Robert C. Bowman, M.D.
Certain students are more likely to choose family medicine: students born in rural areas, those born in less densely populated urban areas, those of lower income levels, those who were born in the same state as their medical school, and those who are older at graduation. These characteristics all appear to be proxies for socioeconomic level. Direct studies confirm the relationship between choice of family medicine and student socioeconomic level.1
Choice of Family Medicine Over Time By Socioeconomic Proxy Group
|
Allopathic Public Graduating Class of |
1975 |
1980 |
1985 |
1990 |
1995 |
1999 |
|
Student Age at Graduation |
|
|
|
|
|
|
|
20-25 years |
12.7% |
10.0% |
8.9% |
6.6% |
10.0% |
9.9% |
|
26 years |
15.0% |
13.2% |
12.5% |
10.2% |
16.4% |
12.5% |
|
27 years |
13.5% |
14.7% |
13.5% |
13.2% |
18.2% |
13.7% |
|
28-29 years |
12.1% |
14.0% |
15.7% |
14.3% |
18.3% |
13.3% |
|
30 years and up |
13.9% |
14.5% |
15.6% |
17.4% |
22.5% |
18.4% |
|
Population Density of Birth County |
|
|
|
|
|
|
|
Less than 100 per sq mi |
19.8% |
20.3% |
19.0% |
19.4% |
27.2% |
22.2% |
|
100 - 250 |
15.3% |
15.5% |
15.2% |
16.4% |
21.6% |
17.6% |
|
250 - 1000 |
14.8% |
14.4% |
16.1% |
12.8%* |
20.4% |
15.2% |
|
1000 - 5000 |
12.8% |
12.3% |
12.3% |
11.5% |
16.9% |
13.6% |
|
Over 5000 |
9.1% |
6.9% |
8.1% |
10.5% |
13.6% |
8.8% |
*Adjacent years were more consistent. The table excludes atypical schools, osteopathic, and all private schools (Puerto Rico schools, Duluth, Mercer, Minnesota, Uniformed Services, and University of Missouri Kansas City). Inclusion of all allopathic schools tends to lower the choice of family medicine and lessens the impact of age, but the relationships remain. Data from 2004 American Medical Association Masterfile. 1999 data used as 2000 data does not include those who made late choices of FP, late choices of location, or whose data was delayed in inclusion.
Different ethnicities with lower income levels have greater choice of family medicine as well. Parent Income and Ethnicity and FP Choice Students who were born in rural areas or in the same state as their medical school, students who are older, and lower income students who are white, black, or Hispanic are the most likely to distribute where needed and are the ones disappearing from allopathic medical school admissions. These long term declines and the rapidly rising parent income levels of matriculating students indicate significant and ongoing changes over at least 30 years.
Association of American Medical Colleges Minorities in Medicine studies note that there have been major declines in the 4000 students from the lowest income quartile. Those whose parents made less than $40,000 annually have been declining at a rate of 400 each year. The highest income quartile has been increasing at over 700 each year. This higher income group is half as likely to choose family medicine. These changes alone translate to 50 fewer family physician graduates each year.
Health policy changes (creation of family medicine, Medicare, Medicaid, primary care funding changes, managed care forcing fewer positions in subspecialties) such as those seen in the 1995 column in the table above have the most dramatic impacts on family medicine choice, but the characteristics of the students admitted have a say as well. With national data on all medical students during stable health policy, it is possible to predict family medicine workforce from allopathic schools as soon as income or birth data is collected on the new matriculants or 7 years before entering the physician workforce.
The elimination of the lowest income medical students also means fewer to rural areas, fewer choosing poverty primary care locations, and fewer retained in the same state as their medical school. Medical schools should carefully consider their missions and admission policies if they hope to continue to maintain state funding. Although lower income students do have a slightly higher failure rate, long term studies do not reveal differences in physician performance. 1 In fact, there is every reason to believe that physicians sharing common origins with their patients are more likely to be effective in such settings. There is much more to family medicine than a future for itself. Family medicine represents a future for patients who most need health care, underprivileged students in most need of career opportunities, and low resource states and regions of the nation who must be efficient with scarce resources.
Consistent Family Medicine Choice Over Time
References
1. Cooter, R., J. B. Erdmann, et al. (2004). "Economic Diversity in Medical Education." Evaluation and the Health Professions 27(3): 252-264.