Robert C. Bowman, M.D.
Physician distribution is often presented as difficult, unlikely, possible in only a small group of medical students, or a function of poor economics and education in rural or underserved areas.1, 2 However distribution is unlikely only in a minority of the medical student origins. Only the medical students with origins in the top 30% of the nation are unlikely to distribute. This is the group most connected to major medical centers and medical schools by income, urban origins, or parents who are physicians or professionals. Because 70% of admitted medical students come from this minority 30% of the population that rarely leave major medical center locations, distribution is difficult.
Distribution to rural and underserved locations beyond physician national averages of 11% and 7% respectively is possible only under specific conditions. One condition is selection of trainees with origins outside of major medical centers: rural, lower income, middle income, or underserved. The second condition is specific choice of family medicine, a choice that doubles distribution levels outside of major medical center to rural and to underserved areas. In some specialties including family medicine, distribution levels are increased with older graduates. Some of this distribution is due to inner city or rural origins that delay entry to medical school and result in older age graduates, but older age also includes different life experiences. Combinations of factors greatly enhance distribution such as older age, distributional origins, and choice of family medicine. Distribution by age, by maturity or other factors related to age, or by selection of those most committed to family medicine is the likely explanation for enhanced accelerated graduate distributions.
Accelerated grads are the oldest group yet discovered. In elite non-distributional schools about 18% were older than 29 at graduation, 22% was the norm for all US MD Grads, 28% are older for all choosing family medicine, and 56% of accelerated grads were older, twice the level of family medicine and three times the level of elite students. Second and third careers and expanded life experiences are the rule rather than the exception. Older graduates are less likely to be the children of professionals.3 A related factor is that they are less likely to be born in counties with medical schools, counties with the highest levels of professionals. These both mean that older graduates are less connected to major medical centers by geographic proximity and by parents. Older graduates clearly have double the choice of people careers such as family medicine and psychiatry. They also have had prior careers involving areas such as teaching or ministry as described in those most service oriented by Madison.4 Older graduates are also known to be more service oriented, along with females, married students, and those with a business-like approach as described by O’Connor.5 Rural interested seniors were about 4 years older, were more likely to be married, attended rural high schools at high levels, chose family medicine at 68% levels, and volunteered to serve the underserved at twice the levels of other students throughout medical school. They were twice as likely to know their final career before medical school (early commitment); twice as likely to be dissatisfied with their medical school experience; twice as likely to leave major medical centers for volunteer, elective, rural, international, and military experiences; and 5 times more likely to be interested in a socioeconomically deprived area.6 Those forced to decide a year earlier may have greater commitment to family medicine and to distributional careers.
Younger graduates are more likely to be found in elite schools, subspecialties, and major medical center locations. Older graduates are more likely to be found in schools graduating family medicine, primary care, rural, and underserved physicians. Osteopathic medical schools have 30 – 40% older graduates, greater rural and underserved distributions, and the highest levels of family medicine choice. The enhanced distribution of accelerated graduates appears to be related to older graduates and graduates who are more committed to family medicine.
1. Cohen JJ. Why doctors don't always go where they're needed. Acad Med. Dec 1998;73(12):1277.
2. Kassebaum DG, Szenas PL. Rural sources of medical students, and graduates' choice of rural practice. Acad Med. Mar 1993;68(3):232-236.
3. Harth SC, Biggs JS, Thong YH. Mature-age entrants to medical school: a controlled study of sociodemographic characteristics, career choice and job satisfaction. Med Educ. Nov 1990;24(6):488-498.
4. Madison DL. Medical school admission and generalist physicians: a study of the class of 1985. Acad Med. Oct 1994;69(10):825-831.
5. O'Connor SJ, Trinh HQ, Shewchuk RM. Determinants of Service Orientation Among Medical Students. Available at www.sba.muohio.edu/management/mwAcademy/2000/38c.pdf . Oxford, OH: Miami University Farmer School of Business; 2000.
6. Bowman RC, Schuchert M. Rural Interested Senior Medical Students. AAMC Graduation Questionnaire. 1995.
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For info on the databases, sharing research, or ideas - rbowman@unmc.edu