Divisions in Physician Career and Location Choice Related to Age at Graduation

Robert C. Bowman, M.D.

The more things change the more they stay the same. Physician workforce has been in a constant flux under the assault of changes in medicine, health policy, American education, and patterns of immigration and migration. Longer term trends have progressively changed areas such as student income levels, concentrations of income, and the availability of opportunity. Other areas such as subspecialization, practice patterns, training methods, Medicare, Medicaid, and dominant types of medical schools have remained relative constants. In recent years schools, students, and class sizes have stabilized to allow closer observation using indicators such as physician age at graduation. A consistent factor such as age can help simplify workforce analysis.

Researchers have studied some of the factors related to older age at graduation. Older graduates may develop interest in becoming a physician after exposure to a health experience or health career. Life experiences may shape a later decision for a medical career.(xu) Others may be delayed in a more consistent fashion that may be worthy of study.

Delays in medical school admission may be due to obstacles of education, income, culture, college finance, professional school finance, or other differences. Those raised in lower income areas or populations may not attempt admission, they may try and fail, or they may gain admission at a later age. Maldistributions of income and education may also delay admission for all except the top 30% who can afford private school, college preparation, college, medical school preparation, and medical school. Higher status students may skip grades, benefit from the steady career advice of parents who are professionals, or gain early admission. Lower income, inner city, and rural origin students can be left behind without steady and significant investments in education infrastructure. Maldistributions can move up the socioeconomic scale to middle class students if allowed to persist and increase.

Progressive changes are most apparent in recent medical school admissions. The 16,000 medical school students admitted each year now include 3000 more medical students from parents making over $100,000 compared to 10 years ago. Medical students admitted from families making less than $40,000 have decreased by 1500 and the middle group has decreased by 1500 as well. The replacement of 3000 medical students each year with the broadest range of origins by 3000 or more of the narrowest range of origins can certainly impact physician workforce.  

If delays in medical school admission correlate with socioeconomic differences and geographic origins, older age graduates my have different career and location choices shaped by more extensive and different life experiences. Those who have been ministers, teachers, and serving professionals favor generalist primary care careers. (Madison, Service Orientation) Two major divisions of medical students emerge with relevance to physician workforce. One group has a broad range of humble origins, different education experiences, and different medical schools for training. The narrow group concentrates in specific colleges, medical schools, and fellowships. This is a group defined by thirty years of life in the most socially organized families, the most urban locations, and the highest income areas of the nation. Even without government investments, this group faces few obstacles to medical school admission. Opportunity for the middle and lower income group is far more dependent upon distributions of education and opportunity organized at the community and state level.  

A few medical schools apparently prefer or recruit older graduates.  Older Graduate Preference Older graduate career choices may fit with the admissions policies of a school or they may fit the mission of the school regarding training or preferences in careers or locations. A few have established admissions tracks for older graduates. Osteopathic schools and the allopathic medical schools graduating the most family physicians have twice the number of older graduates compared to the majority of allopathic medical schools.

For decades those entering medicine at older ages were considered by economists to be less likely to consider a prolonged medical education training involving surgery or a fellowship. This has been based on the assumption that older graduates are aware of fewer potential years of practice remaining and the need to have shorter duration of training. (Ernst and Yett) Massive changes in costs of college and medical school tuition and the costs of living prior to finishing training may shape career choices in different ways.

A number of other changes are likely to impact physician workforce and age at graduation.

·        Changes in Admissions By Age – Older graduates have only recently gained acceptance for admission. During the 1970s expansion, those graduating at older than 29 years of age increased from 7% to 17% of US MD Grads. Changes in age during this time period complicate workforce analysis related to age.

·        Changes in Admission By Origins – Increasing parent income levels and replacements of lower income, middle income, and rural born medical students are a few of the changes. Asian and foreign born medical students have increased to 30% of US MD Grads. These are all changes in admission that mean replacement of the most distributional types of students by those least likely to leave major medical centers. Even with the addition of new sources of youngest age student types, about 22% of US MD Grads remain older than 29 at graduation. Medical students have become both younger and older.

·        New Medical Schools - The medical schools created in the 1970s admitted more diverse students in socioeconomic and geographic origins. Those most different were also older and more likely to be found in family medicine, rural, and underserved practices.

·        Generalist Focus – The general practitioners before 1970 were older and different in other ways. Studies in the 1970s and 1980s tended to focus on generalism and combined primary care studies with less specific emphasis on family medicine. Career and location outcomes can be difficult to predict with a mixed set of subjects.

·        Shifting Sands Over Time - A study of 2500 graduates found 1100 different career pathways. (Zuckerman 1960) Career and location outcomes may well be shaped by the timing after graduation. In past studies physicians tended to move away from primary care and rural locations to specialization and major medical center location. (AAMC longitudinal Study of Medical School Graduates of 1960) These studies involved medical schools that included few physicians in rural states, few if any family physicians, and physicians graduating in a period with little or no expectation of state or federal support. Newer studies involve different schools, different health policies, and a new specialty that does not fit this pattern.

·        Admissions of Black and Hispanic Students – Until Civil Rights, admissions of diverse types of medical students involved only two schools. Limited studies associated exclusive career and location choices for the few Black medical students that were admitted. These studies may represent an atypical sample or the selection of only the most exceptional students. The Black and Mexican American students gaining admission to all medical schools represented the broadest range of origins and demonstrated the greatest interest in locating in underserved areas. (AAMC MIM) Black and Hispanic family physicians are found in underserved locations at 20 – 25% or 4 to 5 times the national mean of 5.4%. (eth)  

·        The New Specialty that Distributes and Lasts - Family practice residency graduates from 1997 – 2003 remained in family medicine at 98% and continued in office based primary care at 90%. Family physicians are found in rural locations at a constant 24% and underserved locations at a constant 10% for each class year since 1975. Both figures are double national distribution levels for physicians. Earlier graduates were found in both locations at slightly higher values. Family medicine concentrations outside of major medical centers remain a defining characteristic that maintain distribution years or decades later. The family physician primary care retention contrasts with all current and past forms of primary care.

·        Primary Care Retention – At least 43% of the 1960 – 1977 class years of US MD Grads that trained in primary care residencies left primary care entirely. More recent graduates do much better and much worse. Office-based general pediatrics has remained a constant 70% of pediatric residency graduates, but levels of general internal medicine have plummeted below 20%.(gar) Medicine pediatrics careers deteriorate throughout the match, residency training, and the first decade of practice to less than 20% levels. Physician assistants across the nation have declined steadily by about 1 percentage point a year for the past ten years in primary care, family medicine (40% to 28.5%), and rural practices (25% to 16%). (aapa) Nurse practitioners cannot demonstrate greater levels and all primary care continues to be shaped by the same training locations and health policies, but clearly the outcomes are not the same.

·        Limited Studies - Literature limited to individual programs or schools greatly limits evaluation of any type of practitioner. Decisions on national health policies must consider career and location choices across the nation and across the entire span of a physician career. Studies of single programs, first career choices, and first location choices can be misleading.

·        New Wrinkles in Workforce Interpretation – The timing of data collection in a specialty such as family medicine may not be critical. For specialties that collapse back into major medical centers or those that change careers over time, the timing may determine the career and location outcomes. Studies that closely follow residency graduation may not demonstrate age effects if older age graduates remain while younger graduates do not. After a decade has passed, the effects of age may be more easily seen. Even in family medicine, those found in nearly 100% office based care in rural or underserved urban locations are different than the typical 90% in urban office based family medicine, and are also different from other family physicians in office-based, teaching, research, administrative, or hospital based careers in major medical centers. Age and other characteristics may also be different. 

Career choice studies have also divided physician specialties into categories. One grouping includes surgical, person oriented, or mixed. (Yufit 1969, Wasserman 1969) Age was not used in this categorization, but few graduates of this period were different in age, diversity, and other origins. Changes in the concentrations of students, income, education, professionals, population, and physicians may mean the ability to classify physicians into various types, specialties, or categories by age at graduation.

Previous studies regarding older medical students were not possible. Only in recent decades has the nation admitted significant numbers of older medical students. Only in the past 40 years has the nation had health policy supportive of primary care, lower income areas, and rural locations. Only in the past 36 years has the nation had a stable primary care career that retained graduates in primary care and outside of major medical center locations.

Studies involving age, career choice, and practice location may help to understand physician workforce in some of the most important areas.

Methods

This is a descriptive study comparing age, career choice, and medical school factors. The 2005 OfficeMax version of the Masterfile includes 203,627 graduates of United States allopathic medical schools for the 1987 – 1999 class years. These are the most recent graduates in the Masterfile that have had time to distribute to near equilibrium conditions after the completion of training. This group represents 40% of total United States workforce. It is a group with a steady 16,000 graduates a year. This group of recent graduates is health policy neutral for the entire period since it includes relatively equal proportions of graduates with lower primary care choice (1987 – 1990 class years) and higher primary care choice (1995 – 1997 class years). This is also a group that preceded the rapid increases in parent income level beginning with the 2001 US MD Grads (1997 – current matriculants).

The US MD Grads that were missing career, location, or birth origins; those who were born in military bases, Puerto Rico, Guam, the Virgin Islands; those attending military or Puerto Rican medical schools; and those found in military locations or outside of the 50 states were excluded. The remaining group of 93% of the US MD Grads for 1987 – 1999 includes 189,163.

The major physician specialties were compared regarding the percentage in each specialty by age group. In addition the age mean for each specialty was calculated. The average MCAT scores for a medical school were collected from medical school web sites for 2000 – 2003. This average was compared to the percentage in each specialty to generate Pearson correlations. This is not individual MCAT data but secondary data from the medical school attended by the US MD Grad. This reflects the selectivity of the school, not the exclusiveness of the graduate. Medical school mean age may also reflect a similar selectivity, but in an opposite direction.

The usual age range of US MD Grads at graduation year is 25 – 30 years. Medical students age 26 are the most common type of medical student with 31%. Age 27 adds another 20%. Those younger than age 26 are about 5% of graduates. Those over age 29 are 22%.

Comparisons across the usual class years can divide US MD Grads into 3 groups: specialty choices that increase with age, are neutral, or that decrease with age. The changes would be more dramatic using a wider age range, but this would fall outside the normal age range of students. Those younger than 26 at graduation are an atypical group with more foreign born, Asian, urban origin, and highest income origin graduates and fewer rural born and lower income graduates so the age 25 and 26 graduate choices were combined for a baseline comparison.

The percentages of those in a specific career who were age 25 or 26 at graduation were compared to the percentages age 29 or 30 years of age. The career choices are also compared to medical school class characteristics for mean age of the graduating class for each medical school for the 1987 – 1999 graduates of the school and for the average MCAT score for the school for the 2000 – 2003 matriculants. Although the MCAT score is not class year specific to this group, sets of MCAT scores correlate with each other, with the MCAT average, with MCAT ranking, and with individual bioscience components at 0.86 to 0.96 or above.

A positive correlation with the age variable confirms career choice increase at the medical school level. A negative MCAT correlation means that the percentage of students at a school choosing a career such as family medicine decreases as the MCAT average score of the school rises. Both age and MCAT score appear to be measures of the selectivity of the medical school regarding admission. Both relate to important measures of physician workforce.

The database of medical schools used for correlations was a restricted list. Medical schools with specific younger age admissions (Kansas City, Northeast Ohio, Puerto Rican schools), the military school, and schools focused on family medicine and rural location (Mercer and University of Minnesota schools) were excluded.

Finally the author prepared 3 rating scales, one for General, one for Direct Patient Care, and one for Procedural/Technical/Subspecialty. Each career was scored from + to +++ in both scales. The table was ranked and grouped by correlation with mean age of medical school graduates.

Results 

Characteristics of Medical Student Careers Related to Age and School MCAT