11046819There was another article on NPR this morning about Brad Duke. For those of you whose memory of current events is slipping (I didn’t remember him either) he was the Powerball gazillionaire from 2005. Well, not a gazillionaire but a $225 millionaire. In this follow-up he seemed like a very nice young man, the kind I would want my daughter to marry (well, the cash WOULD be a plus). He lives modestly, manages his money well, and in general he is doing quite well. He told interesting stories of all of the people who tried to separate him from his money. In the story, an interesting fact came out. It seems that 70% of Lotto winners who win over $10,000,000 will be broke in a couple of years. Advice to lottery winners from financial planners: Don’t forget who you are.

Lottery winners and students who have made it into medical school have a lot in common. Many really good students are strongly encouraged to buy a ticket in the pre-medical school lottery. I suspect the enticement of money doesn’t hurt. Preparation for the required entrance testing begins before high school. Failure to perform well on one of the pre-admission tests results in disqualification. Once accepted into a pre-professional college curriculum, a single bad semester will result in disqualification. Though not as bad as the odds of winning the lottery, not great odds.

The acceptance to medical school is the winning ticket. Those who are successful in obtaining entrance into medical school have a 98% chance of becoming a physician. They are exposed to multiple strong role models throughout their medical training. Though they will likely say in the admissions interview “I like science and I want to help people” the evidence shows that are they will pick a career based on projected income, and perceived specialty status (the higher the better) when making their final career selection.

While our students may have won the lottery, Alabama has not.  Of our 67 counties, 60 of them have insufficient primary care. An additional 128 primary care physicians are needed now to relieve the existing shortage and over 400 are needed now just to provide optimal care. Given that the average age of the primary care physicians in Alabama is 50, we need our own lottery ticket and creating medical schools is not it. 86% of the students in our medical schools are Alabama residents but only 14% of these students come from rural Alabama. The results of the most recent “match” provide evidence that the existence of these medical schools is insufficient to respond to this crisis. UAB, the largest of the allopathic medical schools in Alabama,  put 12 students from a class of 200 (7%) into family medicine. Although 35 students were placed into Internal Medicine, the literature suggests that at most 8 of those will specialize in primary care. South Alabama, with a class size of 77, put 7 (10%) into family medicine and 21 into internal medicine. Based on projections, 4 of these IM residents will go into primary care. Given these numbers, best case scenario is that 28 graduates of the allopathic medical schools in Alabama will provide primary care. This is well under half of the projected need. In addition, 50% of these  medical students will leave the state upon graduation, presumably including at least some of students choosing primary care.

So what do we do? First, we need to stop treating medical school admission like winning the lottery. As my friend  Josh Freeman points out, we are lottery winners because we physicians have rigged the game. This needs to change. Secondly we need to rig the game to make sure the right people get a winning ticket. We know that it is possible to select students who are much more likely to seek out primary care and rural practice. Students are more likely to return to a community of the size they were reared in. Students who attend osteopathic schools are more likely to practice primary care upon completion of their studies. Students who attend a small college are more likely to practice primary care. Students with a spouse from a rural area are more likely to return to a rural area. These folks, if qualified, deserve a ticket. Lastly, a grown-up somewhere needs to take control of how many and what kind of doctors come out of the residency end of the pipeline?

As it stands now, the lowest paid physician is in the top 3% of all wage earners. Can’t we find people who consider this a winning ticket?

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