Birth Origins and FP Choice

Robert C. Bowman, M.D.

For changing composition of US allopathic students and graphics see Origins Changes

Medical students of different birth origins choose family medicine at different percentages. This is more than just rural and urban. The best indicators are socioeconomic. Students from all but the highest income, most urban locations choose family medicine in greater numbers. Higher MCAT score indicates urban origin and parents who are have greater levels of income, education, and professional occupation.

Proximity to a medical school also impacts admissions and career choice. When comparing birth county income quartiles to hold income and education factors constant, those born in a county with a medical school have better admissions probability, lower choice of family medicine, and other distributional choices are also less.

Foreign born US allopathic students are even less likely to choose FP, unless they are older. Age and FP Physicians Generally foreign born and Asian students tend to be younger. The foreign born group is the fastest rising group of students admitted.

Choice of Family Medicine: Birth Origins

Robert C. Bowman, MD

Dr. Bowman is the Director of Rural Health Education & Research, Department of Family Medicine, University of Nebraska Medical Center, 983075 Nebraska Medical Center, Omaha NE 68198-3075. Phone 402/559-8873 Fax 402/559-8118. Email rbowman@unmc.edu     http://www.ruralmedicaleducation.org

Key Words: family medicine, rural background, rural origin, rural, underserved, medical school admissions, career choice, rural medical education, physician workforce, distribution

ABSTRACT Background: This study investigates the relationship between medical student birth origins and choice of specialty, particularly with regard to family medicine. Methods: This national study used American Medical Association (AMA) Masterfile data and family medicine databases provided by the Robert Graham Center. The primary cohort involved 17,518 self-designated family medicine and general practice physicians compared to all US allopathic graduates of 1994–2000 (n = 110,639). Results: Students born either outside of the 50 United States or in US counties of over one million were both admitted to medical schools in increasing percentages in the past 30 years, and are also the least likely to choose family medicine. Students born in less population-dense areas, older students, and instate born students were more likely to choose family medicine and distributed where most needed but have been admitted in lower numbers. Health policy changes in the 1990s greatly improved the distributional choices of allopathic medical students, with greater impacts upon those least likely to distribute. Discussion: The physicians most likely to distribute are the least likely to gain admission. Those more likely to choose family medicine are also more likely to choose rural practice locations regardless of specialty and to choose rural family medicine, primary care, office-based primary care in poverty locations, and psychiatry. The nation's policies in education, medical education (admissions), and health are important factors in physician distribution and will need major revisions to meet the ever-increasing needs of rural and underserved peoples in the country. (247 words)

Introduction

Fewer medical students in the United States are choosing family medicine. This is a major concern since family medicine is the physician specialty that distributes in the same pattern as the US population. Accompanying decreased choice of family medicine is decreased choice of primary care, decreased choice of rural practice location for all physicians, and increased student choice of subspecialties. Such changes are likely to greatly reduce health care access and increase the cost of medical care and may also result in lower quality health care (Starfield)

The choice of family medicine has most often been considered a result of medical school influences. Not surprisingly most of these studies were done by researchers affiliated with medical schools. This medical school perspective may limit a broader viewpoint involving student origins, education, access to college, standardized testing, and socioeconomic barriers that students face. Other studies have noted that schools emphasizing research generally do not do well with choice of family medicine or physician distribution (Rosenblatt, Senf). Although schools graduating more researchers are less likely to distribute physicians, the real issue may be a separate factor that correlates positively with research and negatively with choice of family medicine and distribution.

The choice of family medicine appears to be related to socioeconomic factors. Students with lower income origins are known to choose family medicine and primary care in greater numbers (Cooter, Madison). Rural origin students, older students, and underrepresented minority students have the most challenges gaining admission and tend to have the lowest Medical College Admission Test (MCAT) scores (Wheat, Basco, AAMC data). They also share the lowest income origins. There are significant gaps in income levels between students admitted and rejected (AAMC data). Education difficulties have multiplied for inner city and rural areas, the known origins of many family physicians (Xu, Funding Gap 2004). Increasing mean parent income levels for those admitted to medical school indicate that lower income students are being left behind (AAMC Minorities in Medicine, AAMC Data Warehouse). More tragically many may not even apply. This would explain increases in the national MCAT averages in recent years, especially the one point rise in bioscience MCAT (AAMC MCAT). Another explanation would be students "gaming the system." Students with higher income levels are more able to afford the top colleges and top preparation courses. The costs of applications, test preparation, and college continue to rise, often at double-digit rates. It is certainly possible that the students most likely to choose family medicine, the ones with the lowest income levels and facing the most education barriers, are being excluded from medical schools.

The goal of this study is to investigate the influence of birth origins on physician career choice related to family medicine.

Methods

The American Medical Association Masterfile (Masterfile) and American Academy of Family Physician databases were accessed with the assistance of the Robert Graham Center and the support of the Federal Office of Rural Health Policy. The databases were used to identify all family physicians (FP) and all general practice (GP) physicians who finished training from 1997 - 2003. Birth origins (city, state), class year, and age were available for over 98% of physicians graduating from US allopathic medical schools dating back over 40 years. Birth city and state were converted to county of origin. This was usually an easy task, but some of the towns were more challenging since there were duplicate names in some states, name changes, and towns such as internment camps and military towns that no longer exist. The story of physician birth origins is the story of America during some of its most challenging years. Use of multiple internet search engines allowed the categorization of towns by zip code or county locations over a six-month period of effort by the author. The county of origin was also translated to Federal Information Processing Standard (FIPS) codes and then to 1993 urban influence codes (Ghelfi and Parker), metropolitan or nonmetropolitan designations, and population density (1970 Census). Practice location zip codes were also converted into rural-urban commuting area (RUCA) codes (WWAMI). The RUCA coding was grouped into 4 categories using Categorization A suggested by Hart: urban/urban-focused, large rural, medium rural, and isolated rural categories (Hart). Medical student admissions ratios were calculated by dividing the medical students who were born in each type of county by the 1970 population in each urban influence code county type 1-9. This admission ratio for the seven years of graduates was divided by seven and multiplied by 100,000 to obtain a per year per 100,000 ratio. The year 1970 was the approximate birth year of this cohort of students. County income levels of that time period were also appended. Another comparison involved ethnicity comparisons using Association of American Medical Colleges data on admissions as a numerator and census data on 18 to 24 year olds as a denominator (AAMC MIM). Student origins also were coded as Instate Births for students born in the same state as their medical school. Ethnicity data was also available by entire class for over 95% of allopathic students (AAMC data warehouse) and specifically for over 90% of individual family medicine residency graduates from allopathic medical schools (Masterfile), allowing choice of family medicine determinations by ethnicity. Zip codes with a Community or Migrant Health Center (BHCDA) or those where 20 % of the population was at or below poverty levels were considered poverty zip codes. Zip codes that were unique were translated to the nearest zip code geographically that had a population.

Results

There were 110,639 graduates of U.S. allopathic medical schools from 1994-2000. Of these graduates there were 15,355 self-designated family physicians and 1581 self-designated general practice physicians in the Masterfile and 1546 (or less than 10%) that did not have specialty data listed. Another 585 family physicians were added to the database from family medicine sources for a total of 17,521 FPGP physicians. Over 13,560 FPGP doctors were listed in office-based practice, another 1390 were not classified (most likely office-based), an additional 1548 were still coded as residents, and 840 were in hospital based practice.

The physicians likely to choose family medicine were not limited to rural origins. Medical students who were born or raised in all but the most densely populated areas of the nation were more likely to choose family medicine.

Table I. Choice of Family Medicine By Allopathic Graduates

*Final totals of physicians in each category range from 103000 to 110,600. Note that these values for choice of family medicine were 30 % greater than any time in the past 20 years because of increased FP choice in the 1995 – 1998 graduating classes. Family medicine choices are now 40 % below these levels listed.

Increasing Dominance of FP Unlikely Students

Students born in counties of over 1 million and those born outside of the 50 states are the least likely to choose family medicine and are designated for this study as FP Unlikely students. This FP Unlikely group involves 63% of students and shares the highest income origins. Another way of expressing this is that medical students born or raised in less than 10% of the geographic area of the nation provide over 70% of the nation's physicians. The schools with the highest percentages of FP Unlikely students are also in the most densely populated cities. This suggests a birth origin impact upon medical school choice as well. Studies of Asian students choosing family medicine reveal that the most densely populated cities in California were the final practice locations of 700 even though only 100 were born there. The others originated mostly from Chicago, Michigan, and New York City.

Increasingly, medical schools are recruiting and admitting FP Unlikely students. The FP Unlikely students are also the least likely to choose rural family medicine, office-based primary care in poverty locations, and rural practice for all types of physicians. Medical schools are also admitted more and more who were born in out of state locations and in counties with high income levels. Over 40 medical schools have over 80% of their class composed of FP Unlikely students, making it difficult for such schools to graduate family physicians.

The schools with the most FP Unlikely students also have the highest Medical College Admission Test scores and the fewest older students. The connections between scores, socioeconomics, student characteristics, and distribution are ripe avenues for exploration.

The general trend is that medical schools are not admitting the outliers. The youngest and oldest, the poorest, the lowest scoring, and those from the most and least densely populated areas are not being admitted to the same degree as in the past. The MCAT bioscience score is up 1 point in the last decade (MCAT). The age range in the schools with the highest MCAT scores is a narrow spike with a greatly restricted age range. This is certainly consistent with the narrowing process that has been a concern of leading medical educators for decades, especially those concerned with the current use of standardized testing in admissions (Herman, McGaghie, Cohen century).

Table II. Distribution, Admissions, Age, and Income Levels

*Admission ratio for Urban Influence code 1 would be 9 if the foreign-born students who are raised mostly in the most urban counties were included. About 9.6% of allopathic medical students have origins in codes 3 - 9. County types 1,2,3,5,7 also have higher educational attainment levels, more colleges, more hospitals, more physicians, and a higher ratio of primary care physicians (Ghelfi and Parker)

Those born in nonmetropolitan areas and military bases are categorized as FP Likely students. This group continues to decline in number along with the instate born or those who were born in the same state as the medical school. The FP Likely group and those born instate are also more likely to choose rural locations (regardless of specialty choice), primary care, rural family medicine, and urban primary care poverty practice locations. The declines in instate and rural born have extended back for decades. It is not surprising that the nation continues to suffer from a shortage of physicians caring for rural areas and for underserved populations.

Student Characteristics, Age and Origins

Younger students at graduation from medical school also had greater probability of admissions (AAMC data warehouse) and lower levels of distribution to the careers, locations, and populations most in need. Younger students tend to be the more urban in origin, regions of the nation where the levels of income are the highest. Younger students are more likely to have skipped grades or may have been granted early admission and may also have the highest test scores. Only 6% of those graduating at age 25 were born in rural areas, 9% of those at age 26, and 13% of older students.

Student age appears to be a proxy for socioeconomic considerations involving income and education.

Medical students who were born in less urban areas, older medical students, those born in military bases, and instate born students, were more likely to choose family medicine. Population density figures yielded the most dramatic variations, ranging from a low of 7.6% choice of family medicine for those born in the most densely packed urban areas to 76% for those born in the most frontier regions.

Population density of birth origin may well be the best socioeconomic representation available from secondary data.

Older students have been admitted when applicant pools decrease and also when there have been expansions of class size. Admissions committees would rather admit younger students. The combination of older age and FP Likely characteristics enhances the choice of family medicine and distribution. Older students were also more likely to choose rural locations and psychiatry. The choice of psychiatry careers doubled from 3% to 6% for students age 25 compared to those age 31 at graduation.

Breakdowns regarding age reveal a pattern where older students trend toward direct contact patient care, primary care, family medicine, generalism, rural location, and behavioral aspects. Younger students tend to make career choices involving technology, procedures, and less direct contact with patients. The only exception to the primary care preference with advancing age was medicine pediatrics, but again this is not a surprise. Recent studies of this specialty revealed that the ability to preserve subspecialty choice is a major consideration of this group (med peds study).

Those born in the same states as public allopathic medical schools had greater choice of family medicine. Most allopathic private medical schools did not share this distributional tendency. Instate born students may represent those with limited income levels, families, or debt who may not have any viable medical school options in states without either a public medical school (lower tuition) or without a school with broad admissions policies. States with special rural admissions may give such students some hope. Schools with special admissions tracks and those with a rural mission did admit more rural born students. In states with poor investment in education, poor distribution of education funding, or lacking specific aid, there may be even less hope for lower income students born in such states. They may lose interest in medicine long before college.

Global Competition for US Medical School Admissions

The fastest growing component of FP Unlikely students involves students born in other nations. This group doubled from 1300 (out of about 15,500) students in 1987 to 2600 by 1992, but did not increase significantly for the classes of 1993 - 2000. Those born in the lowest income groups and areas of the nation now face international competition, just like US workers in other areas. Asian medical students are the largest component of this international group. The total Asian group has risen to 22% of all allopathic students (AAMC Data Warehouse) and this group, predominantly born or raised in the most urban areas of the nation, has the least family medicine choice for any ethnicity, at 7%. This is the same distribution into family medicine as those born in the most urban areas of the nation, the area known to be the primary residence of Asian citizens and residents in the US. For Asians born in other countries, three US cities contain 45% of the foreign-born Asian population (Census Asians). Asian choices appear to be no different than comparable choices of other students with similar characteristics of age, income, education, and origin. The Indian-Pakistani group which is the fastest growing group in US allopathic school admissions (likely due to English language spoken, parent income, parent education) is the least likely to choose family medicine of any group at 2.3%. The rural and poverty choices of Asian family physicians born in other countries are much higher than the same choices of Asians born in the US. Vietnamese students chose family medicine at the highest levels of any ethnicity at 24%. Vietnamese parents of medical students have the broadest income distribution of all ethnicities (AAMC Minorities in Medicine). Asians born in the Midwest had much higher choice of family medicine. Ethnicity studies add to the consideration of socioeconomics and choice of family medicine.

Table III

Allopathic US Medical Student Admissions, FP Choice, Income Levels