Articles by "Social Responsibility"
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The recent Beyond Flexner postings and social mission articles have revived interest in Academic Medicine's Season of Accountability and Social Responsibility by William T. Butler, M.D. Dr. Butler gave this address to AAMC in 1990 and expected a response - one that never came.

The following are predominantly Dr. Butler's words with an update regarding the lack of progress regarding his calls to action.


Public Concerns About the Overall Health Care System

Dr. Butler declared that academic medicine had entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. His recommendations are followed by comments regarding academic medicine addressing these concerns or not.
  • Public concerns have continued. There has been no progress in this area. The political arena has been a distraction, but the concerns continue. The same types of headlines listed not only are seen in the media headlines, but also across social media and numerous Business, Health Info Tech, and other journals and magazines.Medicine has lost respect and physicians have lost substantial ability to shape health care design. 
  • Academic designs have made matters worse for those who deliver basic health access. The partnership between managed care and accountability researchers resulted in micromanagement. This movement has added countless billions in additional health care costs based on assumptions and lack of evidence basis for health outcomes improvement. 
  • Worst of all is that the design changes have made it more difficult for the team members that deliver the care. Some physicians cry out, often those older who experienced much better environments, but not associations or academic designers.
Butler then reviews earlier seasons of academic medicine and the responses. He recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research.
  • Efficiency and confidence are lagging still. Academic centers push for more lines of revenue and fight to keep the highest reimbursement in each line - designs that they largely shaped and maintain. 
  • 1100 zip codes in 1% of the land area have top concentrations of physicians at 45% of physicians in places with 10% of the population. Over half of health spending is transferred to these settings making it difficult for half of the nation to receive even the basic care.
  • The graduate medical education design results in only 6.5% of residency positions found in 2621 lowest physician concentration counties with 40% of the US population. 
  • The expansion of GME is a primary example of the problems of academic medicine - lack of efficiency, training failure, and continued promotion of funding that widens disparities in dollars, workforce, and access. 
  • Residents in their fellowship years are paid only $60,000 and have small levels of benefits but often generate as much as subspecialty physicians paid $400,000 or more with some of the most lucrative benefit packages. More residents at these fellowship
Next, Butler focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. Butler flat out states that generalists are the cornerstone of the medical profession.
  • Generalists have substantially failed due to academic medicine and academic influences that prevent true health care reform - more support for cognitive, basic, office services. 
  • Generalists and general specialties are shrinking as a function of US academic medicine, primarily because generalists, general specialties, and health access are prevented by the designs that academic medicine continues to shape.
Butler describes models of existing, successful programs.
  • The WAMI model looked good because it existed when the financial design for primary care was better 1965 to 1980. Since that time the model and other training models are limited by the financial design and the inherent suppression of generalists - particularly family medicine. 
  • The models that Butler promoted in the article were limited to only a small influence regarding solutions for underserved rural or urban practices. 
  • The financial model prevents any MD DO NP or PA training solution. 
  • The Deans Lies and the GME lies continue across MD DO and NP. No promises of improvements in primary care, health access, and care where needed should be made until academic medicine promotes true payment reform - more fuel for the generalists and general specialties.
The author concludes by proposing to create a "National System of Regional Medical Care." He urges the AAMC to continue its leadership by designating a task force to examine how such a regional system could be established within this decade.
  • States used to do statewide and regional planning, but this is largely left up to the largest systems and practices that control the health care dollars. 
  • The regional plan failed to progress.
  • Regional primary care officers in positions above hospitals could actually help to hold hospitals and hospitalists accountable for not coordinating care with primary care offices.
Most of the school and program successes we still revere are really about the one period of time with substantially improved finances - a time when the US steadily sent more dollars to lowest physician concentration counties. This was due to early Medicare and Medicaid 1965 to 1980. An improvement in the financial design shaped improvements in workforce and in access. The rush for schools, programs, special incentives, and pipelines to claim credit obscures the obvious reason for improvement.

Dollars injected into the care of those poor and elderly were specific to lowest physician concentration counties then as now, if we chose to do so. The original designs are not the same and the dollars are unlikely to go where needed as determined by designs from the 1980s to the present.

There are those who can point to "their program" or curricula as successful, but a rearrangement of the deck chairs type of success is failing 200 million people as will more easily be seen in 2040. As is often said it is amazing what can be accomplished if no one cares about who gets the credit but it is also true that those who claim credit falsely distract from the investments of time, talent, and treasure that do make the difference.

We are already a decade too late in workforce improvements specific to these counties to be in place by the 2040s. True reforms specific to most Americans by 2050 seem even more distant.

Care for most Americans left behind requires an entirely different financial design. This is the only way that the traditional health professional education design will to work for MD DO NP and PA. 

Anyone who promotes anything other than major financial reform as a solution is giving false hope. Health care interventions that do not improve patient outcomes and can worsen them are condemned, for good reason. The same should be true for those who promote any solution for health access that does not substantially improve the financial design.
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Periodically there are calls for Academic Medicine to be accountable for health care in areas such as health care workforce. This accountability includes the larger dimension of people with substantial limitations in their health care such as rural populations or underserved urban populations. The access situations are worsening across primary care, mental health, and general specialties - those who provide 90% of care for half of the population most in need of care. The lack of any significant improvement for decades indicates barriers not easily addressed. In fact it may well be that the top priorities for academic and largest systems are such that true reforms are prevented - reforms that would address the primary care, mental health, and basic services payments that are essential for distributions of services and broadening of health access.

A social mission or accountability would require academic and other health care leaders to stand up for higher payments for basic services, decreases in costs, and increases in support for providers caring for increasingly complex patients. Instead there are no such cries and there are new designs that make the financial design worse - and make it more difficult for the team members to deliver the care to the half of the population most left behind. 

Health care is about people and health access practices are over half dedicated to personnel. The support of the personnel who deliver care is most important. Designers and their designs have had adverse impacts. 

Making a difference is about tens of billions a year redirected where dollars can matter most. Without financial design reforms, training designs are incapable of generating the graduates that can be supported where they are most needed. Academic leaders can continue to avoid responsibility or even blame for worse designs while they can continue to cry out for more support to train more graduates - even if those graduates cannot actually go where needed or serve most Americans most behind by design.

Most Americans are getting the minimum with less to come. 

More special social mission events and articles have not ended with calls for accountability or demands for true reform in payment - so they have failed.

More primary care associations have been created and funded with more special projects and greater support of innovation, regulation, and certification - making matters worse.

Not even family medicine with 70% of graduates in office based primary care has grasped the design flaws that make matters worse - sending academic entities farther away from social mission and accountability for the basic access of greater proportions of Americans.

More special schools, programs, pipelines, and promotions will not result in necessary health access improvements arising from MD DO NP or PA graduates. In fact the numerous announcements each month represent a distraction from real primary care solutions.

Academic Centers Lack the Perspective of the Need for Major Change

Perhaps this "social mission" or "social responsibility" appears to be quite difficult for academic entities and those that they influence. Curricular emphasis is easy and temporary. True health reform is hard work. Reforms have usually arisen outside of academic centers as seen in Medicare and Medicaid - although the case can be made that the academic, foundation, government, association, and corporate designers managed to redirect Medicare and Medicaid after only 15 years of operation. Managed care took less than 5 years. ACA was dead on arrival for true reform such as balancing cognitive vs procedural. 



Access to care is a horizontal, decentralized broadening of mission quite different from the vertical, highly specialized care organizations specific to academic institutions. Previous essays have discussed the process of academization or distancing, making it difficult to consider situations and conditions. 

It Can Take Decades to Realize the Limitations of Academic Efforts

As a medical student I had great respect for academic medicine and medical centers. My time as a rural physician trained me in dimensions untouched by academic training - community, health access, care where needed, social dimensions. Even as I learned more, I still clung to academic medicine as a solution and hoped to bridge the academic and rural communities in my quest for solutions for health access. It is quite clear that this cannot happen now or for decades to come. 

The financial design prevents generalists, general specialties, rural practice, primary care, mental health, small practice and care where needed. The academic designers continue to sit on panels and influence government in ways that prevent true reform. True Reform    

The thirty years teaching, researching, and delivering health access as an academic physician were great years and involved great people and great meetings - but the research and the academic interventions even coordinated across preparation, selection, and training have resulted in no progress in basic health access. Nebraska still has the same levels of inadequate workforce across the same 70 counties that still have physicians despite substantial efforts at all levels and a genius family medicine residency program design (shaped by Jim Stageman and Mike Sitorius working with state and institution players). The Nebraska county map over the fifteen years of observation had different names and initials with more family physicians, but fewer internists and little change in delivery capacity. 

My editorial work as North American editor of Rural and Remote Health confirmed little progress. The research in the US as in other nations indicates the successes of various programs or models. But despite the successes, the lowest physician concentration counties remained lowest with inadequate workforce - and many fell to even lower concentrations as funding declined, hospitals closed, or economics changed. 


A medical school or training program can be stellar in "social mission" 
with great documentation of superior results 
but half of the people in the state remain to have improvements in access.

More commonly the studies are as flawed as those that promote international graduates as solutions - studies that fail to consider 30 - 40% who leave the US and that fail to consider departures from primary care and from areas of need in the years after graduation. 

With More Study the Truth is Obvious

It finally registered that most Americans are losing in health care design as in the designs for education, economics, banking, housing, and other areas. Why expect different when economics, education, health, and their designs are so closely related to one another? If you truly understand the social, personal, local determinants that shape 60 - 70% of outcomes, then you can begin to see the numerous flawed perspectives and solutions.

Lowest physician concentration counties confirm these adverse changes and the difficulties of addressing care where needed without True Reform. Students and residents interested in family medicine desire Equity. Family physicians Paid Less for Doing More Where Needed are frustrated and they are moving away from primary care as have all other primary care sources for the last few decades. The recent implementations of pseudo-reforms in payment have made matters worse and the designs have moved all the way to Discrimination in Payment.

Pay for performance has been widely promoted by family medicine leaders for some time and the associations continue to support these designs, even as they discriminate against family physicians in particular and other providers choosing to care for the most complex populations that inherently have the worst outcomes.

Once again lowest physician concentration counties represent lowest levels of workforce and access and highest concentrations of most complex patients with the most chronic diseases and other situations, environments, and conditions that make care even more complex.

Academics should sound off when practices and policies are not evidence based - yet they have not done so. Family medicine associations should be looking for issues to support such as opposing discrimination in payment, especially when the evidence basis for innovative designs is lacking. 

Do Unto Others...

The academic message for science, evidence basis, and public good have been compromised over the decades. Now when I see the social mission preached from academic leaders, even those respected for social mission articles, it is hard to listen. Those speaking fail to see the lack of progress despite the rhetoric for decades. Great concepts presented are as limited as the results for the last 40 years.

Real gains and real changes take real dollars, tens of billions more for primary care where needed. Only about 40 billion goes for primary care in lowest concentration counties with half enough primary care. Yet this is tolerated and made worse as more billions are subtracted in each of the new categories - HITECH, ACA, MIPS, MACRA, and Primary Care Medical Home. Worsening collections and turnover costs are bad, but the financial design actually prevents lowest concentration counties from being able to support more team members to deliver the care. 

More are falling behind in more ways with much worse to come. Health care design continues to leave greater proportions of Americans behind. The 40% in lowest workforce concentration counties will be 50% by 2040 as hospitals close in these counties and as housing affordability collapses in higher concentration counties force more of the most medically and financially vulnerable to move to lowest concentration counties.

Why would we expect different when most Americans are falling behind 
in economics, education, and other key societal areas? 

The social mission in medicine begins and ends with basic health access. For many Americans, health care fails because access fails.

Next is a review of the Academic Medicine Scorecard compared to the call for accountability made in 1990 by Dr. Butler, Chairman of the AAMC at the time.
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