Robert C. Bowman, M.D.
Explaining the Distribution of Family Physicians involves an understanding of who responds to market forces, and who does not. There are independent and dependent types for a variety of reasons. When the nation implements supportive health policy, all work together to serve the nation. When the nation changes course away from education and health policy, all suffer.
It is a most confusing time. Some family physicians are having the best of times and others the worst. Despite the current challenges that seem to assault family medicine from all directions, there are clearly family physicians in states and communities that are thriving. Generally those about as far away from Washington DC in 2005 as possible are the ones who perceive themselves to be in the best of times. Those who are closest to or most dependent upon DC, state governments, and the political, academic, and financial structures represented are the most challenged.
Best of Times and Worst of Times: A Matter of Timing
The best of times for family physicians is a matter of geography, finance, health policy, and timing. The timing involves peaks and valleys according to graduation. The family physicians who graduated the earliest and did the most procedural training and who have privileges are doing the best. Those who graduated more recently during times with less “independent” training may be struggling more although they are early enough in their practices as to be difficult to evaluate.
The status of family medicine has changed with the times. There are decades that coincide with better times. These include the creation times of the 1960s, the growth of the 1970s, the stagnation of the 1980s, the renewal of the 1990s, and this brings us to the 2000s.
Interestingly, family medicine has actually had the best of times and the worst of times, all within the past 10 years.
Best of Times and Worst of Times: A Matter of Perspective
Perception shapes reality and vice versa. For simplicity family physicians have been divided into two types, those who are “dependent” and those who are “independent.”
The best of times and the worst of times for “dependent” family physicians have to do with state and national health policy. These tend to be urban or academic physicians. The creation of Medicare, Medicaid, and family medicine meant good times for all of family medicine. Massive increases in Medicaid, improvements in Medicare, and managed care re-created great times in the 1990s. The best of times also involve much better times for those most likely to be the patients of family physicians: the less educated, the poor, the elderly. (Mold, Graham Center)
Independent or Community-Associated Physicians
The best of times and the worst of times for “independent” family physicians involve a perspective that is more focused on community instead of health policy. They have practices that are favored by special types of practice modes, high volume patient loads, and/or procedures. They tend to be rural physicians or those who are in high growth communities. Many of these physicians may actually be wondering why so many are raising a fuss.
Of course the independent family physicians are not completely independent. They are perhaps better termed community-associated family physicians because their situation is linked to the well-being of their particular community locations. These physicians do tend to be independent types and this is often why they have made the practice location choices that they have made. They tend to be white, male, older, lower income, instate born, or rural born. They are more likely to be in office-based practice instead of teaching, research, or administration. Encounters between academic and service-oriented physicians are interesting and extremely valuable (The Invisible Faculty by Joseph Hobbs, M.D.), but there are differences as well.
The independent family physicians in growing or stable communities are doing well. They have the ultimate respect given professionals of any type. The community association is much more of a bond with expectations and responsibilities but also great benefits. They are pillars of their communities, do the broadest scope of practice, and see the patients that they want and even exclude those that they do not want to see. In studies of medical students doing long term rotations about 10% return to the rural community where they did their preceptorship (RPAP), but there is evidence that the top communities do much better.
Those in communities facing great challenges are having a difficult time. In the most difficult situations there is little choice but to leave or retire. Economic changes are a major part of this decision but there are other factors. There is a dividing point that varies state to state somewhat an also in proximity to large urban areas or interstates, but the counties with 17 people per square mile or more are growing and those with less than 17 per square mile are shrinking in population without exceptional measures or significant wealth. Shrinking population is not a good sign for someone hoping to establish a new practice and live there 20 or 30 years.
Dependent or Health Policy Associated Physicians
The dependent or health policy-associated family physicians are more likely to experience significant support from others including medical schools, medical facilities, graduate medical education, Title VII, National Institutes of Health, Community Health Centers, National Health Service Corps, loan repayment systems, and state funding of family medicine.
The dependent or health policy-associated physicians are more likely to be urban or academic. These family physicians also tend to be urban born. In my Birth Origins Articles, those in academic medicine had a greater tendency to have higher income and more prestigious medical school (higher MCAT, increased research/NIH, low choice FP) origins.
Dependency is a relative term, since the primary care types in general tend to be less dependent as patients do come to them directly. It is of note that other physicians outside of family medicine are much more dependent, with the exception of office based primary care and psychiatry that have more of an ability to function on their own. Perhaps one of the take-home lessons of managed care for all specialists was that they needed to find ways to be less dependent upon primary care physicians.
The dependent physicians face many challenges in the current times including Medicaid cuts involving in some cases the majority of patients, decreases in Medicare reimbursement, insurance company excesses, rebound from managed care (particularly academic), and competition from urgent and emergent care.
One of the primary reasons for family physicians to be dependent is that they are involved in their patients to a greater degree. Changes in their patients cannot help but impact them greatly. These are difficult times with great loss of health care coverage and the neglect of basic needs including housing, day care, transportation, education, disability, and the social infrastructure. These are also compounded by lack of access to legal services and representation.
For academic family physicians there is increasing job stress from the multiple increased demands of patient care plus more teaching, and more research. There are also liability increases impacting low volume procedures that must be taught. There are also more efforts to insulate and defend medical education from the city or state government or citizens groups who are increasingly aware of significant inequities and more than willing to place blame, even if they are unwilling to support funding or taxes.
Physician Distribution: Decisions of Dependent Physicians and the Nation
The career and location decisions of the health policy dependent types are the most important in distribution efforts. The United States had the most successful distribution of physicians in the nation’s history in the allopathic graduates of 1995 – 1997. The reason lies in the 50% increase in family medicine choice for the medical students who were born in metro areas. These medical students are the largest groups including 47% of total students who were born in metro areas of over 1 million and 23% who were born in metro areas of less than 1 million. To some degree the 14% that were born in other countries were involved as well since they were raised in the most urban US cities. The older (over 29 years or 21%) and rural (nonmetro born 10%) students that always have greater choice of family medicine had a 30% increase in choice of family medicine. A clue to the reasons for career choice change is also provided in the atypical pattern. Usually older, rural born, instate, and lower income line up for the same career and location choices. This time the instate and younger students had greater change in career choice. This may well have to do with their desire to train and to return to the same locations where they were raised. During managed care, the best probability of practice at or near their birth or medical school training origins involved choice of family medicine. Birth origin studies confirm their increased choice and increased retention within 60 miles. To sum up, the reasons for the best distribution were
Managed Care Comparison Table Managed Care and Choice of FP
In short, the nation managed to engineer a perfect storm involving physician distribution.
The nation has reversed course completely in just a few years with the decline of urban poverty choice lagging slightly behind, but still present.
During the 1990s, just about every family physician had a reason to be pleased with the course of events. Also family medicine was prospering with policies involving 3000by2000 that emphasized a broader focus of admissions of the lower income types more likely to choose family medicine. The nation made inroads toward admitting more Black, Mexican American, and other lower income medical students. There was also a leveling of the playing field as reflected in national income levels. The patients of family physicians benefited from improvements in education, child health coverage, and social programs. However there were, and still are, areas of the country that did not provide the same support needed for thriving family medicine.
Favorable and Unfavorable: Decisions Made By States
These areas that remained unfavorable to family medicine have made decisions that involve health and education. When comparing states across the United States with varied population, geography, coastlands, cultures, and other differences, one would expect some states to do better in education, others better in health, others better in “efficiency” measures such as unemployment, insurance costs, and health care costs. This is not the case.
States run in packs. States such as California, Florida, and Texas do not rate well in basic education, health, and efficiency. States such as Iowa, Nebraska, North Dakota, South Dakota, and Minnesota are at the opposite end of the spectrum. Bright Future Rankings The states with the best education, health, and efficiency ratings tend to be the states that had more family physicians. The states where the students are most likely to choose family medicine insure that FP and low income types
· can graduate from college,
· can enter medical school because admissions is broad and the state has invested in enough medical school positions,
· can be trained in primary care and underserved practice,
· can be supported in residency from state and federal dollars,
· and can stay in a state because there are locations supportive of family medicine, education, child coverage, care of the poor, liability reform, and other issues important to the practice of family medicine.
These education, health, and efficiency rating scales include health costs, child health coverage, auto insurance costs, unemployment, graduation rates, per capita education investment, liability claim costs, welfare costs, and prison costs. As simple measures, they mean less, but taken together, they are the cost of insulating “us” vs “them.” Basically it costs much more to support great wealth because in the process there is usually great poverty not far away.
· High income - No FP - Family medicine types are not likely to want to care for the rich, nor do the rich prefer them. Sadly the major impact of helping those well to do and well educated to avoid the trauma of too much care is not appreciated.
· Broad Income - Independent FP - Family medicine does care for the middle ground and there are resources there. This demands independent types with personal management skills.
· Low income - Dependent FP - Family medicine cares for the poor and less educated, but only when the resources are provided. FPs that are less able to manage because they identify with patients, populations, teaching, academic leadership, or other interests are in this group.
The states with the consistently the best scores and rankings have strong 0.65 to 0.7 correlations with measures of family medicine. (Bright Future Rankings) These measures include
The states with the least FP friendly health, education, and medical education policies tend to be states that have greater urban population concentrations and higher income concentrations. Education and health policy is less favorable. This is reflected in lower concentrations of family physicians, as low as 19% in Washington DC and Massachusetts. It is not a surprise that family medicine cannot function efficiently enough to allow FPs to populate Washington DC where chronic poverty, the worst achievement test scores, and the worst divisions in the health, education, and social conditions exist in perhaps the entire nation. In such situations it is also clear that social status is more of an indicator of health outcomes than medical care. Medicines are probably unimportant compared to basic societal changes and restoration of hope and mobility.
From an FP match standpoint the highest income populations and those in the grip of chronic poverty are the least likely to choose family medicine. Where there are significant percentages of both in the same location or population, overall FP choice will be less. When there is a broad income distribution, as in rural, Vietnamese, or Mexican American populations, there will be greater choice of FP. Rural and Black populations appear to be limited by chronic poverty in many areas, with greater impacts to lower college and medical school participation for black males and rural males.
To examine income distribution in allopathic medical students,
Figure 1: Parent Income and Ethnicity and FP Choice
Figures 2: Broader Distributions of Parent Income
Figure 3,4 Higher Income Distribution and Comparison
Elite Education, Scores, Income, and Population Density
When examining the pipeline to college and to medicine and to family medicine, the students that can escape chronic poverty tend to have elite test scores. Elite test scores mean different schools, education, greater chance of private school or top college, different socialization, and different career choices. Such students are less likely to choose of family medicine. In this case they are much like elite students of higher socioeconomics. Comparing Physician Distribution and the MCAT
Elite is not limited to test scores alone. Already 60% of allopathic medical students come from the elite 20% highest income level in the nation. The highest income and highest education and highest parent education levels involve the most urban born and Asian students. Regardless of ethnicity, those with the highest education, income, and population density origins have the least choice of family medicine, as low as 2% for Asian Indian students and 4% for those born in some of the most urban, highest income counties in the nation. Elite also tends to involve different upbringing and there are studies that indicate that the elite are less likely to have awareness of important national considerations such as significant health access problems existing in the nation. The elite do have the greatest potential for elite medical schools and future leadership positions in medical education. The elite schools also have the ability to select out the elite students, which may also limit distribution since the schools with the highest MCAT scores have the least distribution levels. Distribution of Physicians
The lowest choice of family medicine across the nation involves cities, counties, states, and populations with great divisions between rich and poor. Family medicine requires a middle ground, especially a middle ground with good quality education access. The best FP choice levels involve broad distributions of wealth. The choice of family medicine is also reflected outside the US in those born in Puerto Rico and in the career choices of students born in other nations.
The best choice of family medicine is seen in students with the broadest and most equitable distribution of income and education, including Vietnamese students, rural born students, and Mexican American students. These populations also have some of the lowest college graduation rates and the lowest levels of parents attending college. The students most likely to choose family medicine are populations with a greater percentage who were the first in their family to attend or complete college. The combination of above average to excellent high school graduation and lower college graduation is a consistent predictor of high choice of family medicine in a population. The states identified as those with the least investment in education and the most inequitable distribution of education resources to low income school districts (Funding Gap 2004) are also the states graduating fewer family physicians. Bright Future Rankings
Education, Medical School Positions, and Admissions
There is also a bonus involved in education investment and broad distribution of education. When both high school and college graduation rates are at the top levels for those born in a state or population, then there is high level choice of family medicine careers and also research careers. Efforts at the medical school level to increase the schools with both primary care and research emphasis may be far less successful than efforts to improve state education. Another way of looking at this is that the qualities most important for research and for family medicine are much more widely spread in the population than just in the well to do. The more children that we leave behind barriers of income, the more we lose great human potential. Research By the Ages
Another way to increase family medicine, psychiatry, office based primary care in poverty locations, and research is to admit the older student types that have increased choice. The students who are age 29 – 31 at medical school graduation still include reasonable numbers of medical students for impact and this is a group with much higher choice of these important careers. Choice of these maturation-related careers declines in the most numerous 26, 27, and 28 year olds and there are far fewer who are 32 and above at graduation. Age is a reflection of those with superior ability not only to do well in medical careers, but also those who can overcome the barriers of education and income.
Age and Physician Specialty graphics
States who fail to support enough medical school positions are less likely to graduate family physicians. Family physicians tend to have lower income levels and slightly lower MCAT scores. In the competition at nearly all medical schools, they are edged out in the competition for admission. In Asian and White students, there is a very narrow margin for admission and not involivng MCAT scores. It is entirely possible that income impacts on socioeconomics involves a significant portion. Lower admissions of rural born and older students, known to have lower income origins, is likely. Younger students have higher income and education origins and higher MCAT.
In states with fewer medical school positions, the preference for the higher income and higher MCAT students is even more likely. The states with the highest ratio of medical school instate positions have the greatest choice of family medicine and rural careers. Part of this involves greater percentages of rural population, but controlling for rural population or examining rural states with fewer positions reveals lesser choice.
Efficiency
Family medicine has some of the highest overhead levels: personnel, equipment, office costs, and liability. Most of these are fixed costs and problems with cash flow mean difficult and stressful decisions about personnel and the ability to serve patients. New bureaucratic, regulatory, and information technology costs make matters even more difficult. Cuts in reimbursement, massive loss of patients through Medicaid coverage changes, managed care shifts of patients and services, and rising liability costs are difficult to manage in the best of times.
Matters have been complicated in recent years with forced changes of physicians as noted by Mold . This is also inefficient, costly, and disruptive to the kind of continuity care involved in family medicine.
States also are efficient or inefficient. Again this has to do with education and income distribution. The same education-oriented states have lower health care costs, likely due to more who are in the middle income and education levels. This means fewer who are costly due to low education levels and fewer who are elite in education and in health demands. Liability claim costs are lower in the efficient states, so are auto insurance premiums. There are fewer densely packed collections of lower income peoples and also much higher income peoples. It costs less for education outcomes and the better education outcomes mean less employment problems. Efficient states have more to spend on education and choose to do so. They also have less prison and welfare costs. Bright Future Rankings
The education, equity, and efficiency areas that lead to more family physicians are associated with certain states and populations.
what does it take to make family physicians happy? The answer for most if not all family physicians is that they are happy when the nation decides that it is important to take care of their patients: the poor children, the single parent, the working poor, the lower income populations, those different in education, in income, and in population density. (Mold, Graham Center, Birth Origins Articles, Decreasing Rural FP Physicians, Reimbursement and Physician Distribution)
Family Physicians Are Different, they are not wedded to higher income or prestige or position. In dependent or independent modes, they are bound to their patients and communities.
In times and in locations when the nation focuses on education, child health coverage, equity, and efficiency; then there are more family physicians.
In times and in places when there are fewer family physicians, it may well be time to make different decisions or move someplace else. In places such as Washington DC, New Orleans, Philadelphia, and other major cities with lower percentages of family physicians, the population has been leaving at 5 – 12% levels each decade.
No one can take credit for all of the societal and governmental efforts that lead to a better life, but there are clearly measures of better living. Having family physicians around is one of those indicators.
Family medicine is a great match for a nation that is not too rich or not too poor. Family medicine cannot survive in a nation that is divided increasingly into rich and poor, but neither can a nation survive this.