Choice of Primary Care

Robert C. Bowman, M.D.

Abstract

Research efforts regarding medical student choice of specialty have traditionally focused on influences during medical school. There are increasing indications that this is too late. Medical students are young adults with a lifetime of experiences long before beginning medical school. Influences include parents, education, peers, and community. Within these are multiple dimensions involving origins, values, social status indicators, academic preparation and test taking ability, access to varying quality of education, and much more. Some could exert strong influences on the probability of admission and the choice of specialty. This weighted linear regression study involves medical students graduating from US allopathic medical schools from 1994 – 2000 graduates. Allopathic medical schools that graduated more primary care physicians had lower MCAT scores, fewer students born in the most urban locations, more students who were over the age of 30, more students born instate, a western location, and better state education.

Introduction

For a review of the literature and recent publications Choice of FP Update

Methods

Dependent variable = All family medicine, general practice, and office based IM, Peds, and IM/Peds as determined by AMA Masterfile.

Atypical allopathic medical schools were excluded, leaving 113. Atypical medical schools included schools in Puerto Rico, the military school, osteopathic schools (incomplete data on primary care choice), schools with mergers, schools too new for graduates, schools with an atypical mission (Howard, Meharry, Morehouse, Drew, Duluth, Mercer), and those impacted by atypical mission or design (U of MN impacted by Duluth and 6 year design of U of MO Kansas City).

The regression was weighted by % non-metro pop of the state and analyzed with SPSS 11.5.

Independent Variables

MCAT 2000  - Average of Verbal, Biological Science, and Physical Science score for a school in 2000 as noted by internet sources and comparable to data from 2001, 2002, 2003 and partial data from prior years. MCAT Correlations

LONGITUDE – actual longitude of the medical school location, negative with western direction

OVER30 - % of the students who graduated who are over 30 yrs at presumed date of graduation (from class year identifier) Age and FP Physicians

HSXCOLC High school grad rate x college continuation rate – 1998 data from Education Week regarding state to state, another variable using 1986 high school data did not result in significant differences Short and Sweet on Education and Med Ed

INSTAVGY   % admitted who were born in the same state as the medical school Instate Medical Students over time

UrbInf93 - % if medical students who were born in the most urban code (1) or core metropolitan area by urban influence coding (1993 scheme) See graph of changes  Admissions during expansion and after were from the most urban codes 1 and 2.

Median Income of a state in 1990

Bivariate Correlations, Means, and Sources

(Selected Variables in Bold)

Continuous variables and those with less covariance were used in the final model.

MCAT scores were the most interactive with other variables and all in ways resulting in fewer primary care physicians. This includes fewer students over age 30, fewer instate students, more students from the most urban parts of the nation, and more from states with the highest median income. Longitude and state education variables interacted the least. The most urban born variable interacted with instate and severely with median income.

MCAT scores correlated highly with NIH funding, and both of these could not be included in the regression together. Either variable inserted alone resulted in similar regression results.

The MCAT scores from 2000 did not directly apply, but similar studies of later family medicine and primary care graduates reveal the same correlations and contributions to regressions.    See this link

Correlations of Independent Variables Used

Significant Covariances (over 0.3)

Model Summary

Predictors: (Constant), MEDINC, LONGIT, HSXCOLC, OVER30, INSTAVGY, MCATALL, URB0N93

Dependent Variable: REALPCPR                                

Weighted Least Squares Regression - Weighted by RURAL92

Predictors: (Constant), MEDINC, LONGIT, HSXCOLC, OVER30, INSTAVGY, MCATALL, URB0N93

Dependent Variable: REALPCPR                                

Weighted Least Squares Regression - Weighted by RURAL92

Coefficients

a          Dependent Variable: REALPCPR                    

b          Weighted Least Squares Regression - Weighted by RURAL92

Each percentage point increase in primary care choice by medical students represents an additional 1.31 students choosing primary care in a typical graduating class.

·        Medical school locations 250 miles further west have a 1 percentage point increase in students choosing primary care (Represents 1.31 more PC docs per graduating class). 

·        Each 10 percentage point increase in higher education opportunity results in a 1 point increase in choice of primary care .

·        Medical schools with an average MCAT 1 unit higher graduate 3.1 percentage points fewer primary care physicians or about 3 - 5 fewer PC doctors per graduating class.

·        Each 12 point increase in instate percentage results in a 1 point increase in PC choice.

·        Each 7 point increase in students born in the most urban parts of the nation results in 1 – 2 fewer PC graduates.

·        Each 4 point increase in older medical students increases PC by 1 point.

Discussion

Although most choice of medical specialty efforts have focused on influences after admissions, the decision for specialties such as primary care and family medicine may involve admissions of those most likely to choose primary care. The common theme in the variables presented is social status.

This study should not be taken as a literal cause and effect relationship. The variables involved are likely proxies for influences that are more direct, specifically interactions involving social status.

Theory to Explain the Findings

Students of lower status origins tend to be rural, older, and born in the same state as the medical school. Students of highest social status are from the most urban parts of the nation. Asian medical students exemplify this group that has family characteristics of urban location and higher income, higher education and a much greater degree of professional parents.

Any admission other than the most urban and highest social status increases the potential for a choice of primary care and family medicine. See predictions of FP "match" based on background and ethnicity (social status)

Median income is important to provide the resources for state education, best reflected by college continuation rates. In areas with the lowest income and education within a state (rural or inner city) or in states without the income or state education resources, it is difficult for those of lower social status to be admitted. Eventually some are admitted as older students

Given this theory, students who are rural, Native, Black, Hispanic, and older who are from the highest social status will be less likely to choose primary care and careers serving the underserved. Asian and urban students of somewhat less social status would still choose primary care and family medicine.

The influences of family of origin can also explain the impact of social status and choice of primary care. Those students with families that have had increasing social status would have influences resulting from more humble origins. Those students who have higher status origins, but who have had significant concerns regarding the abuses of social status, will also tend toward a career where they can make a difference in the lives of those of patients in the most need of physicians.

The MCAT is closely associated with urban, income, and research. Only primary care, family medicine, and Ob-Gyn have negative correlations. Other specialties have positive correlations. Speeded intellect may be a poor measure of admissions as it discriminates against those who are more likely to choose primary care, family medicine, and obstetrics.

A broader approach to admissions could greatly improve specialty choice by physicians. The following involved regressions of similar characteristics with the independent variable being the percentage of students choosing that specialty.

FPs Are Different Table

MCAT up 1 point in past 15 years

There was a 9 percentage point increase in over 30 year olds in past 20 years from 8.4 to 17.6 %

Slight declines in graduation rates 5 - 6 % over 10 years

Medical students were 49% born instate in 1980, down to 35% born instate in 2002 graduating class..

Differences Across the Nation

Primary care choices in the east tend to be pediatrics, internal medicine, and medicine/pediatrics as compared to family medicine in the Midwest and west. Schools in the east also tend to have emphasis on research and higher ratios of internal medicine physicians not choosing office-based practice. Older students in such schools do tend to choose primary care and family medicine in higher percentages in such schools, but do not have the dramatic differences seen in schools further west. Older students in such schools may be a mix of “second chance” students from high and lower status, as well as students admitted for research and intellectual criteria. Older students in the non-eastern locations tend to be older, instate, rural and lower scoring on the MCAT.

Family Physicians Are Different

Choice of FP Update Progress beyond the Arizona Study

Short and Sweet on FP Choice

Choice of Family Medicine: Past, Present, Future

Admissions Summary

Admissions and Social Status

MCAT Correlations

Admissions and ORIGIN

See Rural Birth Origin tables.

Admissions Summary

Before Admissions

Career Predictors

www.ruralmedicaleducation.org