MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. Health care reform is back on the front burner. In the weeks and months ahead, the Republican-controlled House will vote on whether to appeal the Patient Protection and Affordable Care Act, while Democrats try to do defend last year's sweeping law. But would you believe that political wrangling is the easy part.

MR. KOJO NNAMDIThe real hard work of transforming our health care system will fall on doctors, would-be doctors and the medical schools that train them. Millions of formally uninsured Americans will enter the health care system in the coming years. And most experts think, we're facing a shortfall of at least 100,000 primary care physicians. American medical schools produce some of the world's finest young doctors, specialists and researchers, but some worry they're not producing the kinds of doctors we'll need in coming decades.

MR. KOJO NNAMDIOthers say, they're falling short on a different score. Failing to live up to their responsibilities to serve vulnerable populations in the communities where they operate. Joining us to discuss this is Dr. Luis Padilla, medical director and family physician at the Upper Cardozo Health Center in Washington, D.C. It's a part of Unity Healthcare. Dr. Padilla, thank you for joining us.

DR. LUIS PADILLAThank you, it's a pleasure.

NNAMDIAlso with us is Dr. Robert Taylor. He is dean of Howard University's College of Medicine where he also serves as chief academic officer. Dr. Taylor, thank you for joining us.

DR. ROBERT TAYLORThank you for inviting me.

NNAMDIDr. John Prescott is chief academic officer at the Association of American Medical Colleges. Dr. Prescott, good to have you aboard.

DR. JOHN PRESCOTTIt's a pleasure to be here, thank you.

NNAMDIAnd Dr. Fitzhugh Mullan is a professor of medicine and health policy at the George Washington University School of Public Health, and a clinical professor of pediatrics at George Washington School of Medicine. He was the lead author of a report last year titled, "Social Mission of Medical Education: Ranking the Schools" which appeared in the June 2010 issue of the Annals of Internal Medicine. Welcome, Dr. Mullan. Let me start with you.

DR. FITZHUGH MULLANThank you, Kojo.

NNAMDIWe all know about U.S. News and World Report and its annual rankings of Colleges and Universities, but you have proposed a different kind of ranking system, Measuring what kinds of doctors a school produces and where they end up serving. How do you measure something like social mission?

MULLANWell, we were concerned about the three elements of medical education which were the number of minorities produced, the number of primary care physicians practicing after education, and the number of doctors in shortage areas. Putting those together, we called them a social mission and we set about designing a system that would measure that in a way that all could examine it and consider it.

NNAMDIWell, the study apparently got under the skin of some major medical colleges, did it not?

MULLANWell, as with any ranking system, there are folks who perform or appear to perform better and those who don't perform so well. And from the schools perspective, I think people were concerned if they were on the lower end of the rankings and that's quite appropriate. In terms of organizational responses, there have been varied, but in general, people have been supportive of trying to measure this and doing it in a way that was numerate, scientific, and that's what we tried to do.

NNAMDIThe study measures the percentage of students who become primary care physicians, the percentage of students who work on health professional shortage areas and the percentage of students who are under-represented minorities; is that correct?

MULLANThat's right. Those were the three elements, we think taken together, represent a major contribution to the social mission. This is population health, this is doctors in your community, this is making sure that there is a full representation or full effort on the part of medical education to produce the doctors that will be needed particularly as we increase our demands on our healthcare reform.

NNAMDILet me bring our listeners in on the conversation. You can call us at 800-433-8850, what do you think? Do local medical colleges owe something to the communities in which they operate? Call us, 800-433-8850 or send us a tweet @kojoshow or go to our website kojoshow.org, join the conversation there. Dr. Prescott, your organization represents medical colleges across the country and you disagreed with this methodology and the broader conclusions or the broader assumptions of this study. Can you please explain?

PRESCOTTSure. Thank you very much. Well, I think this study does provide Howard University, Morehouse, Meharry and other medical schools with well deserved recognition for the work that they've done in each of those areas they talked about as far as increasing the diversity and as far as educating primary care physicians and also with making sure that we have primary care physicians throughout our communities.

PRESCOTTBut like other ranking systems, this new study does fall short and provides only a limited view of the many ways that our nation's 133 medical schools fulfill their social missions. And, I think, that the fact is that medical schools meet societies health care needs in many way. Through the integrated missions of medical education, through research, patient care and community outreach.

NNAMDIDr. Taylor, Howard Universities College of Medicine did particularly well on this ranking methodology. Obviously, as a historically black college, Howard has a higher percentage of minority students. But those students also seem to be choosing slightly different career trajectories. What was your take?

TAYLOROur take is that we were very pleased. Howard -- service and social mission is what Howard does, as you know. Our college of medicine, indeed, our university, was founded over 140 years ago on a mission to provide service to the underserved. And we accept students based on that premise and we interject the theme of mission and service throughout the four years of medical school. We, in fact, get it in through their DNA. So it's not surprising to me that we do well in this.

NNAMDIHoward University, Morehouse College, Meharry Medical School did very well on this. They were in the top three as a matter of fact. Schools that did poorly included Johns Hopkins and Georgetown University. I had the opportunity in February of participating in a black history month presentation at Morehouse Medical School and I, frankly, was impressed by the level of historical knowledge that the students there showed. It was almost as if I was in a liberal arts situation rather than in a medical school situation. Does the university do anything specifically to try to inject that level of social consciousness in its students?

TAYLORWe do. We talk about health policy, we talk about the history of Howard University College of Medicine. We have great teachers who historically have been able to provide a historical frame work of why we exist as a college of medicine. And, in fact, we have activities throughout the four years of medical school that attempt to instill in our students the concept of service to the underserved.

NNAMDIDr. Padilla, you come at this issue from a number of interesting perspectives. As a primary care doctor who graduated relatively recently, you made the decision to pursue this kind of medicine and your clinic offers care to underserved communities. Why did you make that decision?

PADILLAIt was a multitude of factors. I had an interest in primary care, there was -- at the time when I was in medical school, I received a National Service Corps scholarship, which then obligated me to work in a underserved area. But at the time that I received the scholarship, I was already interested in working in primary care and underserved communities, and particularly in the Latino community. So I think it was a multitude of factors that lead me to this career choice.

NNAMDIBut you also recruit young doctors for your clinic. And you say the number one challenge you face is workforce development. What do you mean by that?

PADILLAWell, I think, it's just a -- the pipeline of qualified applicants that are coming in. We've seen a decrease, and particularly we've seen a decrease in the number of family physicians that we're able to recruit into our network. So overall what I'm seeing now is a number of foreign medical graduates that are applying for positions with Unity Health Care and less family physicians in particular.

NNAMDIHere's the math for the next ten years. There are roughly 140 medical schools across the country. By most estimates, America would have faced a shortage of more than 100,000 primary care doctors by the year 2020, even before the passage of healthcare reform which could add 35 million people to the ranks of the insured. Does the current system of medical education produce the right kinds of doctors, Dr. Prescott?

PRESCOTTI think that we do produce the right kind of doctors. We certainly are producing -- we don't produce enough of them right now and we are faced with a challenge of meeting this need, this -- over 100,000 physicians that you were talking about. And certainly the numbers get worse as we go to 2025. We have an aging population, we have a population that's increasingly demanding more medical care. We've got physicians who are changing their lifestyle.

PRESCOTTWe do need all kinds of doctors. We certainly need primary care physicians but without the backup, without additional specialists, without other individuals who can help provide total care, we are going to need -- we actually do need, as I said, all types of physicians moving into the future.

NNAMDIDr. Mullan, is there a mismatch between the kind of doctors we need and the kind of doctors we are, in fact, producing?

MULLANWell, as a country, the United States is very specialty heavy and primary care short. If you look at developed industrial countries such as ours, we are at one end of the spectrum. And we've headed in that way over the last half century with a little turn around in that. There was a brief period in the 1990's when students showed a greater interest in primary care on the beliefs that we were going to have health care reform at that time, and, of course, we didn't.

MULLANThe incentives, it should be said, in specialty care, this is once in practice, are much greater than in primary care. We pay about on average twice as much for a specialist as our generalist. And that's got to be a bit discouraging for people looking down the road. So there are a number of things that can be done outside of medical education but medical education is key because medical schools do the recruitment. The people who are your doctors today were selected by a dean of admissions at some point in a medical school, and the doctors in the future will come the same way.

MULLANSo what those schools do in terms of who they select and then the four years that the students spends in the school, what sort of educational environment, curricular offerings and what sort of role models and attitudes they encounter are very important, and I think a lot could be done there to make things different.

NNAMDI800-433-8850 is the number to call. We're talking about whether or not American medical schools should, in fact, have a social mission. 800-433-8850, here is Patricia in Mount Airy, Md. Patricia, you're on the air. Go ahead, please.

PATRICIAThank you for taking my call. I am very interested in when there's mention of the medical schools throughout the United States. Why are there not information given about the osteopathic medical schools which are as equal to the M.D. program and yet they also have the added dimension of osteopathic manipulation techniques which help keep the body in a holistic state? I've rarely heard reference to osteopathic medical schools.

NNAMDIWell, we've done at least one show on it on this broadcast and with your suggestion, we may be doing more. But, Dr. Mullan?

MULLANIn our study, we looked at osteopathic and allopathic medical schools. For listeners who are unaware, there are well over 20 osteopathic schools and about 130 allopathic schools today. In the period we looked at, there were 141 of both and we rated them. You will be interested to know that osteopathic schools did better in two of our dimensions. They produced a higher percentage of primary care physicians and higher percentages of physicians in shortage areas.

MULLANThey did not do as well in terms of under-represented minority admissions.

NNAMDIPatricia, thank you very much for your call. Dr. Taylor, Dr. Padilla -- well, Dr. Taylor first. Why are primary care doctors so important?

TAYLORThey are important because they're the first line in the health care system. Most physicians, most patients don't end up going to specialists right out the bat. They provide a first line of defense. They're a triage mechanism to sort out what direction a patient needs to go in. Generally they are more broader in their approach to disease states. And they're more generalist in their practice. So they are very important for the health of the nation and to the community.

NNAMDIWe got an e-mail from Emily who says, "How can new doctors not be enticed by higher paychecks associated with specialty practice. When our legislators can get it together and stop cutting physician reimbursement from Medicare patients, then maybe we can recruit quality doctors to primary care." You think that's one of the problems, Dr. Padilla?

PADILLACertainly salary disparities is a big deterrent when you look at the average salary of a primary care provider versus a specialist. But I would also add to Dr. Taylor's list of the importance. And I think this is a primary question for us because I think primary care right now is battling for its existence and people are saying why do we need primary care when we can provide care with subspecialists. So I would say care coordination, increasing health disparities, increasing access to preventative treatments, reducing health care costs. I think this adds to the list that Dr. Taylor mentioned.

NNAMDIDr Mullan, let's talk about cost. Medical degrees are very expensive. And like most professional degrees, they are getting more costly. If the average medical student graduates with a gigantic debt hangover, is that why so many decide to choose specialties?

MULLANWell the debt level of medical students today is extraordinary, depending upon whether it's a public or private school. On average, it's well over $150,000 for the graduating student. Now when you go onto life with that kind of medical mortgage hanging over your head, you're bound to think about finances. However, it must be said that to date, all of the studies that have been done to look at what this is doing to career selection, specialty choice, does not show that people in primary care are shying away from it because of cost. That is, people who choose primary care, many of them have large debts, what they also have is commitment. And they can work that down over time. So, yes, debt is a problem. Yes, debt is a disincentive in many ways, but at least thus far those students who have been educated in, and seem to have the passion for, primary care continue to go there.

NNAMDIDr. Prescott, the idea of debt, does that worry the Association of American Medical Colleges?

PRESCOTTIt's one of our primary concerns. And as Dr. Mullan had just talked about, it is a -- the debt is enormous and we are pleased at least that it does not seem to be a major factor with the selection of specialties at this point. But for students to graduate with this much debt, there are individuals who don't even consider a career in medicine. Sometimes when they simply hear about the debt that medical students face, there are many options that students can take as far as dealing with that debt. And I think that once those things are explained and once schools and other societies get the word out about how students can actually deal with the debt, we'll find more and more students actually looking at careers in medicine.

PRESCOTTYou know, as Dr. Mullan had mentioned before, there are many issues that are out there that affect why a student will go into primary care or why they decide not to go into primary care. And I think that's important that we look at the work environment that is provided to students who are going into primary care.

NNAMDIGot to take a short break. And when we come back, we will continue this conversation on whether or not medical schools, American medical schools, have or should have a social mission. But we're still taking your calls at 800-433-8850 or you can comment or ask a question on our website, kojoshow.org. If you've already called, stay on the line, we will get to your call. I'm Kojo Nnamdi.

NNAMDIWelcome back, we're talking with Dr. Fitzhugh Mullan, professor of medicine and health policy at the George Washington University School of Public Health and a clinical professor of pediatrics at George Washington School of Medicine. He was the lead author of a report last year titled "Social Mission of Medical Education: Ranking the Schools," which appeared in the June 2010 issue of the Annals of Internal Medicine. Also with us is Dr. John Prescott, chief academic officer at the American Association of Medical Colleges. Dr. Robert Taylor, dean of Howard University's College of Medicine, where he also serves as chief academic officer. And Dr. Luis Padilla, medical director and a family physician at the Upper Cardozo Health Center in Washington, D.C., which is part of Unity Health Care.

NNAMDIDr. Taylor, having a school like Howard or George Washington or Georgetown in your jurisdiction has all kinds of positive benefits for a city. Many people, however, feel that medical schools owe more to their home community than just treating illnesses and delivering babies. Is there a contract, if you will, a social contract between a college and its community, a medical school and its community? I know that for -- I've been associated with Howard University for more than 30 years and I used to live in the Shaw neighborhood for 20 of those 30 years, where most of my neighbors felt that Howard University Hospital was their neighborhood public hospital and treated it as such.

TAYLORAbsolutely. I think that there is a social mission that institutions like Howard feel we have to fulfill. And I think historically we've done that. Our patients -- we have patients that come to our hospital that have been patients for 30 years or longer. And they wouldn't dream of going anywhere else. I think we fulfill that social mission by having our own hospital. Howard owns its own hospital unlike other medical schools, most medical schools. The hospital business can be quite challenging. In addition to that, I think we do a lot of things in the community. For example, we opened a student-run clinic that takes -- provides free care. We will be opening a school health program at Coolidge High School, for example, in conjunction with the Department of Health. So we have a lot of neighborhood community programs in education as well as research.

NNAMDIDr. Padilla, same question, do you think there is indeed an unexpressed social contract between a college of medicine and the community it's in?

PADILLAI do. I think that for a couple of reasons. The most obvious is the financing. The majority of medical education both medical school and residency, particularly residency, is publicly funded. I think Dr. Mullan will speak more on this, but $9.6 billion in residency education are taxpayers. So I think the money alone kind of calls into question what the obligation is for the academic health center and its responsibility towards the community. Also, the community needs. I mean, we're talking about health disparities. We're talking about access to care. We're talking about workforce issues that unfortunately haven't been met by medical schools or academic health centers.

NNAMDIDr. Prescott, are medical schools in fact not living up to that implied contract with their communities?

PRESCOTTWell, I have to disagree with the speakers. Medical schools are living up to the social contracts. Medical schools do have a social contract with their communities and their communities can be defined, it could be the local community for some schools -- I mean, I was the dean at West Virginia University School of Medicine, we had a contract with the state. We were the state's medical school. And many other medical schools in states feel the same exact way. That's their community. And we have other schools, like our Uniformed Services School of the Health Sciences, which has a national contract. They do have a national mission. And I believe very strongly that schools go out of their -- they state their mission. They follow their mission and they do kind of contribute to their communities.

NNAMDIWhat good, therefore, are rankings, Dr. Mullan? Your ranking system shows us that schools like Howard, Meharry, Morehouse are living up to their social contract and that some other schools may not be.

MULLANI think the importance of ranking is it allows all parties to look at the data. It is easy for any institution in any setting to claim that it is doing a certain mission. But the question is what are the facts? In this day and age in clinical medicine, we have gotten very good at demanding outcomes research, not simply that an intervention took place, a surgery took place, a medication was given, but a month, a year, five years since what does that mean in terms of outcomes? Is the patient alive? Is the patient doing well, and what is the relationship to the intervention? In medical education, we haven't done that very often, looking downstream. Our study looked at the graduates when they were actually in practice and then walked backed to their schools and identified them by schools. And what we found was quite a broad range of responsiveness to the social mission.

MULLANCertainly schools have different missions, either stated or presumed, and certainly a variety of expressions that would be expected. But for each school and for the country as a whole, when we are faced as a country as a whole with a huge mission, that is caring for everybody, and particularly now we put energy into the underserved, how are we gearing up to deal with that and how do our schools position themselves to deal with that. I think that's what the study laid forth.

NNAMDIAnd by the point that Dr. Padilla made that, in fact, I am paying for the residencies and internships, does that make it a part of the social contract?

MULLANI think it certainly does. Most schools have actually legal contract, state schools clearly have a relationship to the state based on the funding from the state legislature. Private schools who are not taxed have a community benefit presumption, which is tracked in various ways, often not terribly carefully. But there is a presumption, I do believe, on both the public and private side that medical schools do have a commitment to the community and particularly to what in this day and age we'd call social mission, which is very much on the national agenda.

NNAMDIHere is Neil in Silver Spring, Md. Neil, you're on the air. Go ahead, please.

NEILHi, Kojo. Yeah, hopefully -- anyway, my son has put himself through medical school and is doing residency at Mayo Clinic and he's accumulated probably close to $250,000 to $300,000 worth of debt. And I would make a suggestion that the Medical Association might want to approach Congress and ask Congress to change the tax laws so that these educational expenses can be capitalized and, if you will, depreciated or amortized, written off over a reasonably short period of time. You know, four, six, eight years, and that way the risk would be substantially reduced to these medical students who, frankly, they sacrifice a huge amount of their youth and so on and so forth.

NNAMDIDr. Prescott?

PRESCOTTThe caller has a good idea and actually there are several ways in which to deal with that debt. There are programs, the National Health Service Corps, something the WAMC strongly supports is a wonderful program. And if your son is interested in doing primary care, it's a great way of helping to pay back some of those loans. Certainly, there are ways in joining the military along the way, which might be a way again to get some additional funding to help pay those loans back. As far as working through the other mechanics, changing the tax law, that I can't really help you with and I don't know enough specifics as to help recommend a specific course with regard to that. Go ahead.

NNAMDIYou wanted to say something Dr. Mullan?

MULLANWell, I think the question that the caller puts to us is a really tough one. And I would reemphasize the notion that when medical students are prepared to practice primary care and do it in shortage areas, the National Health Service Corps provides that. It was doubled by the stimulus bill, that is, the amount of money and ultimately the amount of positions in the National Health Service Corps. And with the health care reform law that doubling will be permanent and grow. So there's going to be good opportunity for young people in medicine, many of whom have a passion for equity and have a passion for what might be called social mission to see themselves through school even with scholarships or loan repayments provided by the National Health Service Corps. And the tradeoff, the covenant there is between the government that will pay to have folks go to shortage areas in return for reimbursing them or paying for their medical education. That's a pretty good deal and it's out there and we hope more students will take advantage of it in the future.

NNAMDIDr. Padilla, is that something you took advantage of?

PADILLAI did, I did. And I also serve on the National Service Corps Advisory and the National Advisory Council as well, so I'm a big proponent of it. I was wondering if I can just go back to Dr. Prescott. He made an interesting comment about looking at the environment in which primary care providers work and operate and that being a factor in driving people to that career. I think that that's true, and also the environment in which those learners are taught. My experience at Wake Forrest, and I think I got a very good education at Wake Forrest, a private education, expensive. But the environment wasn't always friendly to primary care, and in particular, it wasn't always friendly to family medicine.

PADILLAI think when students are interested in that, they should be encouraged, there should be stronger mentoring, there should be more positive role models. And, unfortunately, many of us, at least myself, got the experience when you declare that you want to be a primary care doctor and it was like, oh, why do you want to do that? You're smarter than that. So I think that there is, you know, there are a lot of work that we can do in our profession to really encourage young learners to do that and make that a positive career.

NNAMDIDr. Taylor, historically, black colleges and universities came into existence when there were no opportunities for African-American students in mainstream academia. But today, that is no longer the case. Why is it do you think that Howard and Morehouse and Meharry nevertheless attract students, mostly minority students, who have the sense of primary care mission, if you will?

TAYLORYeah, I think it's mostly legacy and I think it's how we teach our students and what our passion is. I think that from day -- from even during the interview, we discuss service and this social mission concept. And from day one, we are talking about it and modeling it in our students. So our biggest recruiters are our students, it's not the admissions committee, it's the students that they interact with when they come for their interview. And they have a sense of family, they have a sense of legacy, they have a sense of purpose and this passion is contagious. And students are driven to Howard because of that.

NNAMDIWhich doesn't seem to be the kind of environment you experienced at Wake Forrest, Dr. Padilla.

PADILLANo, and again that was my own personal -- I mean, I'm sure maybe Dr. Mullan had a different experience, but I've heard this as well from other medical students that, you know, depending on where you are, you may not be going to a school that has that kind of strong legacy in primary care and it may not be as friendly.

NNAMDIOn to John in Westminster, Md. John, you're on the air. Go ahead, please.

JOHNYes, can you hear me?

NNAMDIYes, we can. We can hear you very well, John.

JOHNGreat, thank you, Kojo. Thanks for having me on the show. I'd like to say I'm a family nurse practitioner. I have been for 22 years. I've had the pleasure of working with many family practice physicians and specialists. And what they offer to the patients in the United States is just phenomenal. And I'd also like to add that with our change towards primary care, I would just like to reiterate the point that family nurse practitioners and other nurse practitioners and the effect that they can have on the direct patient care especially from a primary care standpoint.

NNAMDIAnd I guess you'll hear a chorus of amens around this table to that. Dr. Mullan?

MULLANThe presence of nurse practitioners and also physician assistants in the clinical workforce is very important. This is an American creation. The nurse practitioner and the P.A. were invented literally in the 1960s and have grown, so there are almost 100,000 nurse practitioners and almost that many physician assistants working amidst the physicians of the country and providing care as we speak. The key thing is in primary care that nurse practitioners have been more steadfastly acting primary care, PAs are acting more like physicians, roughly two-thirds in specialties, one-third in primary care. A lot could be said about that, but in the main they're a terrific asset, and we need more of them as we strive to cover all of our citizens.

NNAMDIJohn, thank you very much for your call. "This is a question specifically for your guest representing the Association of American Medical Colleges. Isn't one solution to our shortage of physicians simply to allow accreditation of more med schools?" Dr. Prescott?

PRESCOTTSimply having more medical schools will not solve the problem with regard to the number of physicians that we need for the future. We are going to need -- it's one of the things that we're doing. We're expanding class sizes and we are actually increasing the number of medical schools. And currently, we have 133 U.S. medical schools. We also have osteopathic schools, the number is 20 plus of those schools. But (unintelligible) class sizes increased.

PRESCOTTBut then comes a point in which students go on and get through their residency programs and go on to graduate medical education, and that number has changed very little over the past several years. If that number stays the same, we will graduate basically the same -- well, we'll continue to graduate more physicians, but we'll only have a -- we'll have a bottleneck with regard to our graduate medical education, and we will not be seeing more and more physicians practicing in the U.S. because of the limitation on the graduate medical education.

PRESCOTTSo that's -- we can increase the class size, which we're doing. We're hoping that Congress increases the number of students that it helps sponsor through residency programs, and we think that will be an important aspect to this in the future.

NNAMDIHere's Anne in Woodbridge, Va. Anne, you're on the air. Go ahead, please.

ANNEAll right. Thanks for taking my call. I love your show.

NNAMDIThank you.

ANNEI wanted to just put this in, because I've been thinking about this issue. Why there isn't an ROTC-type program for doctors, they could go in, totally paid, have to serve in "country clinics" for four years, and then they come out with lots of experience, plus their education and no debt. In the meantime, people could come in with their tax forms, their tax returns, and say, this is how much I did make or didn't make, and that's how much then you prorate it on how much you pay to see this primary care physician.

ANNEIf you don't make any money, then the government's going to pick up that $20 fee. If you make $20,000 a year, you can pay $20 or $40 for your visit.

NNAMDII don't know if that's the...

ANNE(unintelligible), nothing, you know.

NNAMDII don't know if that's the basis on which the National Service Corps operates, Dr. Padilla, but I'd be interested in hearing your comment.

PADILLAIt is. The National Service Corps has two major programs. It's available both for physicians, osteopaths, allopaths, nurse practitioners, P.A.'s. It has a scholarship program that provides your medical education funding, which I took advantage of, and then it also provides loan repayment opportunities for you to pay back. In addition, the community health center network is exactly what she's talking about.

PADILLAWe charge our patients on a reduced scale based upon the income that they make. If they have no income, they don't get charged.

NNAMDIGotta take a short break. When we come back we will continue this conversation on the social mission of medical schools. If you have already called, stay on the line. If the lines are busy, you can shoot us an e-mail to kojo@wamu.org, or go to our website, kojoshow.org, make a comment or ask a question there. You can also send e-mail to kojo@wamu.org. I'm Kojo Nnamdi.

NNAMDIWe're talking about a social mission of American medical schools with Dr. Robert Taylor. He is dean of Howard University's College of Medicine where he also serves as chief academic officer. Dr. Fitzhugh Mullan is author of a report titled, "Social Mission of Medical Education: Ranking the Schools." He's a professor of medicine and health policy at the George Washington University School of Public Health.

NNAMDIDr. John Prescott is chief academic officer at the association of American Medical Colleges, and Dr. Luis Padilla is medical director, and a family physician at the Upper Cardozo Health Center in Washington, D.C. Back to the telephones. Here is Becky in College Park, Md. Becky, you're on the air. Go ahead, please.

BECKYI have a question about the ranking -- the criteria for ranking. Because what I did not hear in there is advances in research. And you specifically mentioned Johns Hopkins and Georgetown as being low in the rankings, but those are schools that are noted for research. Practicing physicians can improve the health and wellbeing of possibly a few hundred patients, but a real research breakthrough can cure hundreds of thousands or millions of people. So why didn't you include that in your social contract?

NNAMDIIndeed, Dr. Mullan, for people like myself who have never pursued a medical education, we perhaps tend to think of medical schools as basically producing the same kind of doctors and the same kind of academic work, but there have always been researched focused schools and schools that focus more on things like primary care, hasn't there?

MULLANThere certainly has been a growing emphasis on research in many schools. And since the middle of the 20th century, when the NIH became a very strong supporter of research, we've seen certain institutions step out in that regard, and that is obviously in the public interest. That is what generally is called public good. In our study, we attempted to look at the educational mission that is common to all medical schools.

MULLANResearch can be done surely by medical schools, but there are independent research institutes, there are pharmaceutical companies, there are universities in other aspects who do research. Likewise, in patient service, there are many other places that patient service is done other than medical schools, but education can only be done of doctors in medical schools. So that is undeniably a core function, and we were measuring education to education.

MULLANAnd research is a prominent feature and a very valuable feature of many schools. We did look at the amount of NIH funding received, compared to the schools ranked in the social mission. And there is a relatively inverse relationship, that is, the more funding for research there was, the lower the social mission score, which some people consider obvious, others consider well, why is this. Why is a research intensive institution not likely to be as contributory to these population health concerns as they might be.

MULLANAnd I think that's an important question. Finally, it is important to note, we looked at both the outcomes in research, and the outcomes in social mission, and in the top quartile, the top 25 percent of schools for social mission, and top 25 percent schools for NIH research dollars, there were actually six schools that scored in both. So it is good evidence that you can be a research intensive school, and also be quite productive in terms of the social mission of medical education, which I think is a lesson we should all look at hard.

NNAMDIIn that ranking system, here's how some of the local schools ranked. Howard University College of Medicine was third; University of Maryland School of Medicine, 36; George Washington School of Medicine, 60th; Eastern Virginia Medical School, 79th; VCU, Virginia Commonwealth University School of Medicine, 85th; University of Virginia, 99th; Georgetown University Medical School, 110th; and Johns Hopkins, 122nd.

NNAMDIWe got this e-mail from Stephanie who said, "I'm a 31-year-old former teacher. I did Teach for America, served on the Navajo Nation who will be a first year medical student at Eastern Virginia Medical School this August. I'm thoroughly committed to primary care medicine. A few comments. One, I only applied to medical schools that had a strong reputation for community service. I cannot fathom medicine without a social mission.

PRESCOTTTwo, I was accepted to several out-of-state and private schools, but could not justify the cost of attendance if I want to be realistic about choosing a primary care residency. And three, the National Health Services Corps is an interesting option, but the loan repayment is currently only $50,000 for two years of service. It doesn't come close to the average medical student indebtedness. It must also be said that the reputation of the NHSC among medical students, is not always a positive one." And I have no idea what she's talking about, Dr. Padilla. I know -- I have no understanding why she said it's not a positive reputation.

PADILLAWell, firstly, the amount that she's speaking about is for a two-year obligation, but if you do five years, the total is $145,000. So I do encourage her to look into that and then extend that obligation. In terms of the National Service Corps reputation, I've heard that as well. But it is turning around, there's additional funding. I think there is additional -- look at that agency in terms of what it needs to provide that underserved work force.

PADILLASo I think, what I've seen in the National Service Corps in the last three years is a major turnaround in terms of their customer service, in terms of the satisfaction that their scholars and loan repayers have with the agency, and a commitment by that agency to really gear up and address the work force needs across the country.

NNAMDIDr. Prescott, you had a comment?

PRESCOTTYes, I did. I just wanted to agree. I think that the National Health Service Corps is a wonderful organization, and I would strongly encourage the caller to reconsider. It's a -- it's truly -- I've never heard of the complaints with regard to reputation, and it's actually even something in which people have -- it's something you strive to -- to actually belong to. It's funny, in my class many, many years ago at Georgetown, 70 percent of our class were on service commitments, either National Health Service Corps, or military scholarships.

PRESCOTTAnd these were very important. And so you are getting good individuals to go into these programs, and they have wonderful reputations. I really do believe that she should reconsider.

NNAMDIDr. Taylor, we got this email from Garrett. "Please describe the current opportunities for students to engage in the community while they are in the medical school training."

TAYLORWell, there are numerous opportunities for community participation. As I mentioned earlier, we last year opened a student-run clinic, the so-called, New Freedmen's Clinic. We're grateful that the WAMC funded us for a portion of our financial portfolio, and we funded through the dean's office. In that clinic first-year students serve as the front line registering patients. Second-year students do other kinds of things like vital signs. Third-year students, along with attending physicians, see the patients.

TAYLORThere are people from -- there are students from the business school, social work, all interacting in a team-based patient-centered kind of relationship. There are also opportunities for national and international mission work. We've sent students to Haiti, we've sent students to Africa, and to other countries. So there are lots of opportunities, and we encourage that as a part of the service learning requirement that we have at Howard.

NNAMDIOn to Josephine in Silver Spring, Md. Josephine, you're on the air. Go ahead, please.

JOSEPHINEThank you, Mr. Nnamdi. I am a first-year resident in family medicine. I went to the Medical College of Virginia, and actually at the time that I went -- I graduated in 2007, they placed a lot of emphasis on us training to become primary care physicians. And we went out to the clinics and worked with doctors, and it left -- I mean, it left an impression on me, you know. I learned so much from that that I wanted to become a primary care physician.

JOSEPHINEHowever, most of my classmates like everywhere else, did not go into primary care. My concern, or my -- as I've done my first year of medicine -- of residency, I have wondered why there are so few fellowships for primary care physicians. It's almost like we're cut out of fellowships all together. And I think that if primary care physicians could do more fellowships, this would solve the problem of shortage of primary care physicians, and also reduce -- I mean, make it more attractive to students to come into primary care.

JOSEPHINEYour pay would be better, there would be less of a need for some of the -- for some of the specialties. For example, I am interested in doing a fellowship in obstetrics and gynecology. My concern, however, is that (unintelligible) highly trained enough to do deliveries and cesarean sections, that I will have trouble getting hospital privileges, I mean, because of the fact that I'll be competing against obstetricians and gynecologists, despite the fact that I can do cesarean sections if I'm well trained.

JOSEPHINESo I was just wondering what your panel thinks about that.

NNAMDIDr. Mullan?

MULLANI believe by fellowship you mean training beyond residency; am I correct?

JOSEPHINEYes. Like one -- one year of obstetrics and gynecology. That's all I need, and I feel like I would be of greater service to my community, where I could like to go into an underserved community, be able to provide the whole spectrum of primary care, including obstetrics and gynecology, where I should be able to deliver babies, and also do cesarean sections.

NNAMDIOkay.

MULLANThere are a number of fellowships associated with all disciplines, and they are perhaps less in primary care, and you make a good point on that. I think the most important, or the most troublesome issue, however, is people selecting residencies in primary care, particularly in family medicine, which a number of years ago were hotly sought after by U.S. graduates, particularly in the mid-1990's.

MULLANAnd then for a variety of reasons, became less popular, and today something -- over half the positions are not filled by U.S. medical school graduates. That is, when they graduate from school, they do not select primary care. So this is a problem for the -- developing the pipeline into practice for family medicine, and for other primary care disciplines. General internal medicine, the general internist that takes care of you or your parents, is someone who is now in increasingly short supply.

MULLANMore and more internists are sub-specializing, and of those who don't subspecialize, many take jobs as hospitalists where individuals work in the hospital and coordinate care. A valuable asset in the hospital, but they are not selecting community-based primary care internal medicine, and therefore, it will be harder for you and me and others to find general internists when we want care. So those are the problems with the pipeline, which are not an easy fix for anybody.

MULLANThe point of this study is that medical schools which are the launch pad can do more to both expose people, paint a positive picture, and work with young people and the system to make it more user friendly on the primary care side, and produce more graduates into primary care, and shortage areas and (word?) , which is what the country desperately needs.

NNAMDIJosephine, thank you for your call. Good luck to you. Here is Emeru in Washington, D.C. Emeru, your turn. We're running out of time. Please make your question or comment brief.

EMERUOh, sure. Kojo, this is a very important program. I thank you very much. I have a question for the panelists. Why is it that foreign graduate physicians who undergo, you know, so much scrutiny, and thousands of physicians are out there who are qualified to do the job, but who are not allowed into a residency program? They have to go through -- maybe they have to wait five, six, ten years before they are allowed to go into the residency program. What is the reason?

NNAMDIDr. Prescott.

PRESCOTTWe certainly encourage, and we do have foreign medical graduates come into the United States all the time and enter residency programs. There are requirements that they must fulfill. We do that to make sure that we have physicians who are capable of working well within the U.S. health care system, and who have the proper knowledge base and the skill sets that we're looking for.

NNAMDIAnd I'm afraid we're running out of time very quickly. Emeru, thank you very much for your call. I wanted to share this e-mail that we got from Chris in North Bethesda. "Would shifting to the British educational model, where students enter their medical studies as undergraduates attract more students because they would have to complete fewer years of total education, and presumably incur less expense?" Maybe, but probably not going to happen, Dr. Taylor.

TAYLORYeah. Actually, at Howard, we do have a BS M.D. program. It's a six-year program, and about 10 percent of our class each year is accepted into that program. Some of our most competitive applicants do quite well. Interestingly enough, most of them don't go into primary care.

NNAMDIAnd I'm afraid that's all the time we have. We'll have to get into the reasons for that on another occasion. Dr. Robert Taylor is dean of Howard University's College of Medicine. He also serves as chief academic officer. Dr. Luis Padilla is medical director and a family physician at the Upper Cardozo Health Center in Washington. Dr. John Prescott is chief academic officer at the Association of American Medical Colleges.

NNAMDIAnd Dr. Fitzhugh Mullan is professor of medicine and health policy at the George Washington University School of Public Health, and lead author of a report titled "Social Mission of Medical Education: Ranking the Schools." Thank you all for joining us, and thank you all for listening. I'm Kojo Nnamdi.