Presentation to Rural Canadian Family Physicians November 9, 2002

Powerpoint presentation at CANADA3.ppt

Medical Schools and Restoration

Role of Rural FP Posting - about the Canadian meeting and comparisons

Restoration and CDMED in Brief Form


Robert  C. Bowman, M.D.   About the Site and Author

Associate Professor

University of Nebraska  Family Medicine

Director Rural Health Education and Research

Co-Chair NRHA Rural Medical Educators Group


It is a great honor to be invited to share thoughts with fellow physicians who are devoted to serving others. I bring greetings from the National Rural Health Association as Co-Chair of the Rural Medical Educator Group

My main topic today is restoration and I do believe that rural family physicians have a great role to play in restoration in the world today.


I would also encourage you to consider three locations to share your ideas and models and data.
• The first is Rural and Remote Health through Paul Worley in Australia. This International Electronic Journal is a new way to share.
• The second is the Journal of Rural Health from the NRHA. This is a combination of research articles and practical ideas for rural physicians.
• Finally I would be happy to help you share your information and stories. My website is the World of Rural Medical Education. It is a collection of works by a variety of authors and physicians. Sometimes the best program models and the most practical information cannot be found in journals. As a family physician would do with patients, I pledge to find you an answer, from myself if I know, from others on our list serve, or specific questions to someone who does know. Everything on this web site is open for copying, revisions, use, contributions, and sharing. I welcome your thoughts and inquiries. Some of our best items come from student and resident questions with responses by many of our rural docs.

Also might join list serves at Rural Med Ed US by emailing or in Canada at or by emailing David Topps at

My main topic today is restoration and I do believe that rural family physicians have a great role to play in restoration in the world today. Rural practice taught me that everyone had to cooperate to make things work, doctors, administrators, and community leaders. I ask therefore that you all dedicate yourself to working with each other, doctors, teachers, associations, schools, programs, and government, to work together. The time for arguing, competing, and glory seeking is over. There is too much at stake in your nation and mine and in the world.



Medical Schools and Restoration

uMedical schools need restoration in the worst way.

uPeople need restoration more than ever

uRestoration is a community asset almost entirely

uRural docs and communities can lead us in this

uNations need the restoration that we can bring


I will early on admit to being a facilitator of ideas rather than a speaker. My best communications are similar to yours, one on one with people as patients or students or those I am learning from.

It is this privilege of being a lifelong student that I claim today and I would like to share what I have learned. I will also be talking about something that you know about much better than I do, for you have lived in rural communities much longer. I envy you.









Medical schools

uRestoration in curricula

uRestoration in hidden curricula

uRestoration in admissions


Restoration in Curricula - Generalist, Rural, Priority of Student

Rural Preceptorships Are the Best Medical Education

Why a Preceptorship Is Better

uGjerde - Wisconsin - equal

uStudent evaluations in NE other states - the best

uResident evaluations also



uRPAP students vs controls

uRPAP equal or better in 21 measures

uStudents lower then above median


Minnesota one of only a few states to show twice the rate of physician gain in the nation. Others had osteopathic schools or a statewide approach such as Arkansas.

To understand RPAP you need to know 2 things – 1 is that the Minnesota legislature mandated it. 2 is Jack Verby

Jack was a rural doc from 1951 –1971. He was well respected in the state by all. His plan was to bridge the gap between rural and academic communities. Students went out for rural, back, and then back to rural towns to practice. Faculty, even specialists, went out to teach students, at least in the early years. One of those faculty, the chair of surgery, was responsible for getting RPAP replicated in Syracuse. Jack loved to make connections. He also got regularly roasted by the academics and learned evaluation and program design and published in the best journals in the nation and world, documenting the success of the program and its potential. Jack also developed rural health systems, realizing that these were the best way to educate students.

Not only that, the long term rural preceptorship highlights what I call the community friendly medical education, where students or residents add much more than they take and really support rural docs, rural health systems, and rural communities.

What I learned from Verby. He was a role model for all rural medical educators. He put the things I read into action with a real program with great results. Even more than this, he taught me how


What I learned from Verby.
We have lost the Generalist Perspective

uVerby had to change the rules

uNot just board scores but measure against becoming a practitioner

uBroad measures

uConfidence and competence


Oslers’ Remarks at a time when Generalism Ruled

Osler and Rural Practice

No more dangerous members of our profession exist than those born into it, so to speak, as specialists. Without any broad foundation in physiology or pathology, and ignorant of the great processes of disease, no amount of technical skill can hide from the keen eyes of colleagues defects which too often require the arts of the charlatan to screen from the public. "Remarks on Specialism," Boston Medical and Surgical Journal, 126:457, 1892.


This does not mean that specialists are evil, but it does mean that we need to insure that physicians have a firm foundation, one that is best laid in generalism Frankly if we cannot convince medical schools of this, then we must indeed make our own generalist medical schools

Osler: The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.

Doing research well is a great challenge


In my experience, research is one of the most selfish things that one can do. It takes total immersion and dedication to a narrow concept. It is the opposite of service and caring. It is very difficult to do it and continue to be as relevant in medical education. Again research is not evil, it is just those that do research have a hard time doing teaching and administering the broad functions of a medical school.


Osler: By all means, if possible, let [the young physician] be a pluralist, and–as he values his future life–let him not get early entangled in the meshes of specialism. "Internal Medicine as a Vocation," Medical News, New York, 71:660, 1897.


Loss of generalist leadership and perspective in medical schools devastating to curricula, admissions, and the mission of medical education. It is even more deadly to medical students and even family medicine residents who get entangled in it.

One of the speakers I remember most in past conferences was America Bracho, a Hispanic female physician from Orange County CA. She got up and pointed out that many of our US medical schools sat right in the middle of some of the most unhealthy and chronically impoverished areas in the country. Some have been there for over 100 years with little change in the areas.

William Butler, former head of my alma mater at Baylor in Houston, once issued a call over 12 years ago for social accountability for medical schools from his podium as an academic leader, although Baylor itself has developed an innovative high school for health professions, few have really made an effort to deal with underserved populations. Dr. Butler highlighted the RPAP model at Minnesota, PSAP, WWAMI, and other models I will discuss. The work of Dr. Butler and others had no impact at all. Admissions, curricula, and leadership are key areas.



Specialist Vs Generalist Perspective


Generalism, Medical Education, and Family Medicine: Complimentary Not Competitive


Medical Curricula from Generalist Rural Perspective

Objectives for Prep of Rural Docs

Objectives for Rural Programs and Curricula

uAchieve clinical competence

uAcquire procedural expertise

uExplore variety

uLearn interface doc and gov’t

uCommunity Role

uBalance personal-professional

uComfort w/ Generalist role

uMaster Doctor-pt

uTrain where teaching priority

uReceive adequate support


Competence and procedures go without saying.  What is key however is early mastery of medicine, so that trainees can move on & explore other concepts and relationships such as doctor-patient, doctor-community. Accelerated and long term preceptorships can offer this. Exploration of a variety of practices, especially early on as a courtship, can insure a good marriage of doctor to community    Meeting the Needs of Underserved Rural and Inner City Areas with Accelerated Graduate Training


This is where it is critical to spend time in rural communities where students can begin to grasp the generalist role


Verby noted that his studies showed that students after 3 months of rural primary care were overwhelmed, at 6 months neutral, at 9 months not want to leave. Most schools have far less PC, usually enough to get students overwhelmed with primary care decisions, uncertainty, etc. Not enough time to see how generalists think, work with patients, work with specialists, work with the community, etc.



Restoration in Hidden Curricula



uAway from caring

uAway from service

uInto subspecialty


Their student requirements keep them away from volunteering, leadership, and service

Medical students become very self absorbed


Med School and Residency Rural Graduation Rates
 Rosenblatt in JAMA, Bowman

Which Medical Schools Produce Rural Physicians? Rosenblatt

Fam Med Res Prog and Grad of RFP Bowman and Penrod

uPolitical - % rural population

uRural Mission



Rural Docs and Med School Leadership

Academic Leaders Deans Organizations

Leadership Factors in Developing RME




Must have rural perspective, most likely former rural docs in these positions. The hidden curricula is most determined by medical leadership, their impact is on curricula, admissions, the environment, attitudes, values, etc.



Admissions Package

uCan choose right, but don’t

uRabinowitz 1% becomes 21%

u78% is rural back + FP interest


The Right Students

urural background

uminority background

ulower socioeconomic Barriers To Entry

uservice oriented Service Orientation


We face rural background and minority background declines due to education policies in many states.  Lower socioeconomic numbers major declines as noted in Toronto Barriers To Entry and likely other med schools since income related increasingly to standardized test scores, students in college with this that are having to work area less likely to do well in grades and MCAT and less likely to be recognized by health professions advisors. Why not service oriented - who better to serve the underserved?



AAMC GQ 1995 Rural Interested Seniors

Characteristics of Rural Interested Students

uOnly 400 of 16000 US allopathic med students interested in town of <10k

uTwice as likely volunteer

uTwice as likely overseas, military

u60% interest in socioec deprived, greater than any subpopulation of medical students so far. One of the interesting things about the NHSC FP physicians who have basically been sent out for training and socialization in rural locations, is that they commonly go to urban underserved locations.


Of course it would be a sad mistake to have an overflow of physicians interested in underserved areas by selection, training, or socialization.


One of the most exciting parts about working with such service driven, mature, students and residents is that they create their own hidden curricula with student groups, service projects, moonlighting, needed changes in curricula, etc. They are indeed the right stuff.


Getting the Right Students

uFirst 4 years in Nebraska frustrating

uKnew principles fairly well, NE seemed far from them

uSmall towns complaining of loss of population and loss of young professionals


Did not know that changes were already in place and the right students in the pipeline.


Rural Health Opportunities Program

Rural Health Opportunities Program

uChadron and Wayne State

uAdmit to Med School as Freshmen

uJeff Hill, former rural doc

u3 years + good behavior and UNMC


However it is not the impact on the few that really makes RHOP, as we shall see later


Summary Medical School Needs

uCurricula - patient focus

uHidden curric - mission for underserved

uAdmissions - right students

uMore later


Students Interested in Becoming a Rural Physician

Student Interest Group Package


Even in Family Medicine

uBob Boyer, doc of year, talks Boyer Links and Presentations

uResidents lament: saddest commentary on current med ed and prep for rural

u“Now I remember why I wanted to become a doctor” after 7 yrs of hidden curricula socializing them away from service and rural and generalist


Bob taught me something more about trying to encourage students to consider rural practice. It is impossible in a short time to capture the obstacles and preparation, but you can focus on the all important motivation. This analogy with the sea and sailors is a good comparison:



"If you want to build a ship, don't drum up the men to gather wood, divide the work and give orders. Instead, teach them to yearn for the vast and endless sea." [Antoine de St. Exupery]  thanks to Chris Ryan

Vast and Endless Sea


Osler put it a different way


The training of the medical school gives man his direction, points him the way, and furnishes him with a chart, fairly incomplete, for the voyage, but nothing more. Osler

"To study medicine without books is to sail an uncharted sea, while to study medicine only from books is not to go to sea at all." Sir William Osler

It is the voyage that matters. It is the hidden curricula that really matters. It is the yearning for the sea that matters more in the recruitment of sailors. We need students who yearn for rural living and the challenge of medicine.

We need the preparation, but we cannot allow the thrill of the voyage to be destroyed, nor can we allow those who do not desire such a voyage to be admitted, for medicine is a career best met with passion by those motivated for service.


We need the structure and leadership of medical schools, but we need the passion and courage of those most devoted to service: Rural Family Physicians. This is how we will restore medical education.


Restoration: The Value of Community

The importance of local market share

u10% increase in market share better than 30% increase in reimbursement for federal programs

uMust retain local patients, services, etc.


My own voyage through rural practice and the study of the literature revealed a curious dilemma. We screamed for help and noted how bad things were, probably scaring good people away from primary care and rural practice. We did not do what we could locally


What I have learned from Rural Practice

uSolutions for patient care most often not medicine

uPatients have more needs than I can meet alone

uMust work with community


What I learned from Building Communities - McKnight

uAll communities have assets and resources

uMust look at positives to get solutions

uLooking at negatives only good if you want perpetually dependent populations


What I learned from Rural Visits

uOklahoma State U visit, consult

uFirst time all docs in same room

uOutspoken Intern - not H and P alone,

uValue is in working with rural FP seeing pts & doing


Docs and Communities can map opportunities to maximize learning, ask 3 questions

The Case for Involvement: Learning in Rural Communities

uWhat do you wish you learned?

uWhat are your local assets?

uHow can you integrate these into learning opportunities?


Rural Visits

uReview of learning opps at start and middle

uMay be one of the only times students ever have face to face eval

uVital information that will be used


The Invisible Faculty by Joseph Hobbs, M.D.


What have I learned Careless Communities - McKnight

uInstitutions and Programs attempt to care

uOnly individuals and communities can care

uGovernment programs can disrupt community function

uThey can also encourage community function


Application to medicine: Medical errors increase with the size of the medical system

Caring is what prevents errors, not quality control and study of systems because someone still has to care enough to do something different.


Rio Heroine Yvonne Bezerra de Mello Criticism from the Pope regarding expenditures wasted   more at  Yvonne Bezerra de Mello


What I learned from patients

uCommunities pulling together for the dying - treasured memories

uOnly communities can care for the most difficult

uCommunities of alcoholics or addicts - Alcoholics Anonymous


I have also learned from my family

uDaughter in Utah, once lost, being restored

uSon in small town rehab center, safe and sober

uInternet community a great comfort

uFaith community sustained us, church, internet, Times Square Church


What I have learned from the Bible

uMajor theme of the Bible is restoration

uProphets almost always preaching restoration

uForgive appears over 150 times

uRestore 100  return 40    renew 10   repent 40   new life 30

All forms together almost as many times as the word love which is noted over 600 times


Worst condemnation proclaimed for not caring about others

Ezekiel 16:49 Now this was the sin of your sister Sodom: She and her daughters were arrogant, overfed and unconcerned; they did not help the poor and needy. 50 They were haughty and did detestable things before me. Therefore I did away with them as you have seen. 51 Samaria did not commit half the sins you did. You have done more detestable things than they, and have made your sisters seem righteous by all these things you have done.


Sodom was utterly destroyed because it failed to care, not for its wickedness although you will see the two go together. Judah in the time of Ezekiel had become a Careless Community.

Do we have such communities, nations?

Best functioning communities were in the early chapters of Acts where all shared their possessions and met the needs of those less fortunate


AC 4:32 All the believers were one in heart and mind. No one claimed that any of his possessions was his own, but they shared everything they had. 33 With great power the apostles continued to testify to the resurrection of the Lord Jesus, and much grace was upon them all. 34 There were no needy persons among them. For from time to time those who owned lands or houses sold them, brought the money from the sales 35 and put it at the apostles' feet, and it was distributed to anyone as he had need.


This does not mean they gave up their primary home, nor did they ignore the rules of government or the bonds of family, they just cared enough to give up the possessions that we all have that are far and above what we need  This was the ultimate do unto others as we would have them do unto us


Community Characteristics Contributing to Success: Advantage Rural

uAwareness of issues   +++

uMotivation from within    +++

uSmaller geographic area ++++

uAdaptability ++

uSocial cohesion +++

uAbility to discuss, cooperate ++

uIdentifiable leaders +++

uPrior success

   From Community Building: What Makes it Work? - Vincent Hyman - Amherst H. Wilder Foundation


Translating Community Principles to Medical Education

Three options

uNeutral impact    rare

uNegative      the usual

uPositive     can do


Positive Impacts: Restoration of Rural Health Systems, Community Friendly or Community Reinforcing Med Ed    Community Friendly Aspects


Combined Outstate Residency Experience

The CORE Program

u2 months rural rotation

u4 underserved small towns

uNot a problem in NE with 45 small systems

u3 years with resident 12 months a year

uCommunities can depend on workforce, shared call where every 2 goes to every 3, or 3 to 4, all add nurse, some even use nurse to facilitate education

uFew patients turned away, builds market share or holds it if recent loss of doc

uCommunity learns how to recruit


MN Rural Physician Associate Program

Duluth Plus RPAP

u9 months rural experience

u$30 - $70,000 in increased revenues

uStudents contributing to workload

uStudents making practice more efficient

uOne on one learning

uPhysician assistant literally

uCost of orientation low. 1 per yr

u2 billion in rural economic gain for

u30 million investment

Over 4 months is a benefit (Paul Worley, Australia)

Nurses praise system
Program directors die for RPAP grads
60 of 900 returned to their precept site


Medical Education need not be predatory, could be better

uLonger rural experiences in medical school

uLonger than 2 month rural rotations in residency

uCommunity health and service projects

uGrant applications, facility funding

uSupport of rural doc networks

Developing Rural Health Systems


-Curriculum and accreditation fights, but worth the effort

-Florida State fought for 2 years

-Identify community needs, assets

-Increase resources or help retain assets


Networks, Facilitate by Med Ed

udevelop leadership, management,

uoffice manager roundtables,

ugroup purchase and negotiate,

ucooperate for teaching, recruitment, retention



uBest Educational Experiences in Med Ed

uBest value to Community

uBest value to trainee, personal and professional


In RPAP - the preceptor gets to know the student well enough to chart progress, strengths, weaknesses, interests, etc. In 9 months in the traditional clinical years, the student will have had over 30 supervisors considering the changes in residents, attendings, etc.



Again Rural Docs and Rural Communities will lead the way



Finally Medical Education, led by Rural Medical Education and Rural Physicians and Rural Communities, can help restore nations


The modest country doctor may furnish you the vital link in your chain, and the simple rural practitioner is often a very wise man. Thayer, W. S., "Osler, the Teacher," Johns Hopkins Hospital Bulletin, 30:198, 1919.


Back to Rural Health Opp Program and Small Colleges

Discussions with College Professors

uImprovement in academics

uIncrease in enrollment

uIncrease in other professionals

uStimulate better teaching for those behind


Right thing for the wrong reason. Academics of first few RHOP groups not as good, so pressured to lengthen to 4 years of college. After first few years, academics improved as the students competed, etc. The real reason to go to 4 years is more likely to court and marry a rural spouse as opposed to 3 yrs or going to urban college like Lincoln, Omaha, etc.Continued Centralization of State Educational Resources and the Potential Impact on the Location of Young Professionals


Realized Small Colleges are the Breeding Grounds of Young Professionals

Breeding Young Professionals and Healthier Rural Communities

uRabinowitz uses small college health advisors to help admissions

uMissouri program failing, chose intellectuals and used any college


The principle holds true for minority feeder programs as well


Nigerian Doctor/Health Minister Visit

uTour of campus, technology

uAll useless in her country

uMy interaction 10 min

As she and her FP leader escort were packing up, I was asking her how she was going to get the right kids admitted so that she could get doctors to return to rural villages.  She was skeptical about being able to get rural kids educated enough to do well at age 17 to pass major obstacle. Yet she must.



Kennedy Blueprint - My Intro    Kennedy and Crisis

This is not about war or peace or Great Society or political spectrum. It is about leadership and vision and calling people to sacrifice and accountability. I am hoping that you see your role in restoring the nations. I am frustrated because I feel that those who are most dedicated to serving the nation, especially schoolteachers, physicians serving the underserved, civil servants, and others who prioritize service over self are not receiving the respect that they deserve.   Sound familiar?

Some would say that better pay was the issue, but I tell you that it is not the salaries that matter, it is the fact that these people chose to make a difference in the lives of those around them. The worst thing that you can do to a person who makes such sacrifices is to inhibit their work by lack of support, cutting off the resources that they need, or ignoring them.

More importantly nations are at risk because they ignore these concerns.


Kennedy 1961 Joint Address to Congress

uMan on the moon proposal

uTime of crisis

uChallenges at home and abroad


"The great battleground for the defense and expansion of freedom today is the whole southern half of the globe--Asia, Latin America, Africa and the Middle East--the lands of the rising peoples. Their revolution is the greatest in human history. They seek an end to injustice, tyranny, and exploitation. More than an end, they seek a beginning".....


“I stress the strength of our economy because it is essential to the strength of our nation. And what is true in our case is true in the case of other countries. Their strength in the struggle for freedom depends on the strength of their economic and their social progress. We would be badly mistaken to consider their problems in military terms alone.


For no amount of arms and armies can help stabilize those governments which are unable or unwilling to achieve social and economic reform and development. Military pacts cannot help nations whose social injustice and economic chaos invite insurgency and penetration and subversion...


This is also our great opportunity in 1961. If we grasp it, then subversion to prevent its success is exposed as an unjustifiable attempt to keep these nations from either being free or equal. But if we do not pursue it, and if they do not pursue it, the bankruptcy of unstable governments, one by one, and of unfilled hopes will surely lead to a series of totalitarian receiverships.”


“Finally, our greatest asset in this struggle is the American people--their willingness to pay the price for these programs--to understand and accept a long struggle--to share their resources with other less fortunate people--to meet the tax levels and close the tax loopholes I have requested--to exercise self-restraint instead of pushing up wages or prices, or over-producing certain crops, or spreading military secrets,

or urging unessential expenditures or improper monopolies or harmful work stoppages--to serve in the Peace Corps or the Armed Services or the Federal Civil Service or the Congress--to strive for excellence in their schools, in their cities and in their physical fitness and that of their children--to take part in Civil Defense--to pay higher postal rates, and higher payroll taxes and higher teachers' salaries, in order to strengthen our society--


to show friendship to students and visitors from other lands who visit us and go back in many cases to be the future leaders, with an image of America--and I want that image, and I know you do, to be affirmative and positive--and, finally, to practice democracy at home, in all States, with all races, to respect each other and to protect the Constitutional rights of all citizens.”

“This decision demands a major national commitment of scientific and technical manpower, materiel and facilities, and the possibility of their diversion from other important activities where they are already thinly spread. It means a degree of dedication, organization and discipline which have not always characterized our research and development efforts. It means we cannot afford undue work stoppages, inflated costs of material or talent, wasteful interagency rivalries, or a high turnover of key personnel.


New objectives and new money cannot solve these problems. They could in fact, aggravate them further--unless every scientist, every engineer, every serviceman, every technician, contractor, and civil servant gives his personal pledge that this nation will move forward, with the full speed of freedom, in the exciting adventure of space.”


We did choose the Kennedy Blueprint at least for awhile, and then we chose the quicker military and economic route and now face global recurrent violence and instability in both northern and southern hemispheres. Also we contribute to problems because developed nations take more than our share. At the height of our haughty attitudes in the richest nations, we even think that we can create institutions that care, and are destroying the family and community that makes life great. It is no surprise that the US is in the top 3 in terms of missionaries being sent from other nations to a nation. (Barna research )


Now as I look back on the Kennedy address, I wish it to be repeated today, with one exception. Instead of envisioning a man to the moon or stars, I would want such a speech today to end with a declaration of a goal of ending communities of poverty. Ending poverty is too much to ask, for even Jesus said that we would always have poor people (Matthew 26:11).


But I believe that we must not tolerate communities, regions, or entire countries of the impoverished. We can make the sacrifices before others suffer greatly. It is impossible to wall ourselves off in ways expensive in dollars and in the pursuit of liberty. We can and must reach out to others in great need. There is no other real choice. RCB


PR 25:21-22 If your enemy is hungry, give him food to eat; if he is thirsty, give him water to drink. In doing this, you will heap burning coals on his head, and the LORD will reward you.


We have taken a different course of action in the world and it has become a place dependent on economics, megabusinesses, military actions.


We can illustrate a different approach, or after military actions a way to heal.


Medical education can change high school and college education. We can increase the number of young professionals in needed areas. We can improve education and services and economics in such areas.


This can be Appalachia, it can involve aboriginal peoples, or Bosnia, or Afghanistan. We have been able to restore nations that already had economics and education and leadership. Can we do the same for those without?


Rural Family Physicians are already in similar areas. We can get the right kids, the ones who most want to return. We can influence schools to boost education and maturation, and somehow not socialize them urban, subspecialty, or out of culture in the process.

We must get the right leaders, the ones who can pick the kids most likely to return to underserved areas, design curricula to boost education and maturation, and somehow not socialize them urban, subspecialty, or out of culture in the process.

I urge you to take what you know  in your heart about communities and working with people

uExplore, teach, write about the concepts

uIdentify and stimulate the right kids

uPractice what you know on patients, family, neighbors

uShow it in interactions with administrators and bureaucrats

uUnite rural and academic communities


Use it to influence

umedical education



ua new generation of leaders



uMedical schools need restoration in the worst way.

uPeople need restoration more than ever

uRestoration is a community asset almost entirely

uRural docs and communities can lead us in this

uNations need the restoration that we can bring



The cultivated general practitioner. May this be the destiny of a large majority of you!…You cannot reach any better position in a community; the family doctor is the man behind the gun, who does our effective work. That his life is hard and exacting; that he is underpaid and overworked; that he has but little time for study and less for recreation–these are the blows that may give finer temper to his steel, and bring out the nobler elements in his character. "The Student Life: A Farewell Address to Canadian and American Medical Students." Medical News, New York, 87:625, 1905.


We also know that without stellar training, it would be difficult to consider rural practice. We have known that for some time.


"The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best-trained physician that can be induced to go there." Abraham Flexner


By the way, Flexner’s ideas are different than how others have applied it.  Flexner would suffer seeing how we have allowed contact with patients to suffer. He would be for preceptorships even though those who uphold his principles in accreditation look down on them.


Flexner’s Impact on American Medicine


Again I had a chance to reflect on how far we have gotten away from the initial concepts of medical education reform and how far we have gotten into rigidity and infrastructure. Somehow we have forgotten that Flexner really wanted to be practical, utilitarian, patient-focused, and connect preprofessional to medical school and medical school to residency training (Robert Ebert, former Harvard Dean, Flexner's Model and the Future of Medical Education, Academic Medicine 67:11 Nov 1992) It was not Flexner's fault that mainly urban colleges and high schools woke up to provide academically prepared candidates for medical school, thus worsening the maldistribution and distressing Flexner, Osler, and others, as well as all of us. We have shown that we can indeed restore high school and small college education with the leadership of medical education in Nebraska to reach out preprofessionally to small colleges and advisors.


More on this posting at Role of Rural FP Posting



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