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
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 firstname.lastname@example.org or in Canada at email@example.com or by emailing David Topps at firstname.lastname@example.org
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
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.
uRestoration in curricula
uRestoration in hidden curricula
uRestoration in admissions
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
Verby MN RPAP
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
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
uLearn interface doc and gov’t
uComfort w/ Generalist role
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
Their student requirements keep them away from volunteering, leadership, and service
Medical students become very self absorbed
Med School and Residency Rural Graduation
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
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.
uCan choose right, but don’t
uRabinowitz 1% becomes 21%
u78% is rural back + FP interest
The Right Students
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
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.
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
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?
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 http://www.brazzil.com/p11apr99.htm 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 ++++
uSocial cohesion +++
uAbility to discuss, cooperate ++
uIdentifiable leaders +++
From Community Building: What Makes it Work? - Vincent Hyman - Amherst H. Wilder Foundation
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
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
CORE and RPAP
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
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,
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
“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 www.barna.org )
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
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
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.