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Making Medicine Mean More: HMS Meets the Real World

By Peter C. Krause

"If you really want to get good training in Primary Care, go to a state school," says second-year Harvard medical student Madeline Wilson '81.

Although Harvard Medical School may be the best place in the world for prospective neurobiologists and molecular engineers, it is playing a catch-up game in general medicine.

When Wilson returned to the U.S. to enroll in the Medical School in the fall of 1983 after two years of Peace Corps work in Liberia, she found that Harvard did not think the social problem of community health care was its worry.

"I don't believe Harvard Medical School believes its mission is to address that problem [community health care]," Wilson says.

Primary care, as opposed to specialty medicine, is the all-encompassing term for community and general health care, and, according to manpower experts, primary care physicians are needed to solve the pressing problems of medical maldistribution that arise when too many doctors go to places like Milton and too few go to South Boston.

For years doctors have decried the structural and financial disarray of modern medicine and one of its clear ramifications, the poor's inaccess to proper medical treatment.

"Substantial numbers of lower income people--not just in Boston, but in the nation--are having trouble. Substantial portions are not served," maintains the related School of Public Health (SPH)'s Director of the Community Health Improvement Program, J. Larry Brown.

Physicians are disappearing from depressed areas such as Mattapan and South Boston, and community health centers are folding--including one in Roxbury this year, SPH Dean of Students Helen Pommer says. "General Practitioners are a dying breed."

The maldistribution of health care and the related problem of a physician "glut"--an overabundance of doctors in some areas--came to light five years ago in a government report that predicted by 1990 that there would be an excess of physicians in almost every specialty at the expense of community and general medicine, Dean for Students and Alumni at Harvard Medical School Daniel D. Federman '49 says.

Despite this universally recognized need for more doctors in rural and inner city areas, Harvard Medical School has only indirectly addressed the problem of health care maldistribution, according to physicians there. The function of the Medical School is to educate students and to provide them with learning opportunities, not to pursue social goals, counters Federman.

"We don't give incentive bows to orient students to any particular path," he says. "We don't have any school program whose intent is to encourage students to practice in any one area."

Although recently the Medical School has revamped its curriculum and reasserted support for students interested in primary care, the school has not done enough to address the distribution problem, according to Dean of Students at the Medical School Myra B. Ramos.

"I think that a good many schools have more stringent requirements than we do, but we're catching up," Ramos says. "The school is increasingly recognizing the social context of medicine."

The creation of New Pathway--a radically new educational program emphasizing clinical studies--and a new core requirement in social medicine, both introduced with the class of 1989, have been steps in that direction.

Although New Pathway is more than just a primary care program, many of the students enrolled are strongly inclined towards community medicine, and the program itself fosters a concern for the individual patient, according to first-year participant Mari S. Miller. "There are quite a number who have interests in primary care. A lot are discovering how much they enjoy getting to know the patients," she says.

The new core requirements in the Social, Behavorial and Quantitative Sciences--approved by the Faculty of Medicine in May of last year--are the first core changes in these three areas since 1974. They have made it impossible to graduate without at least two course credits in Social Medicine and Health Policy, as well as in each of the other two areas.

Although most students already took a balanced selection from the three departments above the minimum requirement, Ramos says, administrators felt that a change of policy was in order. "It's being clearer about our statement of what's important," Ramos says.

The decision to increase emphasis on social medicine was a positive step towards increased awareness, according to Ramos, but it wasn't part of a broad policy change. "I cannot say at this moment that this is a deliberate force of the curriculum. The curriculum is not particularly directive and it would not be in its tradition to be directive in one particular area," Ramos says.

The Medical School has promoted social awareness activities outside the curriculum as well, including community outreach programs and academic societies, Federman says.

With the blessings of the faculty and administration--and a $1200 Medical School donation--a group of medical students formed the Urban Health Project two summers ago to send first-year students all around the Boston area to work on neighborhood health projects.

Students brought their medical knowledge to homeless shelters, health centers, and elderly clinics, so they could practice clinical medicine and provide health care for people who would otherwise not receive it.

"Maldistribution? The project certainly has that object in mind," says Wilson, the Project's Summer Director.

The Urban Health Project is not the only student activism at the Medical School. Wilson estimated that 20 percent of all students are involved in some community health service.

"There is definitely an awareness among the student body," Wilson says. One hundred members of the 160-person class of 1989 have banded together to discuss health issues and tutor at a nearby high school, Wilson says.

Although members of the faculty sometimes advise outreach programs and the Medical School provides some funds, the school is not directly involved in any student projects, Professor of Medicine and Director of primary care at Massachusetts General Hospital John D. Stoeckle says. "The Medical School isn't formally doing very much."

To the school, all the projects are primarily educational experiences for the students, says Co-founder of the Urban Health Project and third-year medical student Larry Ronan.

"The administration was extremely supportive [of the Urban Health Project]. Dean Federman offered his total personal support. But is he more supportive than he is for surgery? No, he is not," Ronan says.

Many physicians and administrators at the Medical School say that although there are things that the school could be doing to counter the maldistribution of health care, the federal government has to act to produce any long-term solution.

The two tools the Medical School has available to it, the curriculum and financial awards (Harvard has no control over the policies of affiliated hospitals) would be insufficient even if the school used them to achieve social goals, according to Rashi Fein, professor of economics in the Department of Social Medicine and Health Policy.

"If life were that simple, then we would have students from other schools that have more requirements distributing themselves better. But these are very serious decisions. One course--even 10 courses--wouldn't do it," Fein says.

Monetary concerns are far more pressing than curricular opportunties, according to Fein. Students leave medical school saddled with huge debts of $100,000 or more, and desperately need practices that will allow them to pay monthly installments of up to $1000 on their loans.

"One should not criticize a student who, having that kind of debt, wants to go where risks are fewer and the economic rewards are greater. He has to pay those dollars back and with interest. And the rural area or the depressed area presents a problem if you owe $50,000," Fein says.

Financial aid awards to students from depressed communities could lead those students to return to their homes to set up practices, according to Fein, but he was skeptical. A graduate who had never seen a ghetto might be less likely to want to establish a practice there, but a someone from a ghetto would be no more likely to return.

The maldistribution of health care is far too great a problem for the school to cure, Fein says. "There is not much that can be done short of state or federal legislation that would provide incentives for doctors to settle in less wealthy neighborhoods."

"The Medical School should do what it can. But there are lots of other things other people have to do too."

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