on primary care physicians and examining the impact of insurance on access
23
CHAPTER II
HISTORICAL BACKGROUND
Introduction
There are 181 accredited medical schools in the United States today, and the federal government spends billions of dollars annually on activities conducted in these schools.
Nevertheless, a 2013 survey of patients in eleven developed countries found that, per capita, the United States had the fewest generalist physicians (The Commonwealth Fund 2016). In the same study, over half of Americans said they could not schedule a physician appointment within 24 hours of calling the provider’s office. Policymakers have viewed medical schools as a tool to increase patient access to physicians in the past, and continue to do so (Starr
1982; Rabinowitz and Paynter 2000; Kamitani et al. 2015). Medical school effectiveness in terms of physician access disparity remediation is questionable, particularly in rural areas
(Rabinowitz and Diamond et al. 2001). The evolution of American medical education is complex and unique, and problems of access have persisted despite many attempts to alleviate them. Access varies by state, and the rural physician shortage crisis has lingered in the nation for many decades (Pusey 1925). Background knowledge of American medical school history is helpful in understanding the current physician shortage. For this reason, I will address the background of medical education in the United States in this chapter.
Early Stages of Medical Education
Using Fox’s categorization (Fox 1927, 754), there are four chronological stages in
American medical school history: First, European practitioners brought medical services and
24 expertise to early American communities. Second, American-born students trained in
Europe. Third, upon the student’s return to colonial cities, the first American medical schools were established, and in the fourth and final stage, medical schools were sufficient for supplying the nation’s physicians.16 I emphasize the fourth stage, since the current sufficiency of American medical schools is questionable, as evidenced by the physician shortage.
European immigration led to settlements along the eastern seaboard, and medical education evolved with society in a concomitant fashion.17 A relatively small number of immigrant physicians served the pioneer population before medical schools were established.
Very few were formally-trained before 1765, and all were trained abroad (Kaufman 1976).18
This was because Europe had well-established institutions and for American students to attend. In contrast, Americans remained mostly rural from the first settlements to the years before the Industrial Revolution.
Ninety-five percent of Americans lived in rural settings, according to the 1790 census (United States Census Bureau 2017). For rural families in this time period, health care was not a financial transaction, but a familial, relationship-based responsibility (Starr 1982).
Most common concerns surrounding disease and prevention were handled with self- sufficiency, and physicians (in short supply, and relatively expensive) were the last resort
16 Fox’s categorization is also cited in O’Malley (1970). 17 The initial Jamestown and Plymouth colonies had severely inadequate healthcare and faced disease and malnutrition, but with physician scarcity, the only option was individual survival (O’Malley 1970). 18 European standards were used to define formal education.
25
(Kitayama et al. 2010; Starr 1882).19 Family caregivers were usually female, and well- respected within the domestic sphere. A medical crisis or emergency primarily necessitated community involvement, and occasionally physician services. New England residents sought out clergymen for medical advice (Kaufman 1976). Clergymen were happy to give it. While this may seem absurd today, the self-proclaimed “physicians” scattered throughout the colonies were hardly more qualified than clergymen (Ibid.).
Medical schools were not widely available, and accessible physicians typically only had apprenticeship experience. House calls in early America were an exercise in long- suffering from a physician’s perspective. The typical day would involve a very high proportion of hours commuting by carriage (Starr 1982). From the colonial period to the
1870s, physicians were marginalized and not deemed to be professionals. Public support for medical education was largely nonexistent in the first century after the Revolution (Ibid.). A new era in American history would change all of this. The influence of the market, perceived need for physicians, training in medical schools, and physician activities are all factors that evolved with the development of the metropolis in America.
As second generation Americans reached adulthood, affluent students pursuing medicine often travelled to Europe. This initiated the second stage of medical education. The
University of Edinburgh in Scotland was the most prestigious school at the time, and
O’Malley describes the city at the end of the eighteenth century as, “the mecca of American youth who sought institutional instruction.” (1970, 474). London was also a popular destination for medical training (Fox 1927). For those who could not study abroad, a convenient and relatively inexpensive alternative was local apprenticeship. Local
19 Larger city populations were first to recognize the need for improved healthcare and medical education prior to the American Revolution (O’Malley 1970).
26 apprenticeships were typically modeled after European apprenticeships, but the standards were lower. For example, British medical apprenticeship was seven years, while American apprenticeships were three or less (O’Malley 1970, 474).
Around 158 years after Jamestown was settled, societal support for formal medical education would come in one of the first cities: Philadelphia (O’Malley 1970, 463).
By the late 1700s, there were only three medical schools in the United States. They were located in three cities on the eastern seaboard: Philadelphia, New York, and Boston
(Ludmerer 1985). The first was the University of Pennsylvania School of Medicine.20 It was affiliated with the College of Philadelphia (now known as the University of Pennsylvania)
(Kaufman 1976, McConaghy 2010). The founders, William Shippen and John Morgan, had trained in Scotland and England. Philadelphia emerged as the most medicine-friendly city in the colonies, and was the proud home to the first medical school with the help of Benjamin
Franklin (McConaghy 2010).21 Only ten students graduated in the first class, but the graduates initiated a ripple effect (Kaufman 1976). The impact of the school was felt far and wide as newly-trained physicians settled in other cities, and spread the reputation of the
Philadelphia school as the epitome of success. Philadelphia became America’s Edinburgh, known as the “medical capital” of America. Graduates of the school were desirable faculty members at fledgling schools around the turn of the century (Kaufman 1976). By 1782,
Harvard College in Boston and King’s College in New York had established their own
20 Established in 1765. 21 The opening of the first medical school in Philadelphia was facilitated by the existence of a hospital. Benjamin Franklin aided the establishment of Pennsylvania Hospital in Philadelphia in the early 1750’s, and the hospital paved the way for the first medical school (O’Malley 1970). O’Malley suggests that Philadelphia was the first because of the large Quaker population in the area (1970). He attributes the Quakers with a unique “utilitarian ideology” that shaped Philadelphia into the birthplace of American medicine (1970).
27 medical schools following the same pattern of European medical education. There were seven medical schools by 1813 and four additional schools opened shortly thereafter, all of them located in eastern cities (Kaufman 1976).
Early medical schools copied European institutions to a degree, but the European approach had to be modified to suit American civilization (Fox 1927). Before long it was apparent that European-style medical training was not suited for the unique and expanding
American territory (Kaufman 1976). Unlike European nations, American settlers covered a geographically large area, and many settled in remote areas. Medical training was centered in eastern cities, and this created a dilemma. In addition, decentralized educational institutions at every level (primary, secondary, and higher education) were not equivalent to the institutions of Europe.22 Generally speaking, American students were not sufficiently prepared for rigorous medical training and many could not access medical schools. The vast
American territory rendered the population distribution an anomaly (Ibid.).
A unique solution came from within the medical profession itself. Physicians responded by establishing small, often rural, proprietary “college” medical schools - an intermediary between the urban college/university programs and the inadequate, time- consuming apprenticeships (Ibid.). Proprietary schools were typically physician-owned, for profit, and had limited facilities and minimal requirements. A uniquely American set of problems - the training of rural students with the barriers of travel, family, and socioeconomic status, were so pervasive in rural communities in the early 1800s that rural medical students struggled to succeed. Subpar, proprietary, rural schools met that need
(Ibid.). The first non-affiliated, physician owned medical school in New England (Castleton
22 Their development would come at the federal level with the Common School Movement and the Land-Grant movement.
28
Medical College in Vermont, established in 1818) was founded by a physician who was sympathetic to local students whom he had observed commuting to New York, 150 miles away (Ibid.).23
The number of medical schools multiplied to one hundred by 1880, and most were independent proprietary or loosely university affiliated proprietary (Ludmerer 1985).
The majority of schools were owned by one or more physicians (Ibid.). As the population expanded westward, proprietary schools provided entrepreneurial opportunities because they were independent and for-profit. They gave physician-founders authority in the form of a territorial sphere of influence with no local, state or federal restraints, and with no academic competition (O’Malley 1970).
Access to medical education in rural areas increased with the growth of proprietary schools, but there was a persistent underlying flaw - instruction was abbreviated and sub-standard (Ludmerer 1985).24 Cities such as Philadelphia and Boston had the most formal and prestigious programs in the country, but they were not science-based. Most proprietary schools were lecture-based, modeled after colonial apprenticeships. There was no quality guarantee. Local citizens enthusiastically supported proprietary schools since the graduates ameliorated shortages in rural areas - despite the fact that these physicians were under- qualified by European standards (Kaufman 1976).25
With low educational standards and a superfluous number of schools, it was difficult to identify a true physician from a fraud (Starr 1982). Between the “physicians”
23 It is important to note that while medical schools like Harvard were university-affiliated, they were proprietary in nature as well, and would eventually need reform. 24 While it was not rigorous, the time commitment was shorter than university programs. 25 European standards were the only standards at the time.
29 practicing medicine without any formal education (only apprenticeship), and practicing graduates of substandard proprietary schools, the profession lacked credibility. For example, in 1848, over twenty-five percent of self-identified physicians in Virginia had apprenticeship training only, yet claimed the same title of “physician” as graduates of reputable medical schools (Transactions of the American Medical Association 1848). Even holding a degree was misleading because curricula and standards were inconsistent across institutions. Not only did the lack of standards contribute to a state of confusion, but victims of malpractice further eroded physician credibility (Kaufman 1976).
The concept of medical research in a university context began in Germany and
France. As medicine became a branch of science, perceived need for well-trained physicians grew (Starr 1982; Ludmerer 1985). By the 1800s, science and medicine were inseparable.
The idea that the underlying causes for disease were directly linked to anatomy, pharmacology, chemistry, biology, physics, pathology, bacteriology, and physiology revolutionized medical training (Kaufman 1976). New discoveries reinforced the value of research, yet up until this point, physicians were not adequately trained in these subjects in
American medical schools.
Medical education in America lagged behind European standards at every level, and although the number of medical schools had multiplied, only six schools approached
European quality.26 Efforts to remedy the situation began as early as the 1830s with the establishment of the American Medical Association (Kaufman 1976). Following the birth of the AMA, the urgency for medical school reform increased, but proposals were meaningless
26 The University of Pennsylvania School of Medicine, Jefferson Medical College, College of Physicians and Surgeons of Columbia University, University of the City of New York Medical Department, Chicago Medical College, and New Orleans School of Medicine (O’Malley 1970).
30 since there were no enforcement mechanisms. Even Harvard Medical College ignored the
AMA’s standards (which were presented in 1851 after extensive research). Kaufman states,
“...Harvard was typical of the American colleges of the day: it made no changes in response to the AMA standards” (1976, 102).27 The situation remained as the Civil War commenced in
1861. The medical education crisis was set aside during the war, but poor quality and inconsistency lingered into the postwar era.
Industrialization and Urbanization
The status of physicians has not been consistent throughout American history
(Starr 1982). As was previously mentioned, a large proportion of physician time was spent travelling in pre-Civil War America. Lack of demand for physician care was common because of a self-sufficient and independent cultural bent, and the poor reputation of doctors made the profession relatively weak. Medical education was inconsistent, and physicians were not entirely trusted as a result. Broad changes within the country itself would alter the medical profession radically. The AMA gained strength, and post-war phenomena such as industrialization and urbanization would bring transformation to the entire society as well as medical education in the years following the Civil War (Ibid.).
In the late 1880s, industrialization led to urbanization: a population shift from rural to urban areas. The American population of approximately 70 million people became increasingly urban as workers were drawn to factories (O’Malley 1970). Urbanization was a favorable development for physicians in many ways. Most significantly, Starr argues,
American physicians rose on the societal hierarchy from marginal to essential. Starr
27 Thirty years later, Harvard made amends, and became a leader in adopting AMA reforms (Kaufman 1976).
31 identifies a period of transformation within the American psyche from self-sufficiency to dependency, and asserts that American society has never recovered from this effect of urbanization (Starr 1982). The urban setting, with individuals separated from their homestead and family caregivers, and ease of health care access, led to “greater dependency” as a result of city migration (Ibid.). Physician services began to meet the new societal need for medical assistance outside of the family circle.
Increased dependence was not the only factor elevating the medical profession.
City institutions and facilities would eventually be conducive to research, and scientific advancements also gave physicians a higher status in society. It was in the city that physicians began to enjoy their reputation as experts. Starr argues that as confidence in scientific progress increased, the ordinary man lost faith in his own common sense, and willingly gave legitimacy to physicians (1982). In summary, physician status positively correlated with movement to cities; dependence, societal need and reverence for physicians solidified with urbanization (Starr 1982).
The shifting American population, and the professional growth of physicians - both a result of industrialization - led to medical education reform as well. City hospitals and universities grew, and cities soon became medical education centers. Industrialization brought greater levels of wealth and affluence that would be a precursor to medical philanthropy- a powerful financial force behind coming changes in medical education
(O’Malley 1970). Changes in medical education and the profession were accompanied by hospital transformation as well.
During the Revolutionary era, some medical schools had instruction in hospitals but it was short-lived. By the early 1800s most medical students were not interacting with
32 hospital patients directly (Deitrick and Berson 1953). The popularity of proprietary schools may be an underlying cause for this. Most hospitals did not have doctors walking their halls.
They were urban, but they were typically charitable, unspecialized “almshouses” for the sick and poor (Starr 1982). They were often affiliated with a religious sect and provided a home for the sick, elderly, orphaned, and mentally ill (Starr 1982). It was not until after the Civil
War that physicians began to perform rounds in hospitals (Ibid.). As city populations grew, hospitals became a central part of medical education, where medical students served the admitted patients as they were learning (Deitrick and Berson 1953). Service and training in hospitals would become a key part of medical education, but not without a cost, as will be discussed in a later section. In addition, another area that experienced radical change in the late 1800s was higher education.
Universities became affiliated with hospitals through medical schools. The modern university was established after the Civil War (1870-1890) (Starr 1982). The development of the modern university would eventually provide medical schools with a generally agreed upon home (Ludmerer 1985). Medical school-university partnerships would facilitate research in connection with affiliated hospitals as standard practice. It is important to note that this design was more conducive to an urban setting (Ibid.). For universities, medical schools and hospitals promoted their image as legitimate research institutions. For this reason, university presidents regularly sought the status and legitimacy of medical education in their offerings.
In summary, the three-part system of hospital, medical school, and university was facilitated by the evolution of cities. Medical schools adopted a three-part mission: education, research, and service (Deitrick and Berson 1953). These goals were achieved more readily in
33 urban areas. In addition, medicine became professionalized in the city. In light of these facts, it is significant that the trend toward physician concentration in metropolitan areas continues even today (Council on Graduate Medical Education 1998).
Medical School Reputation and University Affiliation
With research, medical education evolved from a predictable body of bounded information to limitless discovery and societal progress (Starr 1982). Medical research eventually led to a valuable yet costly transformation in medical education. The link between medical schools, universities, and hospitals was established. It was clear that at the national level, the medical school structure and curriculum would need to change, but there were no mechanisms for enforcement, and high variability among programs continued.
Public support for regulation increased as the legitimacy of scientifically trained doctors became commonplace. Kaufman argues that licensing (which the AMA advocated and wanted to control) was vital to progress in increasing the quality of medical schools.
“From the 1840s to the 1870s, in the absence of medical legislation, the nation was virtually overrun with quacks” (Kaufman 1976, 143). William H. Welch described medical education in the late nineteenth century this way: “Probably medical education had nowhere, at any time, fallen to such a low estate as it did during a large part of the last century in our country”(cited in O’Malley 1970, 501). State licensing came into effect in New York first - after much debate over government interference in medicine - and physicians were then required to have a license to practice (Kaufman 1976). The American College Association, and the American Academy of Medicine were put in place to help delineate appropriate
34 physician qualifications as well, but these regulatory measures did not improve medical education itself (Ibid.).
The structure of the university-medical school relationship varied in the 1800s, as universities and medical schools varied considerably. Universities alone were modernized and secularized and national scientific progress encouraged by the federal government in the form of the Land-Grant College Movement, initiated in 1862 (Wilson 1967). Federal support of higher education in the field of agricultural science and engineering was initiated by land- grant legislation that provided federal land donations for universities in each state. At the time, Europe was advancing in laboratory research. The Senator who introduced the bill cited the “growing giant of Europe” - and pointed out that Russia had many scientific universities, and the United States was weak in research (Florer 1968, 474). Although medicine was not a target of the land-grant movement, it was an important step for medical education. The federal commitment toward modern universities indirectly transformed medical education by providing institutional homes for medical schools.28
Prior to this, some medical schools were affiliated with universities by request, in name only, while others enjoyed administrative commitment and financial support from the university (O’Malley 1970). It was common for a medical school to be financially independent, albeit affiliated. This was the situation at Harvard, which was considered a proprietary medical school (Starr 1982). Physician faculty in university-affiliated medical schools were not necessarily accountable to the university. Standards were slipping even in affiliated medical schools (Lippard 1974). Harvard president Charles W. Eliot (president from 1869-1909) stated that, “The whole system of medical education in this country needs
28 By the 1970s, around fifteen university medical schools were located on land-grant campuses (Wilson 1967).
35 thorough reformation” (Lippard 1974, 2). His solution was visionary, since he improved medical education at his institution by tightening the bond between the university and the medical school. He expanded the curriculum, added prerequisites, promoted research, and modernized the university as a whole (Starr 1985). Although Eliot was first in Boston, the
Johns Hopkins model in Baltimore, under Daniel Coit Gilman as president, became a prototype for medical education with hands-on instruction, science, and modern techniques across the nation (Ibid.).
Private, pre-Civil War colleges were not research institutions. According to policymakers at the time, scientific progress was hindered by pre-Civil War colleges, as they were old-fashioned, religious, narrowly classical, and barely surviving (Potts 1971). In terms of medical education, it is not clear that pre-war, private colleges were as inferior as proprietary medical schools, but they were both rural. In fact, some scholars argue that antebellum colleges were well attended, and boasted high levels of poor students because they were typically locally-centered (Burke 1982; Potts 1971). Policies supporting federally- funded public higher educational institutions perhaps inadvertently initiated the decline of rural schools, since those schools were framed as backward - a recurring theme in medical education as well. After all, federal financial support of existing rural colleges could have been a policy alternative (Burke 1982). Instead, the Land-Grant College Movement contributed to the evolution of American universities and medical schools away from rural settings through the advancement of science and secularization.
Modern universities brought research and secularism into higher education which eventually helped link research with medical education. Seventy-one federally supported
36 land-grant universities are distributed across the country today (Williams 1991).29 Charles
Eliot of Harvard and Daniel Coit Gilman of Johns Hopkins also contributed by modernizing their own institutions (Starr 1985). In addition, the federal commitment to higher education initiated state and other sources to step in and support higher education. It was the federal government’s role as an initiator that created momentum for financial support.
One land-grant medical school highlights the value (and perhaps future potential) of these institutions. A 1967 JAMA article examines a case study of a land-grant medical school: the University of Missouri. The physician-author promoted a successful program at the University of Missouri School of Medicine as a potential prototype for statewide quality access to medical care (Wilson 1967). In this case, nine hospitals across the state entered into an agreement with the land-grant affiliated medical school to increase the research base of the medical school across the state and provide health education (Ibid.). The Missouri
Regional Medical Program emphasized population health care and collaboration among over thirty groups and state departments, all coordinated by the university (Ibid.).
There was an alternative policy that was significant because it was a proposal for the centralization of medical education. It was the idea of a “national medical college” proposed in the chambers of Congress after the Civil War. Much like the land-grant legislation, the intention was to provide standardization and support. Federally supported medical schools could promote high standards and were proposed to be a model for other schools (Kaufman 1976, 115). Historical records indicate that American Medical Association sought the demise of this policy from the 1870s because they had concern about political involvement in the scientific medical progress. The reasoning was that political oversight of
29 Including: the University of California, Berkeley; Massachusetts Institute of Technology; Michigan State University; Pennsylvania State University and Cornell University (Williams 1991).
37 scientific progress in medicine would be like the “protection of sheep by wolves” (Kaufman
1976, 115). Federal support of higher education was underway, however, and would eventually reach medical schools.
In summary, substandard proprietary schools multiplied before the Civil War, contributing to a medical education crisis. Urbanization, industrialization, and scientific advancement were inevitable forces that propelled physicians and medical education forward into a new era. A new standard was desperately needed, but there were no centralized forces to coordinate it. University affiliation became increasingly popular and possible in urban settings. With the financial protection of medical philanthropy, the Johns Hopkins Model became the standard for quality medical education. A short time later, in 1893, a large philanthropic donation for a new and unprecedented medical school in Maryland would provide a model for ideal medical education. There were 131 medical schools in the United
States by 1910 (Kaufman 1976, 167).
Johns Hopkins Model
Johns Hopkins was a wealthy railroad stockholder who envisioned a coordinated hospital, university, and medical school in the city of Baltimore, Maryland (Kaufman 1976).
Hopkins’ $7 million philanthropic gift for the simultaneous establishment of the hospital and medical school led to a unique type of medical education. Established in 1893, Johns
Hopkins School of Medicine was groundbreaking in its modernity. Established along with
Johns Hopkins Hospital, both were linked to the pre-existing university. Part of its uniqueness was attributable to its unusual financial stability that insulated it from needing to
38 increase or maintain student enrollment (Ludmerer 1985). 30 This allowed for a ground- breaking, rigorous four year program from the inception (Kaufman 1976). Freedom from financial concerns allowed for innovation and high standards, making Johns Hopkins School of Medicine an institutional outlier.
Medical students at Johns Hopkins were trained using a model of the “German residency system” which had been successfully implemented in German medical schools for over 50 years (Schmidt et al. 1989). The German model system included affiliation with a university for scientific advances using laboratories. With the growing field of medical research, “It seemed obvious that in order to produce modern, scientifically oriented physicians, the German example had to be followed” (Kaufman 1976, 151). Johns Hopkins was designed to copy the German model and the implementation was virtually flawless.
The German curriculum began to be integrated into medical education. This is evidenced by the fact that 15,000 American medical students travelled to Germany for training from 1870-1914 (O’Malley 1970, 503).31 The German method (French and British methods were also incorporated to a lesser degree) was behind the idea that new discoveries must be emphasized rather than passive learning of a fixed body of increasingly outdated medical knowledge (O’Malley 1970).
Johns Hopkins became the leading exemplar as its reputation spread.
Pennsylvania, Harvard, Michigan, Cornell and Chicago Medical College lengthened their programs and adopted the German model and were relieved to see increasing enrollment as a result (Kaufman 1976; JAMA 1893). Graduates of Johns Hopkins also disseminated the
30 Johns Hopkins University was established in 1876. 31 As cited in O’Malley: Bonner, T. N., American Doctors and German Universities. Lincoln, Nebraska, 1963.
39 highly innovative model throughout the country as they took on professorships elsewhere
(Kaufman 1976). Johns Hopkins was urban, linked to both a hospital and a university, and became an outstanding model for other medical schools. The trajectory toward quality began, and access to medical education decreased for students in areas where schools closed - particularly students in rural and poor communities. Adoption of the German method would become a way to survive after the Flexner Report. In this way, the Flexner Report raised the bar for American medical education, but unfortunately drastically reduced access for some students (Lippard 1974).
Flexner Report
The system in operation before the Flexner Report at least had the virtue of turning out physicians in numbers sufficient to meet the demands of a rapidly growing and geographically expanding population. Although most of them were general practitioners, who by modern standards were poorly educated and lacking in scientific background, they were available to the inhabitants of the ghettos, the crossroads, and the prairies. - Vernon Lippard (1974, 6).
In 1910, Abraham Flexner was commissioned by the Carnegie Foundation for the
Advancement of Teaching to conduct a survey of all 155 medical schools in North America
(O'Brien, Cooke and Irby 2010).32 Of the 155 North American schools, 131 were in the
United States and only 5 of them had been in existence for over 100 years (Lippard 1974).
The purpose of the study was to produce impartial recommendations for medical education reform.
Flexner himself was an educator - not a physician or a politician- and knew very little about medical education prior to his research. He claimed no outside physician
32 American Medical Association requested this study from the Carnegie Foundation.
40 influence on his work - asserting that medical education had deteriorated under physician guidance prior to his report (Kaufman 1976). Interestingly, before he began, Flexner spent a great deal of time at Johns Hopkins, becoming well acquainted with the medical school curriculum and facilities (Kaufman 1976). In fact, his brother earned an M.D degree there
(O'Brien, Cooke and Irby 2010). It was at this stage, prior to the commencement of his research, that Flexner became convinced that Johns Hopkins was an ideal American medical school (Kaufman 1976). This fact leads some to question the objectivity of his report.
The Flexner Report of 1910 was meant to promote quality in medical schools by impartially exposing inconsistencies, promoting high standards and emphasizing science.
Flexner observed the curriculum, the faculty, facilities, student records and overall status of each of the 155 schools, but he proposed narrow alternatives for reform. Far beyond simple observation, Flexner argued for specific goals inspired by the Johns Hopkins model. Since medicine was scientific in nature, he asserted that training should be in universities with teaching hospitals, and laboratories, and should have an emphasis on scientific inquiry
(O'Brien, Cooke and Irby 2010). According to H. G. Weiskotten et al., the Flexner report encouraged university affiliation by advocating for five principles: there must be minimum requirements for medical school admission, instructors must be scientists, observation is vital to instruction, there must be integration with a university and no proprietary interests for faculty, and there must be an endowment for the medical school (Weiskotten et al. 1940,
Chapter One).
The Flexner report showed no mercy in exposing incompetence. Schools with inadequate facilities, curriculum, and faculty were notified of their shortcomings. Fifty schools required only a high school diploma for admission prior to 1910 (Lippard 1974). The
41 level of variation among schools disturbed Flexner, and he was particularly appalled by the financially weak schools. Instead of advocating financial support for struggling institutions, his report recommended closures for them and support for medical schools that were already showing signs of excellence (Ludmerer 1985).
The Flexner report was not a federally-enforced set of regulations or demand for closure. One would assume that this fact would have made the document powerless.
However, Flexner’s recommendations were widely accepted among influential portions of the public for two reasons: philanthropists and foundations followed his report recommendations when donating funds, and progressive-minded journalists blasted the low- scoring institutions and built public support for the suggested reforms (O'Brien, Cooke and
Irby 2010; Schmidt et al. 1989). Administrators at threatened medical schools tried to fight a losing battle after the report was published. Many struggling schools had experienced financial hardship over the long-term and were behind because of factors beyond their control (Kaufman 1976). When the press, and then the politically active public, accepted the conclusions of the Flexner report, the weak, underfunded schools faced negative publicity
(Ibid.). In addition, state legislatures began to utilize denial of licensure to enforce quality standards (Lippard 1974). Because there was no single mechanism of enforcement, and change came through funding, licensure, and public opinion, it is not clear that the report was fully to blame for the closures, but many scholars attribute school closures to the Flexner
Report (Kaufman 1976).
The number of medical schools decreased after the report was published. Around thirty percent of the 155 schools closed their doors (O'Brien, Cooke and Irby 2010). In the
United States in the decade following the report, 46 of the 131 schools closed or joined other
42 institutions (Lippard 1974). Kaufman points to public sentiment against immigrants in the early 1900s as an underlying motive for promotion of Flexner’s recommendations (1976). By reducing the number of medical schools and increasing the standards, those in power could keep immigrants (often poor and less educated) from attending medical school. He calls the closures a way to impose “...ethnic and religious quotas in American society” (Kaufman
1976, 173). It is important to note that reduced access for minority students eventually became reduced access for minority patients.
Interestingly, in 1924, Flexner re-evaluated medical schools to assess the impact of his earlier report. He found that the struggling schools, particularly in the West and South, where most were located, had largely been eliminated (Kaufman 1976).33 Adoption of the recommendations contained in the report set medical education on a path toward quality over quantity, and philanthropists stepped in to fund the transformation.
While Flexner was clear on his mission, one author suggests that medical school administrators misunderstood his goals, making the report inaccurate. Kaufman (1976, 168) asserts that college administrators sought financial gifts. Instead of impressing Flexner, their hope for additional funding led them to exaggerate their need. The need-based grants that they surmised the Carnegie Foundation would be distributing were never part of the intent of the report, and this could have led to inaccuracies in the report.
Perhaps Flexner had a pre-existing bias against alternative non- “German method” schools. O’Malley put it this way: “The pervasive influence of Hopkins on the Flexner report is very evident” (1970, 509). Some argue that the report initiated a domino effect resulting in the closure of weak medical schools. Kaufman cites a letter from James J. Walsh of Fordham
33 Kaufman identifies inadequate public education in the South as an underlying institutional problem that made rigorous requirements impossible to meet (1976).
43
University to Henry S. Pritchett, the first president of the Carnegie Foundation for the
Advancement of Teaching, “In effect, then, Flexner was blaming the other colleges for their failure to do something that was virtually impossible - to reform without endowments, adequate clinical material, and so forth” (Kaufman 1976).34
Others point to evidence of a weeding out process beginning prior to the publication of the report, absolving Flexner of responsibility, and giving credence to journalist and philanthropic manipulation (Starr 1982). Starr cites evidence that the decline in access began before the publication of the Flexner Report (1982). Proprietary schools began to see declining enrollment, resulting in financial struggle and closure beforehand (Ludmerer
1985). Schools with good reputations and solid foundations attracted more money, while weak or proprietary schools diminished. Nonetheless, for a non-government report, Flexner’s report had incredible influence.
Lower-tier medical school administrators observed wealthy urban students in attendance at prestigious schools while poor, rural students enrolled in substandard schools.
They concluded that this was because wealthy students had more rigorous secondary education. The issue of inconsistent early education had persisted over the decades. And, they pointed out, rural students who left to attend reputable urban schools would rarely return. The cost of medical education was so high, they would be compelled to stay in more lucrative urban centers for the purpose of economic self interest (Kaufman 1976). They pointed out that there was little concern for rural or minority physician access in the Flexner report, and too much emphasis on specialties (Ibid.).
34 See James J. Walsh to Henry S. Pritchett, New York, March 28, 1910. Fordham University files, and J.W. Holland to Flexner, Philadelphia, January 5, 1909, Flexner Papers, Jefferson Medical College file.
44
One professor wrote a letter in defense of Chattanooga Medical College asserting its importance despite the lack of research, since the school supplied the local farming communities with general practitioners (Kaufman 1976, 171).35 These rural medical school administrators predicted a decrease in rural general practitioners that would result in physician shortages (Kaufman 1976). They noted that graduates from Johns Hopkins and other university schools who had invested more time into their training would be unlikely to choose practice in a low-compensation area such as the South and rural communities (Ibid.).
Flexner unreservedly advocated for medical school location in large cities because of the abundance of “clinical material” - i.e. patients (Kaufman 1976, 169). He did not look at regional differences in access or compensation. In contrast, he stressed the need for standardization and quality across the nation (Kaufman 1976). Markowitz and Rosner argue that there was a larger conflict over reform going on between two distinct groups of physicians: eastern university medical school doctors and individual private practitioners
(1973). Eastern medical school doctors had the AMA and the Carnegie Foundation on their side. The issue of medical students being disproportionately wealthy has remained over the long term. Fein and Weber found that poor students make up a small percentage of medical school graduates (1971). It is possible that students having to cross state lines or relocate for highly competitive medical training may be contributing to regional physician deficits. As a result, the system is denying access to rural students at lower socioeconomic levels - as was the case in the early 1800s. The hospital, medical school, and university affiliation was facilitated by the evolution of cities, and a pattern of physician concentration in highly populated areas continues to this day (Council on Graduate Medical Education 1998).
35 See Copy in Flexner Papers, Chattanooga file.
45
It is indisputable that the Flexner Report was proactive in promoting higher standards, but improvements came with a cost. The new ideal was so expensive, proprietary schools began to phase out. Medical education was no longer a profit making business - especially when licensing laws mandated a high level of training (Starr 1982).
1920s to Today
After the Flexner Report was published, costs began to surge due to research, personalized instruction, and efforts to follow the German method. Revenue came from a variety of sources: tuition, state appropriations, and parent university resources (O'Brien,
Cooke and Irby 2010). By 1920, state legislatures and universities were typically funding undergraduate medical education (Ibid.). In addition, wealthy individuals created foundations at the beginning of the twentieth century and their support of general education, medical education and medical research had tremendous impact on health care in America (Glaser
1992). Momentum built for large-scale philanthropy as a result of the Flexner Report.
Between 1902 and 1934, nine major foundations gave $154 million to medical education and research (Ludmerer 1985).36 Similar to land-grant universities, initial investments in medical schools paid off exponentially by drawing outside support.
In their 1947 Survey of Medical Education, Deitrick and Berson identify World
War II and its aftermath as a significant and pivotal point in American medical education, almost on par with the Flexner Report. No one anticipated the increase in demand that would
36 Some notable philanthropists who created foundations at that time were Andrew Carnegie, John D. Rockefeller, and Edward Harkness. John D. Rockefeller’s philanthropy heavily relied on Flexner’s input to direct funds to worthy medical schools through his General Education Board (Glaser 1992). Rockefeller’s General Education Board supported medical education at Vanderbilt, Washington University, established the University of Chicago medical school and others. The Rockefeller Foundation supported medical research. The Rockefeller’s Commonwealth Fund established new schools post-WWI (Lippard 1974). The Duke Endowment established Duke University and gave financial support to Duke University Medical Center.
46 arise from the population explosion after WWII (Kaufman 1976). During the war, the demand for physicians rose as the number of wounded and dying soldiers overwhelmed the health care system (Deitrick and Berson 1947). The number of physician graduates was not enough, so programs responded with extended school years and abbreviated, more intense training. At the same time, the number of medical school faculty decreased because of the military service of faculty. The number of physicians was lagging, but the growth of medicine in terms of research and development was profound. By the 1950s, medical schools had university status and public demand for services was growing (Ibid.).
During World War II, the federal bond with medical education tightened.
American medical schools participated in military research, facilitated by federal funding.
Some compressed curriculum requirements to increase the number of practicing physicians at a time of need (O’Malley 1970). Federal aid to medical research went from $87 million in
1947 to $2.05 billion in 1966 (O’Malley 1970, 517). Research support continued, building a stronger relationship between the federal government and the medical science community
(Lippard 1974). This would influence medical education in the following decades. From
1960 -1980, federal support for medical education rapidly increased (Schmidt et al. 1989,
Chapter Two).
Considerable growth took place after World War II with the passage of the GI Bill of Rights. The G.I. Bill of Rights provided financial aid for veterans to attend medical school. For the first time in American history, high numbers of students with limited incomes were attending medical school (Lippard 1974). Subspecialization was supported by the government through grants for postdoctoral fellowships (Lippard 1974).37 In 1966, medical
37 Awarded by the National Institutes of Health.
47 schools received $600 million from the National Institutes of Health, and this was only part of federal support for medical schools that year (Lippard 1974). Because of the new funding, the nation’s schools saw a growing number of faculty, increased research emphasis, and new schools. Fifteen new medical schools were founded from 1960-1969 (Lippard 1974).38
Research led to expertise and narrowed specialization, but there was a concern that physicians would lose a concept of the “patient as a whole” (Lippard 1974). The new emphasis on the biological and technical aspects of medicine were potentially dehumanizing medicine (Schmidt et al. 1989). Family medicine and primary care were once the dominant path for doctors, but that was changing. Federal support for research led to the tyranny of research, and the narrowing of physician expertise. Although the division of labor is appealing, it is up for debate whether important health decisions can be broken into subsections and given to individual specialists in an efficient or patient-promoting way
(Schmidt et al. 1989, 27). Since one coordinating general-practice physician often creates a coherent plan for the patient, ideally, important decisions would be made by that professional. As a result of specialization, certain departments were elevated or marginalized based on research performance because performance was tied to funding (Lippard 1974). In the late 1960s there was an increase in full time faculty, specialization, and graduates
(Ibid.).39 The looming physician shortage, however, showed that reforms were not getting to the root of the issue.
38 University of New Mexico, Brown University, Medical College of Ohio at Toledo, Michigan State, Rutgers, Louisiana State at Shreveport, University of Arizona, Pennsylvania State University, University of Hawaii, University of Texas San Antonio, Mt Sinai School of Medicine, University of CA Davis, University of CA San Diego, University of Connecticut and University of Texas Houston (Lippard 1974). 39 Of note, an alternative path was taken in some other countries. Some adopted policies to maintain a separation between medical research and universities (Lippard 1974).
48
Widespread awareness of the physician shortage took hold in the 1950s, but costs were burdening schools and tying their hands. From 1927 to 1950, the cost of educating a medical student increased 250% and the cost of operating a medical school had increased by around 700% (Deitrick and Berson 1953, 19). A movement toward medical centers had begun in the 1930s, and medical centers were becoming ever-expanding service centers where costs continued to rise (Deitrick and Berson 1953). By 1959, the need for physicians necessitated action. One author notes three things that led to the increased need: rapid population growth in populations with higher need (very young and very old), an increase in health care service use, and competition for physicians in research and teaching (O’Malley
1970).40 In addition, pre-Flexner era physicians were reaching retirement age, and rural areas were experiencing reduced access to physicians (Lippard 1974). Facilities were deteriorating, and medical schools were running out of space.
In response, Congress passed the Health Research Facilities Construction Act
(HRFCA) in 1956, providing matching funds for equipment and construction in non-federal research institutions (which were primarily medical schools) (Ibid.). Following a similar pattern of initiation and momentum, when the federal government stepped in, other sources stepped up. The state legislatures, foundations, and individual philanthropists followed suit and began to fund medical schools (Ibid.). Many schools were able to expand and improve as a result of the HRFCA. Six new schools were founded in the 1950s (Ibid.).41
In the 1960s, public pressure to increase diversity in medical schools (ethnic, economic, and geographic backgrounds) and demand for higher numbers of physicians
40 Based on the content of The Bane Report (O’Malley, 98, xiii). 41 The number of medical schools in 1960 was at 86, unchanged from 1920, because some had closed and others opened (Lippard 1974).
49 contributed to more growth (Lippard 1974). From 1920-1970 the number of physicians graduating per year in the United States dramatically increased from 3,047 to 8,367 (Ibid.).
There was increasing concern among the public that medical education should be available to all (Ibid.).42 Specialists were multiplying, and, without a national health system, there were no methods to control or manage types or frequencies of specialists (Ibid.). President Johnson signed the Social Security Amendments of 1965 into law, creating Medicare and Medicaid.
This was a significant policy step that increased access for many poor and elderly Americans but also increased demand for physicians. By 1967, 42 four-year public universities were producing over half of America’s medical students (Fein and Weber 1971).
Medical students were attracted to city locations for association with hospitals, and specialist training. Not surprisingly, this theme continues today and is a potential factor behind HPSAs. Lippard observes that medical schools were usually located, “...in poorer sections of larger cities” as the 1970s came to a close (1974, 32). Public concern over regional physician shortages increased (Lippard 1974). To address shortages, some programs offered early finish programs in the 1970s. Instruction ended one year earlier through a reduction in student vacation time (Ibid.). By this time, there were 101 medical schools with
12 more underway (Ibid.). Funding was becoming more and more complex as the great financial need required multiple sources of support. Support was sought from distant sources such as the federal government as local support was not adequate.
Physician access projections were not always accurate and were not always heeded. In 1980, the Graduate Medical Education National Advisory Committee actually predicted a surplus of up to 50,000 doctors by 1990 (Wills et al. 1980, v). Nine years later, 28
42 A theme also seen in the land-grant movement.
50 million people in the United States did not have “reasonable access” to health care (Schmidt et al. 1989,18). The concern with an excess number of physicians was not new, and may have come from within the profession. In the early 1900s, when the number of nurses skyrocketed and physicians perceived their incomes to be low, Markowitz and Rosner maintain that limiting the number of physicians became an obsession within the profession (1973). The concern was that numbers needed to be limited to keep the market system working in favor of physicians. Demand for services would stay up and allow for higher charges. They also suggest that the Depression Era was financially difficult and led physicians to want limits on physician numbers.
Markowitz and Rosner argue that, as a profession, physicians have wanted to restrict their numbers for their own financial gain (1973).43 They argue that the loudest physician voices at pivotal times have been East Coast, university-affiliated urban physicians who were the most influential. “The chief mechanism which doctors have used to secure for themselves a high status and income has been the limiting of the number of physicians in
America” (Markowitz and Rosner 1973, 84). They point to medical centers with their hospital, school, and university affiliation as a way to centralized expertise and reduce potential competition between health care providers. They argue that the Flexner Report intended to increase status and protect elite, financial incentives toward efficiency and
“scientific management” including emphasis on research, at the expense of the patient. These physician objectives were promoted by philanthropists such as Rockefeller and Carnegie, using the Flexner Report and the development of urban medical centers.
43 They assert that this was successfully accomplished through the interest group the American Medical Association, representing their interests at all levels of policymaking.
51
Rural medical schools on university campuses had particular obstacles in terms of funding, which made survival more difficult (Markowitz and Rosner 1973). With the three- part need for a hospital, medical school, and university, funding could be a challenge in sparsely populated states. Associated hospitals were hard to come by, and were often owned by the university, and necessitated state funds.44 State and county medical societies often championed the cause of state-supported university medical schools (Lippard 1974, 116). In contrast, urban schools had a superfluous number of accessible, unaffiliated hospitals. For example, Harvard medical school administrators (in the Boston metropolitan area) had a variety of local hospitals to choose from for hands-on physician training in their program.
Another potential explanation of the failure to increase graduates is unregulated specialization. Specialists focus on a narrow skill-set and organ system in the body, while general practitioners coordinate care, encourage prevention through physicals, manage medications, and perform routine and emergency services. Even when physician numbers increase, they will not alleviate the primary care shortage if the majority are specialists. The trend among medical students is to specialize, causing the number of primary care physicians to be on the decline (Whitcomb 2005). Specialization requires more years of training, and often more debt which may encourage specialists to practice in well-paying urban areas with large populations to support their more narrow practice.
As indicated in Table 1, the number of specialists (non-primary care residents and fellows) grew rapidly between 1960 and 2009. This growth continued even after warnings from the Institute of Medicine that there were too many specialists and not enough general practitioners (Schmidt et al. 1989). Medical school expenditures continued to increase, while
44 These included, but were not limited to: the University of Virginia, the University of Michigan, and the University of Iowa (Lippard 1974).
52
Table 1. U.S. medical school growth, 1960-1961 to 2008-2009 Characteristic 1960-1961 2008-2009 No. of Medical Schools 86 126 No. of Medical Students 30,288 76,202 No. of Residents/Fellows 14,417 108,176 No. of Full-time Faculty 11,224 128,683 Medical School Expenditures $437 $78,856 in Millions
(Table published in Miller et al. “Perspective: Follow the Money: The Implications of Medical School’s Funds Flow Models.” Academic Medicine vol. 87, no 12. 2012) Data source: Association of American Medical Colleges. AAMC Data Book. Washington, DC: Association of American Medical Colleges; 2010.
funding came from a complex variety of sources. As the number of specialists increased, the financial complexity increased as fragmented funding sources also increased. Today, general practitioners are in short supply in the United States as evidenced by provisions in The
Patient Protection and Affordable Care Act of 2010. This may be the result of the rapid and unrestrained specialization and spending during this time period.
Because physician training requires residency after medical school, physician location can be influenced by residency availability. A student who wants to complete their residency in the same state they went to medical school can face fierce competition because of limited slots. Some states have begun addressing the shortage by funding more residency slots, but the federal government is the largest source of revenue for residencies through
Medicare (Beitsch 2015). The Balanced Budget Act of 1997 sets the limit for Medicare spending on residency slots, so any increases are budget increases for states or healthcare institutions (Ibid.). This makes progress slow since increased spending is always
53 controversial and the deliberative process takes time. It has also created a bottleneck effect because medical student numbers are greater than residency slots (Ibid.).
The Physician Shortage and Medical Schools In the United States Today
Increased awareness of limited residency slots may, unfortunately, take the focus off of medical school as part of the health care access solution. Some argue that that medical schools are peripheral in the recruitment and retention of rural physicians (Cohen 1999).
However, multiple studies refute this (Rabinowitz, Diamond, and Markham et al. 2008;
Wendling et al. 2016; Rabinowitz and Paynter 2000). While physicians are free to choose where they want to live and work, and medical school is just an intermediary step leading to residency, the location and attributes of medical schools may influence a physician’s decision about where to practice. According to the Association of American Medical Colleges
(AAMC), physicians who attend medical school and complete residency in the same state tend to stay (AAMC 2016). In fact, according to the online 2017 edition of the AAMC
Report on Residents, sixty-eight percent of doctors who finish all their training in one state end up practicing there. This means that the odds are against students from rural areas, in terms of returning to practice in their local area.
A recent study conducted in Japan confirms that medical school location and attributes are important. Kamitani et al. looked at retention within the geographic area of
Japanese medical schools to examine the effectiveness of government policy aimed toward reducing shortages (2015). The Japanese government intentionally built medical schools in areas of need (one in each prefecture) in the 1970s and 1980s in response to physician maldistribution. The sample size in this study was 168,594 physicians. They were chosen
54 from the lists of students who had graduated from these schools. Results indicated that the total number of physicians in Japan went up over time, but the distribution remained geographically uneven. The intent was to increase retention, and the study analyzed the effect of the age of the school and the school’s funding sources. Half of all graduates practiced in the region where their medical school was located, and schools in urban areas had higher retention rates. Medical school attributes such as age of the program and public vs. private were linked with retention (2015). The results indicated that newer, private schools had lower geographic retention of graduates than older, public schools. Private medical schools were more expensive, so students were willing to leave for higher salaries. Urban school regions attracted physicians because of professional connections and support and familiarity with urban patient populations. This research cites other studies showing that publicly funded and locally situated medical schools tend to supply rural areas with physicians, although there are high levels of variation.
The Physician Shortage Area Program (PSAP) of Jefferson Medical College in
Philadelphia, PA was established in 1974 to help address the rural shortage. It is one of several programs seeking to use program design to remedy physician shortages in rural areas.
Data from this program indicate measurable success in terms of rural retention (Rabinowitz,
Diamond, and Markham et al. 2008). Rabinowitz et al. analyzed 3,400 students from the graduating classes of 1978-1993 to see what variables contributed to retention of rural primary care physicians (2008). They found programs that focused on students with rural backgrounds and rural practice plans were most successful at seeing higher rates of physician retention in a rural locations. The study looked at nineteen variables. They found five independently predictive variables for rural retention: rural preceptorship (rural physician-
55 student mentorship), growing up in a rural area, rural college attendance, being in the rural
PSAP program, male sex, and NHSC (National Health Service Corps) scholarship.
Another study focused solely on medical school program characteristics as an important factor to retention of rural doctors and concurred with the Rabinowitz, Diamond,
Markham et al. findings (Wendling et al. 2016). In 2000, Rabinowitz and Paynter examined seven American medical school programs and found that medical schools are essential to supplying rural areas with physicians because they are critical to providing rural residencies and fellowships, which contribute to rural physician numbers. In addition, a systematic review analyzing recruitment and retention of general practice physicians in rural areas confirmed that pre-medical school factors, such as rural background, and training experiences were strongly correlated with rural retention (Brooks, Walsh, and Marden et. al.
2002).
Early experiences (i.e., rural background) have a tremendous impact on the ultimate location a physician chooses (Rabinowitz, Diamond, Markham et al. 2001; Laven and Wilkinson 2003). In a systematic review of 12 studies, rural background correlated with rural practice for 10 out of the 12 (Laven and Wilkinson 2003, 277). Brooks, Walsh and
Mardon et al. also confirmed that rural background and rural residency rotations are significant in terms of recruitment and retention (2002). Given the importance of early experiences, post-training efforts may be ineffective because they are too little too late
(Pathman, Konrad and Ricketts 1992).
There is consistent scholarly literature on nature vs. nurture in terms of physician recruitment and retention in rural areas. The effect of outside influence has been studied when it comes to a physician’s decision to practice in a rural area. Both nature and nurture
56 are important. For nature, characteristics such as being male, appear to influence retention
(Rabinowitz, Diamond, and Markham et al. 2001). Another assessment of 21 quantitative research articles concluded that early influences matter when it comes to rural retention
(Brooks, Walsh, and Mardon et al. 2002). Rural birthplace, rural university education, and medical school performance, however, also impact rural retention, indicating that outside influence can be effective (Rabinowitz, Diamond, and Markham et al. 2001).
Certain populations are experiencing reduced health care access as a result of economic, cultural, and political forces beyond their control. Inner cities and rural populations in the United States suffer from a long-standing physician shortages (Pusey
1925; Eberhardt, Ingram and Makuc et al. 2001). Citizens and residents in rural areas are relatively underserved, are more likely to experience poverty, and are less healthy (Council on Graduate Medical Education 1998; Eberhardt et al. 2001). Rural students often have to relocate to attend medical school, and they may not return to their hometown or other rural areas. At the same time, patients in those same regions struggle with inadequate access to care. One author described the disparities as “suffering” indirectly inflicted through the distribution of medical schools (O'Brien, Cooke and Irby 2010, 19). With limited access, limited means, and increased distance from tertiary care centers, health care decisions can be subpar for rural patients (Meden 2002).
There is a recurring theme in American medical education: opportunity, expertise, quality, and efficiency have been associated with metropolitan areas (Markowitz and Rosner
1973). Given the institutional maldistribution, reduced access to health care almost seems expected for areas without training resources. Yet, there is no discussion about the geographic location of medical schools - even to this day. New schools are opening in urban
57 areas, and even the rural programs at schools like Jefferson Medical College in Philadelphia are not attempting to relocate. Location may matter since equal access to medical school
(required for physician practice) is linked to equal health care access (Council on Graduate
Medical Education 1998). According to O’Brien, Cooke and Irby, the uneven geographic distribution of medical schools is contributing to an overall inability to meet rising demands for medical care nationally (2010).
The historical connection between eastern states (and their cities) and medical schools is one worth studying in light of the national physician shortage. “Across the U.S., the number of medical students in each state tends to correspond to population, but there is a disproportionately large number in the Northeast, where medical education got its start in the late 1700s” (Beitsch 2015). Perhaps there is a relationship between medical school placement and reduced access to doctors at the state level. States that have predominantly rural counties are politically, culturally, and economically distinct from higher population states. If geographic regions with reduced access to health care (i.e., physician shortage areas) have been systematically overlooked in terms of medical school placement and investment, and if physician access is a public good, then one could legitimately assign some level of responsibility for health care disparities on those who “establish justice” in American society
- the people and those who represent them as policymakers. Given the persistent disparities in health care access in the United States, and evidence of successful rural medical school programs, it is important to examine the location of medical schools and the relationship between school location and physician access. I am seeking to add to the literature in this research by testing whether there is a relationship between physician access and the number of medical schools in a state.
58
The impact of historical patterns of decision-making is significant when addressing current and future health care needs in terms of medical education policy. The physician shortage in rural areas is a significant policy concern for the United States today.
The history of the distribution and number of American medical schools makes the question posed at the beginning of the chapter relevant today. Are American medical schools sufficient in terms of physician supply? It is important to investigate whether the nation has reached Fox’s fourth stage of sufficiency in medical education (Fox 1927). My research question is: does the physician/population ratio decrease as the number of medical schools in a state increases? Further, do rural state populations have comparatively less access to physicians than their urban counterparts? And lastly, is there a similar trend in terms of socioeconomic status?
59
CHAPTER III
DATA AND METHODOLOGY
Introduction
In this chapter I will lay out the methodology for testing the hypothesis that the more medical schools a state has, the more physicians per capita there will be in that state.
Using regression analysis, I analyze the preliminary data and then control for population density and poverty - since both factors have limited medical school placement historically.
In addition, I explain why I use the particular data sets I selected for this analysis. Before I provide an explanation of the variables and the outcome in terms of the hypothesis, however,
I will discuss my methodological approach.
Research Approach
I examine the relationship between medical schools and physician access and look at the effect of population density and poverty on the relationship between these variables. I expected to find a statistically significant, positive association between the number of medical schools and in-state physician access, as I define it. In state physician access is defined as the total number of physicians per capita. That is, I expect that the more medical schools a state has, the higher the rate of physician access will be. I also expect to find a positive association between population density and physician access. Specifically, the higher the density of population distribution, the higher the rate of physician access will be. Lastly, I anticipate a significant negative association when controlling for population density and
60 poverty in states. As the proportion of the state under the federal poverty threshold increases,
I expect physician access to decrease.
Data and Methodology
To test my hypothesis, I use secondary, publicly available data from government and regulatory sources including the United States Census Bureau, the Association of
American Medical Colleges (AAMC), the Liaison Committee on Medical Education
(LCME), and the Commission on Osteopathic Accreditation (COCA). The data are from reliable sources and are sufficient for this level of analysis because the sources are either accrediting bodies or divisions of the federal government. In addition, all values were easy to obtain at the state level with little to no cost. I chose two variables to address my hypothesis: the number of medical schools per capita and the physician/population ratio. I include only accredited medical schools, using those listed by the LCME, which grants Doctor of
Medicine (MD) medical degrees, and the COCA, which grants Doctor of Osteopathic
Medicine (DO) medical degrees, since both MD and DO degrees render a person eligible for a license to practice medicine as physicians in the United States.
The unit of analysis is states within the United States. This unit of analysis was chosen because data on active physicians and medical schools were readily available, and not costly to obtain at this level. Limitations of this level of analysis include that it is imprecise since it does not examine the variation at county level. It does not take geographic size, location (such as coastal or landlocked) or number of urban centers into account. County data would be helpful because it would increase the number of data points in the unadjusted analysis and perhaps indicate statistical significance. Also, county data would allow for a more detailed look at rural vs. urban disparities. In addition, some might find the fact that I
61 use data from multiple years problematic, but these data do not fluctuate often since they are tied to the decennial census and the number of medical schools.
Dependent Variable
Physician access is defined as the number of physicians per capita, and it is a ratio scale variable. The 2016 Association of American Medical Colleges (AAMC) Data Book data were obtained including the total number of active physicians per state. United States
Census Bureau data on state population estimates for 2014 were used to determine state populations. Population estimates included all individuals living in a state. I then calculate the physician/population ratio for each state.
Key Independent Variable
I define the independent variable as the number of medical schools per capita in each state. I do this to adjust for variation in state populations and to have a measure of medical school density in each state. To calculate the number of medical schools, COCA accredited DO schools were added to LCME accredited MD programs. Data on LCME schools were listed in the LCME directory, last updated in February 2017. All MD programs, including preliminary and provisional status programs were used. Data on COCA schools were obtained from the American Osteopathic Association in May of 2017 and included multiple locations (branch locations) for single institutions as well as provisionally accredited programs.
Other Independent Variables
I control for population density using data from the U.S Census Bureau.
Population Density (per square mile) was given by county for 2010, so I calculate the sum of all population densities for all counties for each state, and the sum of land area which was
62 given in square miles by county for all states. I then calculate statewide population densities.
I used 2010 data because that is the most recent census data available.
I also control for poverty using the 2016 United States Census Bureau American Community
Survey 1-Year estimates of individuals below the poverty level by state. These were percentages. According to the US Census Bureau, the federal poverty threshold for one person is an income of approximately $12,000 annually and for two people approximately
$16,000 annually (USCB 2016).
Methodology
I conduct two regression analyses to test the relationship between the variables in my hypothesis - one with no control variables, and the other with two control variables. The control variables are population density and poverty. First, I conduct an unadjusted regression analysis using the dependent variable of physician access and the key independent variable of medical schools per capita using the statistical program Stata. I examine the regression line, p value, standard deviation, and correlation coefficient and discuss these results in the next chapter. Then, I use multiple regression analysis, adding the two other independent variables as controls: poverty and population density. I also examine the regression line, p value, standard deviation, and correlation coefficient in those results.
I will further discuss data interpretation in Chapter Four and include the results of both the initial regression and the multiple regression analysis that controls for population density and poverty using the statistical program Stata. The criterion I use to accept the hypothesis is the 0.05 level of significance. I will explain the results in detail in the next chapter.
63
CHAPTER IV
RESULTS AND DISCUSSION
In this chapter, I test my hypothesis that the more medical schools a state has, the more physicians per capita there will be in that state. I provide the results of the data analysis including the two control variables. I then discuss the interpretation of these results.
Hypothesis
I analyzed the data by running a regression analysis using Stata and the results are indicated in Figure 2. In the unadjusted analysis, the p-value was 0.1643 at a p-value threshold of 0.05. This indicates that the null hypothesis could not be rejected. It appears that the number of medical schools in a state is not associated with physician access in states, and my hypothesis was not supported by these data. There was a positive trend, however, as indicated in Figure 2. It is also highly likely that I did not find statistical significance because
I only had 50 data points.
After finding a statistically insignificant relationship in the preliminary analysis, I added the control variables.45 In an effort to further examine the relationship between medical schools and physician access, I controlled for population density and poverty.
I ran a multiple regression analysis in Stata and the results are indicated in Table
2. The p-value for both population density and poverty was 0.00. The p-value for medical
45 It could be that residency and graduate medical education (GME) - which follow medical school graduation as the next step in training - location has more of an impact on physician retention, or there are other factors I have not considered. Other factors will be discussed in Chapter 5.
64
Figure 2: Number of Medical Schools and Physician Access Per Capita
schools per capita was 0.015. All three of these findings were statistically significant because they were below the 0.05 p-value threshold for significance, and thus supported my hypothesis. The low p-values indicate a very strong correlation between all three variables, and the standard error values are low, indicating statistical accuracy. Population density is positively associated with physician access after controlling for poverty and the number of in-state medical schools. This indicates that individuals in urban areas have higher levels of physician access per capita. Poverty is negatively associated with physician access after controlling for population density and the number of medical schools. This indicates that states with a higher proportion of low-income residents experience reduced access to physicians per capita. Even the number of medical schools was significant, showing that the preliminary analysis was not an accurate indication of the complexity of physician access.
Medical schools per capita increases the most per unit of physician access as indicated by the coefficient estimates. The significance of this finding is in the indication that barriers to
65
Table 2. Predictors of physician access (physicians per capita) in states
Variable Coefficient Estimates (SE) p
Medical schools per capita 0.03556 (0.014) 0.015 Population Density 0.00053 (0.000) 0.000 Poverty - 0.06695 (0.017) 0.000
physician access in relatively rural and low income states do in fact exist. The number of medical schools in a state does have an impact on in-state physician access. The controls, however, indicate that wealth and population density increase the likelihood that states are more likely to have medical schools.
In addition to the historical record, another data set that supports the relationship indicated in this study is the percent of a state’s practicing physicians who graduated from an in-state medical school, provided in the AAMC 2016 data book. The numbers range from the lowest in New Hampshire (with only one medical school) at 10.4%, to the highest percentage in California at 62% (with 11 traditional medical schools and 2 osteopathic medical schools).
As of 2016, California, Texas, and New York had the highest number of medical schools in the nation. Based in this information, it appears that doctors are likely to practice in the area they went to medical school. Since California and Texas have so many medical schools and such high state populations, perhaps they have more funds for schools than states with fewer people. States certainly justify funds for medical schools as a way to increase access among their residents. However, a county level analysis may challenge this relationship, and
California and Texas also have very large populations which could reduce the effectiveness of each school per capita.
66
Discussion
I predicted that as the number of medical schools in a state increased, the physician/population ratio would increase. There is no support for my hypothesis in the preliminary analysis, but allowing the controls to have their own effect on the outcome reveals a strong correlation. The preliminary results are an indication that the sample size of fifty is very small, and that other factors indicate the association of medical schools and physician access with urban areas. More medical schools means a higher supply of physicians in that state particularly for wealthy and urban states. This makes sense because medical schools are costly to run and establish and have been historically associated with urban areas as was established in Chapter 2.
One limitation in this study is the conceptualization of physician access I use. It is an overgeneralization to say that physician access is based on the number of physicians per capita in a state. There are several reasons why a head count is not an accurate conceptualization of access. First, physician specialty varies. For example, there could be forty pediatricians in a location but their presence does not increase access if there is a high proportion of elderly individuals in the population in that area. In addition, physicians vary in their capacity. Some see patients in five-minute appointment slots, while others have lengthy office visits. Physicians also vary in what insurance they accept, creating what some call a two-tier system. Medicaid patients, for example have less access to physicians because of physicians who do not accept Medicaid due to relatively low reimbursement rates and no requirement to accept those patients. Lastly, non-physician clinicians provide access, particularly in rural areas and their remediation of lack of access is not taken into account in this study.
67
Another limitation of my study is the small sample size of 50 which was limited by the number of states. I am restricted to this number because I do not currently have the ability to retrieve data at the local or county level. Along with this constraint is the inability to analyze the data at the regional level and/or perform a time series analysis. My control variables were also limited by state-level analysis. Although data at the county level are readily available, I did not use those data to maintain consistency in the analysis.
Yet another limitation, albeit not methodological, is that realistically, a physician’s path toward professionalization begins with high school (or earlier) and progresses to medical school, then residency, sometimes fellowship, and eventually practice.
This study looks at one step in the path toward professionalization, and the impact of the other steps along the way are also highly relevant. The distinct impact of physician graduate medical education (GME) in contrast to medical school training is important because GME programs are largely funded by the federal government with funds from Medicare and
Medicaid (O'Brien, Cooke and Irby 2010), while state legislatures and other sources allocate funds to in-state medicals schools. This will be discussed further in Chapter 5. In terms of medical education, however, lack of medical school access may be a disrupting step for rural students when there is no proximate school. In this context, it is important to acknowledge the impact of early educational experiences, such as those indicated in the literature
(Rabinowitz, Diamond, and Markham et al. 2008; Brooks, Walsh, and Marden et. al. 2002).
A study like this that focuses on medical schools to determine if medical schools impact physician access could expand and look at medical school characteristics, early experiences, and demographics, for example.
68
Conclusion
The results of the multiple regression analysis support my hypothesis, despite the low number of data points. Medical schools are more likely to be in densely populated states, and in states with a higher proportion of wealthy individuals. In summary, physician access and medical school numbers are reduced in rural and low socioeconomic status states. The shortage of physicians in rural areas is a huge policy problem for the United States. Citizens and residents in rural areas are largely underserved and are less healthy (Council on Graduate
Medical Education 1998).
The fact that physician access is lower in some states and is linked to population health status makes medical schools an important factor to consider - especially in light of the results of this research. According to O'Brien, Cooke and Irby, the uneven distribution of medical schools is contributing to an overall inability to meet rising demands for medical care nationally, rural and inner city communities are suffering according to these authors
(2010, 19). My results support this assertion.
In the next chapter, I discuss future implications and conclude with suggestions for further research.
69
CHAPTER V
CONCLUSION AND RECOMMENDATIONS
FOR FUTURE RESEARCH
Aims of Research
My objective in this master’s thesis was to provide state-level evidence that medical school location is a factor associated with active physicians per capita. In Chapter 1,
I explored a theoretical framework as it applies to health care access accountability. In
Chapter 2, I described the chronological patchwork of the nation’s medical school history and its potential impact on contemporary physician access. In Chapter 3, I focused on the methods I used for my research. In Chapter 4, I interpreted the relationship between medical schools and physician access and examined two additional factors: population density and socioeconomic status. In this final chapter, I will address the implications of my findings, the limitations of this study, and suggest directions for future research.
Summary of Findings
The first unadjusted analysis did not support my hypothesis. Since I had a small number of data points using state level data, I expected that to impede statistical significance.
A subsequent multiple regression analysis controlling for poverty and population density indicated that medical schools do impact physician access (as defined in this study) and poorer states with higher levels of population dispersion are more likely to be underserved. In other words, geographic location does matter. Densely populated, wealthy states have more
70 medical schools and more access to physicians. In summary, all three of these variables were found to be factors contributing to access.
Theoretical Implications
The significance of my findings was not only that the hypothesis was supported, but I established consistency between the historical record and the data: medical schools have an impact on health care access.46 Just as one would expect from historical analysis, inner cities and rural populations in the United States suffer from a long-standing physician shortages (Health Resources and Services Administration 2008; Pusey 1925) and the trend is worsening. The projected physician shortage in the U.S. is expected to be over 100,000 by
2030 (Association of American Medical Colleges 2017). In addition, aging baby boomers are contributing to a higher proportion of senior citizen or residents which result in a greater demand for health care (Association of American Medical Colleges 2017). The challenge that presents itself in light of this relationship, is how to define the moral obligations of society.
Of the three theoretical approaches, libertarianism, utilitarianism, and egalitarianism, only egalitarianism would discern a moral obligation in these results since egalitarianism emphasizes equality. For those who view physician access as an integral part of social responsibility, the barriers to access indicated in the analysis, including rural communities and those living in poverty, indicate a problem. Research suggests that health status indicators including rates of life expectancy, timely treatment, and preventative care all increase with physician access (Abrams et al. 2010; Macinko Starfield and Shih 2007).
46 Medical schools have typically been located in urban areas and are more densely scattered in the eastern half of the United States (see Figure 1). Barriers to access appear to also be rooted in historical precedents of myopic decision-making.
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Because rural residents are in poorer health, denying them access marginalizes rural and elderly patients, and elderly patients are a growing demographic in the United States
(Sanborn 2017).
My results would not concern advocates of libertarianism or utilitarianism.
Anyone who can pay can receive care and can travel if services are not in close proximity. In addition, the reality of concentrated physicians in densely populated areas is highly practical, according to utilitarians. The idea of securing access specifically for the elderly in small towns is not a priority for utilitarians, either, since investment in youth and higher volume brings the greatest societal returns.
The Dual Health Care System in a Theoretical Context
Using the egalitarian framework, the central issue at the heart of this research is the question of government-enabled “economic discrimination” that denies health care to the indigent (Cantor 1970, 903). Since it cannot be assumed that uncoordinated placement of medical schools promoted principles of justice, the relationship between placement and access was worth analyzing. The importance of this relationship was based on the framework set up in Chapter 1, and the egalitarian approach. Certain populations are experiencing reduced health care access as a result of economic, cultural, and political forces beyond their control. More narrowly, the lack of government coordination and decentralized power structure in medical education has led the nation to a physician shortage crisis today (Starr
1982; Association of American Medical Colleges 2017). Rural and inner city areas experience higher poverty rates, higher mortality rates, and overall poorer health (Eberhardt et al. 2001; Hart 2001). If, as Norman Daniels asserts, there is evidence that the health status
72 of a population is reduced due to institutional and governmental factors, justification for intervention would be established based on the moral principles of justice and fairness.
The dual health care system (access and quality care for some and very little left for others) is driven by multiple factors that perpetuate reduced levels of health among the poor. Medical schools are just one of many factors contributing to a dual health care system.
The low incentive for physicians to practice in underserved areas, including low patient volumes with fixed expenses, a high proportion of uninsured, compounding lack of support and camaraderie due to shortages, reduced access to cutting edge technology, perceived reduced quality of life, and low reimbursement rates are all significant factors. For example, there are characteristics of Medicare that make rural health care subpar (Heady and Beard
2002) such as significantly lower reimbursement in rural areas.47 It is not only Medicare that reimburses inequitably, but Medicaid. It is significant that physicians are entitled to deny care to individuals with insurance plans that have inadequate reimbursement rates, further reducing access for low-income patients. According to the California Department of Health
Care Services, as of January 15, 2018, the California Medicaid (Medi-Cal) reimbursement rate for a 99213 (a 15-minute evaluation and management appointment) is $24.00, while
Medicare reimbursement for the same code is $73.40 (Medicare Physician Fee Schedules
2018). Given this information, it is easy to see why there is little incentive for active physicians to accept Medi-Cal patients (Decker 2015). Medi-Cal patients are eligible for coverage because of their low income, and yet they have access to fewer physicians than
47According to Emanuel (2008), Medicare is plagued by politics causing slow change and a fragmented approach to revisions.
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Medicare patients in the same communities.48 For physicians coming out of their training with crippling debt, they will quite likely be attracted to areas with high reimbursement rates.
In addition, rural hospital closures and consolidations have increased over the last two decades due to cuts in funding.49 Rural hospitals have inflexible overhead expenses with reduced patient volume, fewer professional networks, and higher numbers of poor and elderly patients (Hart 2001; Eberhardt 2001).50
These factors contribute to a stigma surrounding rural areas as being underfunded, with little institutional support - not an attractive situation for new physicians. Poverty itself is a risk factor for poor health; the poor are more likely to be uninsured and neglected and suffer poor health (Eberhardt 2001).51 From this perspective, it appears that a decentralized institutional power structure has contributed to unjust conditions in the United States.
New Medical Schools - A Misguided Solution?
It is not just the underserved patient, but the underserved medical student that must be considered. Students experience unequal access to physician training. Students in states with few or no schools are forced to move for their training and this may have local impact. Existing literature indicates that rural exposure, including rural birthplace and rural university education, as well as rural clinical training impact rural retention (Wendling et al.
2016; Laven and Wilkinson 2003 ) yet rural students are unlikely to have a proximate
48 They are also more likely to face transportation barriers. 49 Two federal policies: the Balanced Budget Act of 1997 and the Medicare Prospective Payment System (PPS) of 1983. The PPS Medicare payment rate for rural areas is low and generalized, creating a disadvantage for rural hospitals (Heady and Beard 2002). 50 There are exceptions. Hospitals that are defined as Critical Access Hospitals are paid more by the federal government (Shi and Singh 2012). 51 Rural areas and inner cities are characterized by higher mortality rates (Eberhardt 2001).
74 medical school. Early influences matter (Brooks, Walsh, Mardon et al. 2002) and some medical school programs are already targeting the rural and underserved retention problem at the medical school level of physician training, but not in terms of location (Rabinowitz,
Diamond, Markham et al. 2001; Wendling et al. 2016).52
On June 27, 2013, California Governor Edmund G. Brown, Jr. signed a budget that gave the state legislature a green light to fund (annually for the next decade) a new medical school (Pittalwala 2013). The bill allocated an annual $15 million to the University of California Riverside School of Medicine (Pittalwala 2013). A compelling case for funding was made in Sacramento by Senator Richard D. Roth (D-Riverside) and Assemblymember
Jose Medina (D-Riverside) by framing the school as a solution to a particular problem
(Pittalwala 2013). That problem was a lack of primary care physicians in certain counties in
Southern California. The mission of UC Riverside was to increase physician diversity and access in the Inland Empire.53 UC Riverside is not the only institution, and California is not the only state, to encourage students to practice locally. Medical schools in Kansas,
Connecticut, and Massachusetts have similar incentives (Muckenfuss 2013). From 2006 to
2017, twenty new medical schools opened in the United States, and many of these schools
52 Including the following: UC Riverside practice-connected scholarships, Dell Medical School Department of Population Health, Maine Track MD Program, and Cooper Medical School of Rowan University with a vision including emphasis on underserved populations. 53 The goal would be facilitated by The school’s First 5 Riverside Medical Student Service Award Scholarship Program was established to incentivize retention. Medical students could receive up to $40,000 in return for at least five years of primary care pediatrics in Riverside County. Riverside County ranks among the worst counties in the United States for the number of primary care providers per 100,000 residents (Riverside County Community Health Assessment 2015).
75 highlight increased access to physicians as an ongoing objective (Barzansky and Etzel
2017).54
Medical schools with programs designed for rural practice have been around for decades now, and data indicate measurable success in terms of rural retention. In 2000,
Rabinowitz and Paynter looked at seven medical school programs and the positive impact they have had on rural retention. They found that seven schools with programs designed specifically to target rural need have effectively supplied rural areas with primary care and family practice physicians. The Physician Shortage Area Program (PSAP) of Jefferson
Medical College in Philadelphia, Pennsylvania was established in 1974 to help address the rural shortage. Rabinowitz et al. used 3,400 students from the PSAP graduating classes of
1978-1993 to see what variables contributed to retention of rural primary care physicians.
They looked at nineteen variables, and they found five independently predictive variables for rural retention: rural preceptorship, growing up in a rural area, rural college attendance, being in the rural PSAP program, male sex, and National Health Service Corps scholarship. They found that programs that focus on students with rural backgrounds and rural practice plans are most successful at seeing follow through and rural retention. This research, among other studies shows that medical schools are an important factor to retention of rural doctors
54 Number of Medical Schools (MD) went from 125 in 2006 to 145 in 2017. Central Michigan University College of Medicine and Geisinger Commonwealth Medical College, the University of California, Riverside School of Medicine (mission is to address health care professional shortages in Inland Southern California), Cooper Medical School of Rowan University (received grant of 1.75 million from HRSA to address the shortage of primary care providers in underserved areas), University of Texas at Austin Dell Medical School, University of Nevada, Las Vegas, Kaiser Permanente school of medicine opening in 2019, Washington State University’s Elson S. Floyd College of Medicine, CUNY School Of Medicine To Launch In 2016, Seton Hall University School of Medicine, Tufts University School of Medicine has partnered with Maine Medical Center in Portland Maine to create the Maine Track MD Program.
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(Brazeau 1990; Rabinowitz and Paynter 2000; Brooks, Walsh and Mardon 2002; Wilson
1967; Wendling 2016).
It is evident that changes are being made at the medical school stage to improve access disparities, but do they really address the needs of medically underserved areas?
Policymakers rely on medical schools to increase in-state access (Starr 1982; Rabinowitz and
Paynter 2000; Kamitani et al. 2015). Medical school graduates however, not only choose their specialty as an individual preference, they are influenced by medical school characteristics (Kamitani, Satoru, et al. 2015; Fein and Weber 1971), the multi-step training process, and urban settings.
European methods, training standards and institutional norms may have been detrimental to American health care in light of the persistent health care access disparities.
When Abraham Flexner’s recommendations were published, schools that trained women and minorities were closed. Schools that served rural communities were closed. They were subpar schools, but the nagging issue is that American geography and population heterogeneity were never considered. It is clear that rural areas have health care disadvantages linked to federal policies and institutional factors. Medical schools have evolved with medical centers in urban settings and their absence in rural areas continues, yet the expectation that they will be a pipeline for underserved areas continues. The question is, are program modifications effective in urban settings?55
55 Research indicates that early rural exposure and rural clinical training impact rural retention (Wendling et al. 2016; Laven and Wilkinson 2003 ).
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The Role of Graduate Medical Education
We have all these new schools, but we don’t have any new slots. The slots we do have are maldistributed, and that puts Florida at a disadvantage. Joan Meek Dean for GME and FSU Medical School (Beitsch 2015)
While new schools are opening up around the nation, medical residency spots remain largely unchanged.56 Graduate Medical Education (GME) spots are capped by the
Balanced Budget Act of 1997, which set the number of residency positions that Medicare and
Medicaid funds. The funding has not increased despite considerable growth in the United
States population.57 As new medical schools open, the number of graduates from MD and
DO programs are projected to surpass residency positions. There is limited research specifically on in-state retention and GME location, but Koehler, Goodfellow, and Davis et al. (2016) recently examined in-state retention at a Michigan GME institution. Of the primary care graduates, over half began practicing in Michigan after completing their training
(Koehler, Goodfellow, and Davis et al. 2016). A large number of graduates who completed their GME training in Michigan stayed in Michigan, and pre-GME training in Michigan increased that likelihood even more. The authors cited a study in New York with similar findings, including a relationship between in-state high school, medical school and GME training and retention (Armstrong and Forte 2014).
56 Multiple studies indicate that residency is a factor in rural retention (Rabinowitz, Diamond, and Markham et al. 2008; Wendling et al. 2016; Rabinowitz and Paynter 2000). 57 According to the US Census Bureau the US population increased by 70 million from 1980-2005.
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According the Association of American Medical Colleges, 67% of doctors who complete their undergraduate and graduate medical training in one state end up staying there to practice (AAMC 2011,47). Three states: Tennessee, Iowa, and Missouri, have too few in- state residency spots to accommodate their medical school graduates (Beitsch 2015) and a low number of residency positions correlates with low health care quality (Lucey 2017).
GME slots are primarily in teaching hospitals - which are mostly in urban areas, so residents have limited exposure to rural health care (Beitsch 2015) and are unfamiliar with serving this demographic.
Finally, there is the cost of training residents in terms of time and money.
Attending physicians are reimbursed at higher rates, due to Medicare’s reimbursement structure for hospitals. Diagnosis-Related groups (DRGs) are used, and a 1987 increase in the payment rate for teaching hospitals makes teaching hospitals a disproportionate cost burden
(Gottlober 2001). The number of residency slots could be increased at a cost, but attention would need to be given to specialty and location in order to remediate access disparities.
PCPs, GME, Medical Schools and Institutional Priorities
Jordan J. Cohen, MD, former president of the Association of American Medical
Colleges, in his presentation at the 2003 Academic Emergency Medicine Consensus
Conference in Boston, emphasized that health care disparities cannot be solved without strong leadership. He called on hospitals, deans, and university presidents and others in upper levels of authority, to lead in terms of how they speak about medical schools and the stories they tell. Some politicians such as the previously mentioned Senator Richard D. Roth (D-
Riverside) and Assembly, member Jose Medina (D-Riverside), have harnessed public
79 opinion. University deans like S. Claiborne "Clay" Johnston, MD, Ph.D of Dell Medical
School have also come forward to establish a new narrative around novel medical schools.
His strategy has been to create a vision for Dell Medical School as a democratic solution - shaped by the community at every level (University of Texas at Austin 2018). Ideally, rhetoric and public opinion would be in agreement with research. It remains to be seen if new urban medical schools will be able to increase rural retention simply with vision and community buy-in.
In contrast, the federal government has employed multiple strategies to remediate access disparities through federal agencies. The National Health Service Corps provides loan repayment and scholarships in regions known as designated Health Professional Shortage
Areas (HPSAs) to alleviate access disparities.58 The National Institutes of Health is conducting research on geographic health disparities and the Department of Health and
Human Services Rural Task Force continues to address the issue. The United States Centers for Disease Control and Prevention called on epidemiologists two decades ago to create a statistical report on the status of rural/urban health in America (Eberhardt 2001). The
Medicare Incentive Program (MIPS) and the quality of care movement included incentives for rural physician networking and improved quality of care while seeking to reduce costs.
Rural Health Clinics (RHCs) serve rural areas with federal financial support. What is missing in all of this is stakeholder coordination.
Aside from leadership and coordination, other strategies for improving health care access include locum tenens (temporary and travelling) providers, the use of physician
58 Research indicates that financial incentives are not as effective as training in rural locations, while recruiting students with rural backgrounds and/or combining multiple efforts have positive results.
80 assistants and nurse practitioners, the use of telemedicine59 and the J-1 visa waiver program.
Policymakers and leaders should consider place-based medical education in shortage areas, and policies that intentionally create a physician workforce within the local student population. For example, rural residency rotations in community hospitals would not only provide an opportunity for local students, but would increase regional physician access. In addition, investment in federally established land-grant institutions as medical hubs for rural stations/clinics has been tried before and seems promising (Wilson 1967). The development of nurse practitioner and physician assistant training programs in rural public universities would also reduce costs and improve access and quality of care.
Limitations
This research ultimately serves as a starting point for in-depth analysis. The results are limited in scope since access is multifactorial. I did not test for the effect of physician volume, focus on primary care providers, or examine the impact of graduate medical education and insurance. I also did not consider the impact of nurse practitioners or physician assistants, or the quality of care. Further, I was not able to take into account the high number of practicing physicians who are about to retire.60 I only looked at the state level, while regional and county analysis would be illuminating. All of these factors are
59 One successful example is Project ECHO which provides a telehealth linkage between university-based physician specialists and primary care providers in underserved areas. The University of Nevada, Reno School of Medicine (one of many medical schools across the country using ECHO) has adopted Project ECHO to assist underserved Nevadans. Primary care retention is of significant concern in rural areas. As schools responded to the Flexner Report, institutional support and specialization became associated with quality medical education. The problem with this approach was that it devalued primary care and directed medical training to urban areas. 60 Recent data indicate that 33% of practicing physicians are approaching retirement Koehler (2016)
81 highly relevant to physician access and render a headcount an inaccurate measure of access, and a flaw in this study.
In Chapter 3, I was limited by the use of secondary data, the units of analysis, and my definition of physician access. Simply working in geographic area does not make a physician an appropriate provider. It depends on the need of the patient. In general, most patients need primary care, but specialists are also vital though not needed in such great quantities. The small sample size of 50 also had an impact on my results. In Chapter 4, I was limited by the fact that I only looked at one time period and so I could not see the impact of medical schools on physician access in different years or even decades. Since I am looking at a single period of time, I can only assert that medical schools and physician access are associated and have not established causation.
Recommendations for Future Research
This data analysis provides a starting point to investigate the institutional factors behind access disparities. It is a time of growing concern for health care access disparities in the United States. The dramatic increase in new medical schools since 2006, the looming increasing physician shortage, and the higher proportion of aging individuals known as the silver tsunami is increasing demand for providers in rural areas. In a recent JAMA editorial, the author asked whether America’s education systems are prepared or expected to meet the health care needs of the people, specifically to ensure the public good (Lucey 2017). That question is central to this investigation and ties in to Fox’s fourth stage of medical school sufficiency since true sufficiency will meet the needs of the people (1927). Medical schools
82 are increasing physician numbers but they are not targeting underserved states. Perhaps the new programs will yield different results.
Dialogue and research surrounding this issue, along with this thesis, give direction for many possible areas of timely research. Future scholars may consider using only primary care physician data. Studies indicate that rural areas are particularly in need of more primary care providers. An epidemiologic study on health status indicators and medical school proximity would shed light on medical education and the quality of care. Future research should include the impact of medical school placement on medical students from rural and underserved areas. Do they leave rural or inner city communities for training and never return or just decide not to pursue medicine? Further research should examine the increase in medical schools over time and if the new schools are having an impact on in-state access.
Future scholars may want to examine what level intervention most effectively increases physician access. Future research could examine the impact of medical residency and GME on physician access since that is often the last training they receive before practicing independently. Underserved areas are increasingly in need of in-depth analysis of these issues.
Conclusion
There are many associated factors behind physician access, and this study indicates that medical schools are one of them. Since the results were supported by historical events such as the Flexner Report, it appears that the location of educational institutions has an impact on physician access. This research provides confirmation that past decisions are a significant part of the access challenges the United States faces today. The physician shortage is really more of distribution issue. Research in this area is highly salient with potential to
83 further investigate need at county levels. Because of the overarching complexity of the health care system, it is clear that in-depth analysis of disparities in access will contribute to solutions only under conditions of collaboration, cooperation, leadership, and consideration of the entire physician training system in the United States.
BIBLIOGRAPHY
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BIBLIOGRAPHY
Abrams M, Nuzum R, Mika S, Lawlor G. 2010. Health Reform and Primary Care: Implications for patients, providers, and payers. New York: The Commonwealth Fund.
American Association of Colleges of Osteopathic Medicine. 2017. “U.S. Colleges of Osteopathic Medicine” https://www.aacom.org/become-a-doctor/us-coms
American Board of Medical Specialties. 2012. “Accredited Medical Schools” https://www.abmsdirectory.com/pdf/Resources_directory_MedSchools.pdf
American Board of Medical Specialties. 2018. “Directory of US and Canadian Medical Schools.” The Official ABMS Directory - American Board of Medical Specialties. https://www.abmsdirectory.com/abms/Resources_directory_MedSchools.htm
American Medical Association. 2017. “Principles of Medical Ethics”, accessed November 4, 2017, https://www.ama-assn.org/delivering-care/ama-code-medical-ethics
Armstrong, D., R. Chung and GJ. Forte. 2014 New York Residency Training Outcomes: a Summary of Responses to the 2014 New York Resident Exit Survey. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany; 2015. http://www.chwsny.org/wp- content/uploads/2015/09/2014_NY_Residency_Training_Outcomes.pdf
Association of American Medical Colleges. 2010. AAMC Data Book. Washington, DC: Association of American Medical Colleges.
Association of American Medical Colleges. 2011. “2011 State Physician Workforce Data Book Center for Workforce Studies.” AAMC (November) https://www.aamc.org/download/263512/data/statedata2011.pdf
Association of American Medical Colleges. 2016. AAMC Data Book. Washington, DC: Association of American Medical Colleges.
Association of American Medical Colleges. 2017. Report on Residents, accessed March 25, 2018, https://www.aamc.org/data/484710/report-on-residents.html
Association of American Medical Colleges. 2017. “Why Teaching Hospitals Are Important to All Americans.” AAMC News, accessed November 11, 2017, https://news.aamc.org/for-the-media/article/teaching-hospitals-important- americans/
86
Association of American Medical Colleges. 2017. “New Research Reaffirms Physician Shortage” AAMC News (March 14, 2017) https://news.aamc.org/press- releases/article/workforce_projections_03142017/
Barzansky, Barbara and Sylvia I. Etzel. 2017. “Medical Schools in the United States, 2016- 2017.” JAMA, 318, no. 23, (December 19): 2360-2364. doi:10.1001/jama.2017.16702
Bayer, Ronald, Arthur L. Caplan, and Norman Daniels. 1983. In Search of Equity: Health Needs and the Health Care System New York: Kluwer Academic Publishing.
Beitsch, Rebecca. 2015. “To Address Doctor Shortages, Some States Focus on Residencies.” The Pew Charitable Trusts, accessed September 10, 2017, http://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/08/11/to- address-doctor-shortages-some-states-focus-on-residencies
Blum, Henrik L. 1983. Expanding Health Care Horizons. Oakland: Third Party Publishing Company.
Bonner, Thomas N.1963. American Doctors and German Universities. Lincoln: University of Nebraska Press.
Brooks, Robert G., Michael Walsh, Russell E. Mardon et al. 2002. “The Roles of Nature and Nurture in the Recruitment and Retention of Primary Care Physicians in Rural Areas: A Review of the Literature.” Academic Medicine, 77, no. 8 (August): 790- 798.
Brazeau, Nancy K., Michael J. Potts, and John M. Hickner. 1990. “The Upper Peninsula Program: A successful Model for Increasing Primary Care Physicians in Rural Areas.” Family Medicine, 5, no. 22 (September-October): 350-355.
Burke, Colin B. 1982. American Collegiate Populations: A Test of the Traditional View (New York University Series in Education and Socialization) New York: New York University Press
Campana, Aldo. ed. September 30, 2017. “United States of America - Medical Schools” Geneva Foundation for Medical Education and Research, accessed October 14, 2017, url:https://www.gfmer.ch/Medical_search/Countries/USA_map.htm
Cantor, Norman L.1970. “The Law and Poor People’s Access to Health Care” Law and Contemporary Problems, (Fall): 901-922.
Carroll, Aaron E. 2016. “Why the U.S. Still Trails Many Wealthy Nations in Access to Care” The New York Times, (October 24, 2016): A3.
87
Centers for Medicare and Medicaid Services. 2018. “National Health Expenditure Data. Historical.” CMS.gov, accessed March 14, 2018, https://www.cms.gov/Research- Statistics-Data-and-Systems/Statistics-Trends-and- Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html
Chan, Benjamin T. B., Naushaba Degani, Tom Crichton, et al. 2005. “Factors influencing family physicians to enter rural practice: does rural or urban background make a difference?” Canadian Family Physician, 51, no. 9, (September): 1246-1247.
Cohen, JJ. 1998. “Why doctors don’t always go where they’re needed.” Academic Medicine 73 (December): 1277.
Congressional Budget Office. 2010. “Letter to the Honorable Nancy Pelosi.” Washington: Congressional Budget Office.
Constitution of the World Health Organization. 1946. WHO. (July 22, 1946) New York.
Cooke, Jacob E. ed. 1961. “The Federalist No. 10 from Alexander Hamilton, James Madison, and John Jay, The Federalist” Edited and with an introduction and Notes by Jacob E. Cooke (Middletown, CT: Wesleyan University Press, 1961), No. 10.56-65.
Council on Graduate Medical Education. 1998. “Physician Distribution and Health Care Challenges in Rural and Inner City Areas: Tenth Report to Congress and the Department of Health and Human Services Secretary.” United States Department of Health and Human Services. Rockville: Health Resources and Services Administration.
Courtland, Shane D. 2017. “Hobbesian Right to Healthcare.” Journal of Applied Philosophy, 34, no. 1 (May): 99-113. https://doi.org/10.1111/japp.12124
Daniels, Norman. 1985. Just Health Care. New York: Cambridge University Press.
Daniels, Norman. 2008. Just Health: Meeting Health Needs Fairly. New York: Cambridge University Press.
Davis, Karen, Melinda Abrams and Kristof Stremikis. 2011. “How the Affordable Care Act Will Strengthen the Nation's Primary Care Foundation” Journal of General Internal Medicine, 10, (October 26): 1201–1203. doi: 10.1007/s11606-011-1720-y
Decker, Sandra L. 2015. “Acceptance of New Medicaid Patients by Primary Care Physicians and Experiences with Physician Availability among Children on Medicaid or the Children's Health Insurance Program.” Health Services Research, 50, no. 5 (October): 1508–1527. doi: 10.1111/1475-6773.12288
88
Deitrick, John E. & Robert C. Berson. 1953. Medical Schools in the United States at Mid- Century. New York: McGraw-Hill Book Company, Inc.
Eberhardt, M, D. D. Ingram, & D. M. Makuc et al. 2001. “Urban and Rural Health Chartbook. Health, United States, 2001- Facts about rural physicians.” Federal Office of Rural Health Policy. Hyattsville, MD: National Center for Health Statistics, accessed August 29, 2017, http://www.shepscenter.unc.edu/rural/pubs/finding_brief/phy.html
Emanuel, Ezekiel J. 2008. “The Problem with Single-Payer Plans.” Hastings Center Report, 38, no. 1 (February 8): 38-41. doi: http://www.jstor.org/stable/25165292
Fein, Rashi & Gerald I. W. Weber. 1971. Financing Medical Education. “A general report prepared for the Carnegie Commission on Higher Education and the Commonwealth Fund.” New York: McGraw-Hill.
Fenton, Joshua et al. 2016. “Reducing Medical School Admissions Disparities in an Era of Legal Restrictions: Adjusting for Applicant Socioeconomic Disadvantage.” Journal of Health Care for the Poor and Underserved, 27, no. 1. doi: 10.1353/hpu.2016.0013
Flexner, Abraham. 1910. Medical Education in the United States and Canada. Boston: The Merrymount Press.
Florer, John H. 1968. “Major Issues in the Congressional Debate of the Morrill Act of 1862.” History of Education Quarterly, 8, no. 4: 459-478.
Fox, Dixon Ryan. 1927. “Civilization in Transit.” The American Historical Review. 32, no. 4 (July): 754-755. https://doi.org/10.1086/ahr/32.4.753
Fried, Charles. 1976. “Equality and Rights in Medical Care.” Hastings Center Report, 6, no. 1 (February): 29-34. doi: 10.2307/3560359
Fuchs, VR. 1974. Who Shall Live? New York: Basic Books.
Glaser, Robert J. 1992. “The Impact of Philanthropy on Medicine and Health.” Perspectives in Biology and Medicine. 36, no. 1 (Autumn): 46-56. doi: 10.1353/pbm.1993.0053
Gottlober, Paul. 2001. “Medicare Hospital Prospective Payment System How DRG Rates Are Calculated and Updated.” Office of Inspector General Office of Evaluation and Inspections Region IX Centers for Medicare & Medicaid Services, Central Office, https://oig.hhs.gov/oei/reports/oei-09-00-00200.pdf
Hart G. and P. Taylor P. 2001. “The Emergence of Federal Rural Health Policy in the United States.” In Rural Medicine. New York, NY: McGraw-Hill. 2001, 74.
89
Heady, Hilda and Robert C. Beard. 2002. “A Delicate Balance: The Economics of Rural Health Care Delivery.” JAMA 1/2/02: 110.
Health Resources and Services Administration. 2008. “Health Professional Shortage Areas - Title 42 Chapter 61 Subchapter II Part D. Subpart ii § 254e.” U.S. Department of Health and Human Services ,October 8, 2008. https://www.hrsa.gov/advisorycommittees/shortage/Meetings/20100922/section25 4ehpsa.pdf
Henderson, Tim. 2016. “Americans Are Moving South, West Again.” Stateline: The Pew Charitable Trusts, accessed April 11, 2017, http://www.pewtrusts.org/en/research-and- analysis/blogs/stateline/2016/01/08/americans-are-moving-south-west-again
JAMA. 1893. “The Present Status of Medical Education in the United States.” JAMA. 24: January 7, 1893.
James, Richard, Wyn Johanna et al. 1999. “Rural and Isolated School Students and Their Higher Education Choices: A re-examination of Student Location, Socioeconomic background, and Educational Advantage and Disadvantage.”
Kamitani, Satoru, et al. 2015. “Differences in Medical Schools’ Regional Retention of Physicians by School Type and Year of Establishment: Effect of New Schools Built Under Government Policy.” Health Services Research. 15 (December): 581. https://doi.org/10.1186/s12913-015-1240-2
Kaufman, Martin. 1976. American Medical Education: The Formative Years, 1765-1910. London: Greenwood Press.
Kitayama, Shinobu Lucian, Gideon Conway, and Paula R. Pietromonaco. 2010. “Ethos of Independence Across Regions in the United States.” American Psychologist 65 (September): 559-574. doi: 10.1037/a0020277
Koehler, Tracy J, Jaclyn Goodfellow et al. 2016. “Physician Retention in the Same State as Residency Training: Data From 1 Michigan GME Institution.” Journal of Graduate Medical Education, 8, no. 4 (October 1): 518-522. https://doi.org/10.4300/JGME-D-15-00431.1
Laven, Gillian and David Wilkinson. 2003. “Rural Doctors and Rural Backgrounds: How Strong is the Evidence? A Systematic Review.” Australian Journal of Rural Health. 11, no. 6 (December): 277-284.
90
Liaison Committee on Medical Education. 2017. “Accredited MD Programs in the United States” http://lcme.org/directory/accredited-u-s-programs.
Lippard, Vernon W. 1974. A Half Century of American Medical Education: 1920-1970. New York: Josiah Macy, Jr., Foundation.
Lucey, Catherine R. 2017. Is Medical Education a Public or Private Good? Insights from the Numbers. JAMA, 18, no. 23: (December 19): 2303-2305. doi:10.1001/jama.2017.17552
Ludmerer, Kenneth. 1985. Learning to Heal: The Development of American Medical Education. London: The Johns Hopkins University Press.
Macinko A., B. Starfield and L. Shi. 2007. “Quantifying the health benefits of primary care physician supply in the United States.” International Journal of Health Services, 37, no. 1: 111-126. doi: 10.2190/3431-G6T7-37M8-P224
Markowitz, Gerald E. and David Karl Rosner. 1973. “Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine.” American Quarterly, 25, no. 1 (March): 83-107. doi: 10.2307/2711558
McConaghy, Mary D. 2010. “School of Medicine: Historical Development, 1795-1800.” http://www.archives.upenn.edu/histy/features/1700s/medsch.html (accessed June 3, 2017).
Meden, Terry. 2002. “Relationship Between Travel Distance and Utilization of Breast Cancer Treatment in Rural Northern Michigan.” JAMA, (January 2): 111. doi:10.1001/jama.287.1.111
“Medicare Physician Fee Schedules (MPFS)” 2018. Jurisdiction E - Medicare Part B. Noridian. https://med.noridianmedicare.com/web/jeb/fees-news/fee- schedules/mpfs
Medicare Hospital Prospective Payment System How DRG Rates Are Calculated and Updated August 2001 OEI-09-00-00200 Office of Inspector General Office of Evaluation and Inspections Region IX https://oig.hhs.gov/oei/reports/oei-09-00- 00200.pdf
Merkel, Howard. 2014. “69 Years Ago, a President Pitches His Idea for National Health Care” PBS News Hour (November), accessed November 11, 2017, https://www.pbs.org/newshour/health/november-19-1945-harry-truman-calls- national-health-insurance-program
91
Miller, Jeffrey C. et al. 2012. “Perspective: Follow the Money: The Implications of Medical School’s Funds Flow Models.” Academic Medicine, 87, no. 12 (December): 46- 51. doi: 10.1097/ACM.0b013e3182713b77
Muckenfuss, Mark. 2013. UCR: Practice Medicine Here, Study for Free. The Press- Enterprise (December) https://www.pe.com/2013/12/19/ucr-practice-medicine- here-study-for-free/
Murray, John E. 2007. Origins of American Health Insurance: A History of Industrial Sickness Funds (Yale Series in Economic and Financial History) New Haven: Yale University Press.
National Institutes of Health. 2017. “Budget: Research for the People.” National Institutes of Health, U.S. Department of Health and Human Services. March 6, 2017, accessed March 15, 2018, https://www.nih.gov/about-nih/what-we-do/budget
O’Brien, Bridget C., Molly Cooke and David M. Irby. 2010. Educating Physicians. San Francisco: Jossey-Bass.
O’Malley, C.D., ed. 1975. The History of Medical Education. Los Angeles: University of California Press.
Pathman, Donald, E., Thomas R. Konrad & Thomas C. Ricketts III.1992. “The Comparative Retention of National Health Service Corps and Other Rural Physicians: Results of a 9-Year Follow-up Study.” JAMA, 268, 12 (September): 1552-1558.
Pincus, Theodore, Robert Esther et al.1998. “Social Conditions and Self-Management Are More Powerful Determinants of Health than Access to Care” Annals of Internal Medicine,129, no. 5 (September): 406-411.
Pittalwala, Igbal. 2013. “California Governor Signs Budget that Brings UC Riverside School of Medicine Long-sought State Funding” UCR Today, accessed January 16, 2018, https://ucrtoday.ucr.edu/15957.
Potts, David B. 1971. “American Colleges in the Nineteenth Century: From Localism to Denominationalism”. History of Education Quarterly, 11, no. 4 (Winter)): 363- 380. doi: 10.2307/367036
Pusey, W. A.1925. “Medical Education and Medical Service I: The Situation.” JAMA, 84, no. 4 (January 24): 281-285.
Rabinowitz, Howard K., James J. Diamond, et al. 2001. “Critical Factors for Designing Programs to Increase the Supply and Retention of Rural Primary Care Physicians.” JAMA, 286, no. 9 (September): 1041-1048.
92
Rabinowitz, Howard K. and Nina P. Paynter. 2000. “The Role of the Medical School in Rural Graduate Medical Education: Pipeline or Control Valve?” The Journal of Rural Health, 16, no. 3 (Summer): 249-253.
Rawls, John. 1971. A Theory of Justice. Boston: Harvard University Press.
Riverside County Community Health Assessment 2015. Strategic Health Alliance Pursuing Equity. Riverside University Health System. September 2015. http://www.rivcoph.org/Portals/0/CHA_Final_RivCo.pdf?ver=2016-03-14- 140825-950)
Sanborn, Beth Jones. 2017. “Not just primary care, the coming 'Silver Tsunami' will hit specialists as well.” Healthcare Finance News. December 17, 2017, accessed January 23, 2018, http://www.healthcarefinancenews.com/news/not-just-primary- care-coming-silver-tsunami-will-hit-specialists-well
Sade, Robert M. 1971. “Medical Care as a Right: A Refutation.” New England Journal of Medicine, 285, no. 23 (December): 1288-1292. doi: 10.1056/NEJM197112022852304
Schmidt, Henk G., et al. ed.1989. New Directions for Medical Education. New York: Springer-Verlag.
Shi, Leiyu and Douglas A. Singh 2012. Delivering Health Care in America. Boston:Jones & Bartlett Learning, Chapter 8.
Shi, Leiyu and Douglas A. Singh. 2015. Delivering Health Care in America: A Systems Approach Burlington: Jones and Bartlett Learning, Chapter 2.
Sloan, Frank A. & Judith Bentkover. 1979. Access to Ambulatory Care and the U.S. Economy Lexington: Lexington Books.
Starr, Paul. 1982. The Social Transformation of American Medicine. Cambridge: Basic Books.
Stone, Deborah. 2001. Policy Paradox: The Art of Political Decision Making. W. W. Norton & Company.
Transactions of the American Medical Association, 1848 [Philadelphia 1848, pp. 3549-360]
The Commonwealth Fund. 2016. “International Profiles of Health Care Systems 2016” January, http://www.commonwealthfund.org/~/media/files/publications/fund- report/2016/jan/1857_mossialos_intl_profiles_2015_v7.pdf#page=8
93
The World Factbook. 2017. “Country Comparison: Maternal Mortality Rate” Washington, DC: Central Intelligence Agency, accessed November 4, 2017, https://www.cia.gov/library/publications/the-world- factbook/rankorder/2223rank.htm
The World Factbook. 2017. “Country Comparison: Infant Mortality Rate” Washington, DC: Central Intelligence Agency, accessed November 4, 2017, https://www.cia.gov/library/publications/resources/the-world- factbook/rankorder/2091rank.html
United Nations. 1948. “UN Universal Declaration of Human Rights” UN.org http://www.un.org/en/universal-declaration-human-rights/
United States Census Bureau. 2016. “Individuals Below Poverty Level By State.” 2016 American Community Survey 1-Year Estimates.
United States Census Bureau. 2017. Census of Population and Housing, 1790. United States Census Bureau, accessed June 3, 2017, https://www.census.gov/prod/www/decennial.html
United States Department of Agriculture. 2013. “Rural-Urban Commuting Area Codes.” Economic Research Service. 12/31/2013. https://www.ers.usda.gov/data- products/rural-urban-commuting-area-codes.aspx
University of Texas at Austin 2018 Building a Medical School … From the Ground Up Dell Medical School video. https://dellmed.utexas.edu/team-profile/clay-johnston
Vaughn, Lewis. 2010. Bioethics: Principles, Issues, and Cases. New York: Oxford University Press.
Wendling, Andrea, Julie Phillips, William Short, et al. 2016. “Thirty years training Rural Physicians: Outcomes from the Michigan State University College of Human Medicine Rural Physician Program.” Academic Medicine, 91, no. 1 (January): 113-119. doi: 10.1097/ACM.0000000000000885
Weiskotten, H. G. et al. 1940. Medical Education in the United States: 1934-1939. Chicago: American Medical Association.
Whitcomb, M. 2005. “The Challenge of Providing Doctors for Rural America.” Academic Medicine, 80, no. 8 (August): 715-716.
"Why Teaching Hospitals Are Important to All Americans." Association of Medical Colleges. AAMC, 2015, accessed February 6, 2015. https://www.aamc.org/download/253382/data/teaching-hospitals.pdf
94
Williams, Roger L.1991. The Origins of Federal Support for Higher Education. University Park: The Pennsylvania State University Press.
Williams, Sarah C.P. 2016. “New medical schools aim to fix America’s broken health care system” STAT News, accessed January 16, 2018, https://www.statnews.com/2016/05/09/medical-schools-university-of-texas- austin/
Wilks, Judith & Katie Wilson. 2012. “Going on to uni? Access and participation in university for students from backgrounds of disadvantage.” Journal of Higher Education Policy and Management, 34, no. 1: 79-90. doi.org/10.1080/1360080x.2012.642335
Wills J., Garrison L, Jacoby I. 1980. “Modeling, Research, and Data Technical Panel.” Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services, (2).
Wilson, Vernon E. 1967. “The Medical School of a Land-Grant University and Its Relation to the Health Care of the State.” JAMA, 202, no. 5 (October 30): 404-406. doi:10.1001/jama.1967.03130180070013