Rural background related positively
Definite rural origin advantage, correlation 0.65 of % rural born with choice of FP. Maintained contribution in regression studies.
Unfortunately declines in rural background resulting in medical student pool less likely to choose family medicine
Parents’ socioeconomic status relates negatively to choice of family medicine.
Graphic demonstrates Replacement of FP likely students from lower socioeconomic origins (rural, instate, older) students by Asian medical students (consistent high SES)
Status and FP choice in evaluation and the health professions
http://ehp.sagepub.com/cgi/reprint/27/3/252 and
Family Physicians Are Different Section III.
Background and Ethnicity, likely proxies for social status, can be used to predict the FP match since ethnicity and rural birth are known at matriculation. In the absence of government intervention such as managed care, there is little variation between prediction and actual US seniors choosing FP.
Career intentions at entry to medical school predict specialty choice. Students who believe primary care is important, have low income expectations, and do not plan a research career are more likely to choose family medicine.
This may be the low income origins speaking.
Studies noted that when senior medical students were interested in rural practice and also had an interest in research, it was socioeconomic research.
Characteristics of Rural Interested Students
NIH Dollars and FP Doctors and Rural Doctors
The school characteristic related to choice of family medicine is public ownership.
Public ownership has had variable results. Admissions of more instate medical students is likely more important than public ownership. Admissions of instate medical students is declining.
Instate Medical Students and FP Choice
Large programs to increase numbers entering primary care seem effective.
In addition to schools with special programs, one school was founded with the explicit goal of graduating primary care physicians for the rural areas in the state of Georgia.45 This school produces a proportion of graduates in family medicine well above the national average.
The exclusion of the Duluth 2 year model and results from this article is puzzling, giving that Duluth has the highest FP graduation rate among US allopathic medical schools and has been the most consistent.
The Mercer numbers appear to have depended upon admissions and have not been consistent as they have fallen from grace. Morehouse has had the only increases in rural born admissions in the nation, although the numbers are small. Rural plus minority admissions (low income > high income) are the most difficult, and the most needed in the nation.
Required family medicine time in clinical years is related to higher numbers selecting family medicine.
Primary care is complex and takes more time. The Verby Articles demonstrated that even students interested in FP and rural were overwhelmed by PC at 3 months, neutral at 6, and did not want to leave at 9. Without special FP tracks, few students will ever get this length and breadth and depth of exposure.
Faculty role models serve both as positive and negative influences.
Students rejecting family medicine are concerned about prestige, low income, and breadth of knowledge required.
Perhaps these students did not have the same origins and status as those who stay committed.
Students planning on a career in a disadvantaged or rural area are more likely to enter family medicine.
Again a function of origins and social status origin.
Admission Policies
Two studies have found that more primary care faculty on admissions committees27 and an admission preference for generalists were not related to increased numbers of family medicine graduates.23 Although these findings are counterintuitive, these data suggest that admissions policies or committees that favor generalism do not have an impact on the production of family physicians.
Studies of rural born admissions in all US medical schools, including the 47 who say that they have preference for rural students, revealed declines. Those with the most rural population had the most declines. Origin, Admissions, Family Medicine. What schools say is not important and allowing this to convince FP leaders and government leaders is not good. Medical school programs that involve actual tracks did result in more rural born admissions.
See rural born regressions findings at Education is the Key
Admissions policies or committees, that are not backed by infrastructure such as dedicated personnel or programs with specific intent on admissions of those most likely to choose FP, will and have failed.
Also the top dog gets to make the calls, as seen in admissions in Mercer, Nebraska, Duluth, and many other locations for periods of years to decades. The top dog sets the admissions screening and this can be critical, as Basco noted.
This is no different than investments in FP in departments (invest in full fp dept and gets FP), the importance of directors of admissions (looks for FP and gets FP), directors of FP residencies (looks for rural and has power as director and gets rural). Words must be backed up by action for results.
Same with Title VII. Needs specific programs and more than enough to restore and enhance infrastructure to make a difference. Barely enough and cut each years is ridiculous.
Unofficial Climate for Primary Care
Although a medical school may have an official mission and curricula to support the choice of primary care, within the school there is an unofficial culture that may be working at cross-purposes. Two studies have looked at the existence and impact of negative attitudes expressed unofficially by faculty, residents, and students during the process of medical education. Both found that a majority of students report hearing negative comments about their specialty,35,46 and a small percentage report changing specialties because of this. It is clear from these studies that the unofficial culture of medical schools has an impact on specialty choice.
Schools in the east do have a bias against FP even when other factors are controlled, suggests that this climate is well-established. This is not just MCAT scores or research emphasis or urban or lack of FP depts in regressions involving FP choice.
Short and Sweet on FP Choice including regressions with longitude, instate, % over 30 years, state education, and other variables, weighted by rural pop of state
First- and Second-Year Curricula
Two studies looked at curricula in the first and second years. Neither found that courses in the first or second year were related to the choice of family medicine.23,39 The evidence continues to indicate minimal or no effect of early curriculum interventions.
A continual oversight in researcher is evaluating the course rather than the one involved in the course or the role model and particularly how they handled the load, the preceptor in the preceptorship, the faculty role model (research, subspecialist) in the typical preprofessional experience, the FP role model in the early integrated clinical experiences or in student health experiences
Many of the student characteristics that seemed related to specialty choice in 1995 are now less clearly important. Research in the last 8 years indicates that gender, age, marital status, and ethnicity are only weakly related to the choice of specialty. Academic background was never clearly related, and the recent literature has not changed that conclusion.
Age and FP Physicians Age is clearly related to FP and other specialties, with older students increasingly choosing FP. Again this may relate to "second chance" students who did not initially get the type of education or orientation that allowed them to consider medicine earlier in life or came to a decision for medicine via other career pathways.
Career intentions at entry to medical school are predictive of eventual specialty choice; intending a career in family medicine or a practice in a rural or an underserved area are related to eventual choice of family medicine. Although these initial intentions are strongly predictive, there is considerable attrition over the course of medical school. However, recent research indicates that there is also recruitment, and it is the latter that accounts for most of the students who select family medicine residencies at the end of medical school. Another significant new finding is that stated goals to enter family medicine before entry to medical school are not related to eventual specialty choice, although reported contact with a specialty is.
Studies often do not include rural origin, age, socioeconomic status, and other characteristics from birth to year 2 of medical school. These explain the choice of family medicine and some of the inconsistencies as they have changed over time. Many of these characteristics predict "recruitment" or at least reflect admissions that is more likely to admit FP types.
There is inconsistency in this area of the paper. On the one hand the roles of FP departments and faculty are discarded, yet somehow students are "recruited" into family medicine.
Studies of student interest and the national student meeting attendance tend to confirm that these efforts "convert" the converted. At least 61% if not more, of the students attending the 1998 student resident meeting in KC chose family medicine, almost all attended after their decision was made.
It is more likely that a gut check occurs before the match and even before admissions. Students choose to cast their lot with people and a way of life most like them, even with less than stellar experiences. Family Physicians Are Different
One of the inevitable outcomes of 4 years of medical education is that students develop perceptions, correct or not, about the content and characteristics of each specialty. These beliefs about the content and characteristics of specialties are consistently related to choice of specialty; students who reject family medicine are concerned about prestige, low income, and the breadth of knowledge required.
An alternative is that students attempt to fit their own values and beliefs and career plans with their perceptions of the ability of a particular specialty to meet their needs. (see article)
Students from higher socioeconomic status may have a difficult time relating family medicine to their perceptions, especially without some impact on their past experiences before and during medical school to confirm that they can and should make a difference via family medicine.
For family medicine it may be a more complex mix of ingredients that must be addressed in the proper proportions and timing. This also may explain why older students and rural students may choose FP in higher proportions. Older students have have had more time to consider the actual practice of medicine and reconcile the multiple dimensions. Rural students may have had more exposure to an FP model or a more generalist lifestyle.
Given that the above is what we know at this point, unanswered questions include: (1) Why have we seen changes in the last 8 years? and (2) Where do we need to go next?
The changes in the last 8 years are really distortions of managed care, especially the classes graduating from 1994 - 2000. The actual changes are a 30 year decline in family medicine, interrupted by a brief period when government came to its senses.
Those believing in the 8 year decline are missing the real world. See graph on match prediction by admissions (background and ethnicity changes, again social status)
Those aware of the long term decline should be aware that the long term declines in admissions of rural, older, and instate students, plus the admissions increases in students of higher socioeconomic status, are more than enough to explain the decline in family medicine.
The path is clear. It is not our connection to medical education that is most important. It is our link to education, especially through admissions, that matters most.
We need to link more to education and medical education and find ways to get our kind of students admitted to allopathic schools, osteopathic schools, and international schools. International and osteopathic schools are supplying most of our residents and have increasing trends. It makes more sense to emphasize these types of schools, especially when 35 years of efforts in US allopathic schools have yielded few of the physicians most needed in the nation. This has allowed other types of providers to enter a race that should have been family medicine from beginning to end.
Senf article for text and references at http://www.aafp.org/x19661.xml
The truth is, that family medicine, psychiatry, and emergency medicine are front line medical professions that require the ultimate in quality, experience, and dedication. This was as true in the time of Osler and Flexner as it is today.
Right now medicine has sold out, often noting that "other" providers can do primary care. The opposite is true. For many specialties, particularly the technical ones, it may be easier for non-physicians to take over while letting other physicians decide when to access them.
Given the differential between salaries and costs, it may also a better idea to replace some high cost subspecialty physicians with other providers. This is not my suggestion. However medicine better get its act together or the nation will bypass medicine entirely.