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Medical schools are expanding.

That is nothing new in osteopathic medical education. The osteopathic schools have been expanding for some time. 

In 2010, there were 26 osteopathic colleges in 34 locations, which enrolled 5,428 entering students. When I started watching these numbers in 1977, there were only 12 osteopathic schools, and the entering class was 1,163. Osteopathic doctors were still fighting for recognition as "real doctors" — which became hard to deny once they were drafted for service in Vietnam. 

The biggest change in my 50 years of involvement with medical schools, and a major rural breakthrough, has been the growth of osteopathic medical education.

For 30 years (1972-2002) the number of M.D. training schools and admissions slots was pretty constant — around 126 schools and 16,500 entry positions. In 2003 the Association of American Medical Colleges (AAMC) determined that we are bound for a doctor shortage. Their thinking was that the population is growing, Americans are getting older and sicker and will need more care, and, if we insure our whole population, the newly insured will use more doctoring. 

Sounds reasonable. The association recommended that its members expand admissions by 30 percent. Its membership is on track to do so, with 136 member schools planning to offer 21,000 slots to would-be M.D. students in the fall of 2013.

I have a few quibbles. The real issue in American medical education is geographic distribution and specialty distribution. It doesn't matter how many doctors you have if they are of the wrong kinds and are in the wrong places — as they have been throughout my 50 years of medical school watching. 

Most of the allopathic (i.e., M.D.-degree-granting) schools deny responsibility for their alumni's careers, though exceptional schools like the University of Minnesota School of Medicine at Duluth show how remarkably effective a school can be at admitting and preparing students for rural careers even with limited curricular time and resources.

From 1975 until 1998, I reported directly to medical school deans in a succession of schools. My work involved liaison with legislators in five different states, and included such tasks as setting up legislative hearings, gathering data and drafting reports for legislators on, for example, how many students from state A were practicing medicine in state A. 

I worked for eight different deans in three different medical schools. At one point I drafted a report for a regional legislative conference of state legislators that might have been called, "How to Tell When Your Medical School Dean is Presenting Deceptive Information and What Follow Up Questions to Ask." 

It began with the classic prevarication, "Over 50 percent of our graduates are going into primary care." Deans using this statement knew that their graduates started internal medicine or pediatric residencies but that most would keep going straight into the subspecialties.

These eight men (and they were all men) were as varied as any other bunch of business executives — two were scrupulously honest, one not so much. Several were good businessmen; one was not. I could wax lurid. 

But these deans were treated with deference by the legislatures, which I never understood. They were treated differently than were other witnesses, even their university bosses, who would eventually fire them. That legislative deference, that reluctance to ask the hard questions, was not in the best interest of the people of the states paying the bills.

I did notice that the school with cancelable contracts with surrounding states maintained much more robust rural programs than the school with the rural legislative mandate but no legislative oversight.

Too few primary care doctors and too few rural doctors: readers of this column know the pattern if not the details. Here's one easy way to understand and remember the situation, which has held fairly constant for the past 50 years: the percentage of doctors practicing in rural areas is about half the percentage of the rural population. 

Another rule of thumb: We need half our docs in primary care. We now have about 30 percent. And the numbers are getting worse.

Npw that medical schools are expanding, there is an opportunity for state legislatures to get into the habit of asking hard questions of their state medical schools and building some accountability into their reporting systems. 

For example, in a typical state medical school state appropriations may account for less than 5 percent of revenue, tuition another percent or two. This pays for all the undergraduate medical education. 

In many schools faculty practice plan and research receipts may account for over 90 percent of the total. The school will be glad to talk about research receipts but not their practice revenue. The legislature and its staff should require detailed understanding of the many practice plan accounts and why some practice revenues should not help offset teaching costs, tuition and, hence, student debt.

We know, and medical schools know, how to prepare and select applicants for admission who are likely to become primary care docs and to practice in rural areas. At this point, though, most schools have no incentives to meet national workforce needs. 

They appoint admissions committees from the faculty who select young people for admission who look like the faculty members looked at age 22. In other words, exemplary young people who have a probability of practicing in a rural community of about 3 percent.

It's your job to work with key legislators. Get them interested. Keep them interested. Help them ask the right questions. That medical school dean may be a nice person but s/he's just running a large public utility and getting a lot of public perquisites for doing it. 

Is s/he delivering the product you're paying for?

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine. This column first appeard in the Rural Assistance Center Winter newsletter.