Robert C. Bowman, M.D.
Medical students are indeed an exclusive group. When considering income quintiles, a consistent 60% or more of medical students have shared origins with the top 20% in income in the United States for decades.1 Medical students with the most urban origins, the most highly educated (or professional) parents, and the closest proximity to medical schools have the greatest probability of admission. Those with the top probability of admission also have the lowest probability of distribution outside of major medical centers. Traditional market forces will interact from birth to practice to consistently concentrate physicians in major medical centers and away from rural and underserved areas. States and nations and even Americans have made different decisions that have shaped different outcomes.
Admissions
• 70-30 Origins of Rural Physicians - About 70% of physicians found in rural areas were born in urban locations. This is mainly because 90% of medical students were born in urban locations. The remaining 30% of rural physicians come from the 10% of admitted medical students who are rural in origin. Since 20% or more of the population has been rural for decades, this means that rural origin medical students have declined to half the probability of medical school admission. Solutions for rural physician distribution or for distribution to lower income areas of the nation involve more than special admissions tracks. Improving admissions of a broader range of Americans involves American distributions of income, education, preparation, advisement, orientation, and opportunity. To improve rural distribution, the nation must increase the concentration of those found in rural locations compared to all physicians. More than just rural born physicians share this characteristic.
• 70-30 Origins and Distribution - Physicians that share origins with 70% of lower and middle income America are found in rural locations at greater than average levels. However only 30% of admitted medical students come from this middle and lower income 70%. Those older at graduation and family physicians also join this group. Even urban born family physicians are found in rural areas at 20% levels or twice the national average.
• 70-30 Pipeline to Medical School - Those most likely to gain admission to the top colleges that are most likely to graduate the professionals and leaders of the nation are also an exclusive group. About 74% of the college students in the top 146 colleges come from about the top 25% in income.2 Barriers include college funding, college access, college preparation, and career orientation. Funding Gaps in state education also provide barriers for those most distant and different from the students readily admitted to top colleges and professional schools.3 Top test scores and childhood performance can be tracked back to family income, professional family origins, and early childhood development advantages.4
• 70-30 Distributions of Physicians Born in Counties or Cities with Medical Schools - Actually 67% of US MD Grads were born in such locations. Over half were born these locations in the United States and the rest were born in the major cities of other nations. Those born in counties or cities with the highest concentrations of professionals, physicians, and medical schools are also more likely to be children of professionals and physicians. Again getting those born and raised in the most elite locations to distribute beyond major medical centers and medical schools is a difficult task. Rural distributions are less than half of the national average without choice of family medicine.
• Loss of 70-30 Distributions of Instate Born - Only in a few states do medical schools manage to admit the students with the most connections to the state by birth. Those born instate are also found in the state in practice in the highest levels years after graduation. Increased federal and state support during the 1970s gave much greater opportunities to instate born medical students and this increased national levels of instate birth medical students back above 50%. In the past 25 years the levels have declined to 36% with admissions of more and more foreign born and out of state medical students. Instate born students are more likely to be rural born and born in lower income counties. These are populations of students that depend upon state investments to help level the playing field for college and professional training. They are more likely to be found in rural practice. States such as West Virginia with the highest per capita instate born students have the highest rural graduation rates, contributing rural physicians not only with a priority for West Virginia, but also exchanging rural physicians with surrounding states. When states fail to provide the child development, education, college positions, and professional school positions that will keep the state supplied with professionals, they steal these investments from other states and other nations. This is a very expensive and inefficient mechanism for states, the nation, and for the rest of the world, particularly the lowest income countries who lose the most.5
• 70-30 Consequences - The most likely pathways to medical school are clogged with the elite origin students. Those “excluded” or displaced from the usual venues must find different routes. This is a costly and inefficient process that means lower probability of admission, additional years to gain admission, waiting lists, repeated applications, Caribbean medical schools, and much additional effort.
Practice Locations
• 70-30 Major Medical Center Distributions of Physicians - About 70 – 75% of American physicians are found in major medical centers (medical schools or zip code locations with 75 or more physicians, rural or urban) that have only 32.9% of the United States population. National concentration of physicians within the major medical center type of location leaves only about 30% of physicians to cover urban served, urban underserved, military duties, international locations, and rural areas. Major medical center locations self-determine the compositions of physicians and of health professionals. They also have high levels of employment, less than average levels of poverty, top levels of income, and top levels of the most lucrative forms of health insurance. Those determining the types of physicians have made choices that mean the lowest concentrations of family physicians at 7 – 9%. Major medical centers could hire more family physicians and primary care physicians, but other investments can return more revenues or attract more grant funds.
• 70-30 Major Medical Center Distributions of Generalist Internal Medicine and Pediatrics - Over 70% of internal medicine and pediatric generalists concentrate in medical schools and major medical centers (75 or more physicians at a zip). These are also locations that receive multiple lines of revenue support (research, teaching, public health). Primary care in major medical centers is unable to support itself. Those hired by major medical centers have specific purposes including graduate medical education and efforts to increase medical center market shares. The systems that compete effectively use primary care, emergency care, urgent care, and other outreach services to funnel patients to more lucrative services as determined by current health policy. The losses in primary care made up by subspecialty referrals, hospital services, and ancillary services such as pathology and radiology.
Health Policy
• 70-30 Distributions of Primary Care – The nation’s newest physician additions include less than 30% for primary care. Internal medicine residency graduates remaining in office based generalist practice have been the largest source of primary care for decades. Office based generalist retention has steadily declined below 30% and likely below 20% of the current internal medicine residents.6 Cumulative changes in health policy continue to shape internal medical graduates away from office based generalist care.7 Even the nurse practitioners and physician assistants created for primary care and locations outside of major medical centers are succumbing to the combined assaults of health policy and major medical center demand. Those losing NPs and PAs to higher pay (emergency, hospitalist, and subspecialist roles) include training programs and nursing schools (losses of faculty) and all depending upon the highest percentages and receiving the lowest levels of Medicare and Medicaid revenues (pediatricians, family physicians, rural locations, underserved locations). In addition to planned cuts in Medicare and Medicaid in coming years, the nation continues to transfer 70% or more of expenditures into the 30% of beneficiaries that receive care from facilities and major medical centers while total expenditures decline past 30% for the 70% of Medicaid beneficiaries that are women and children and those in need of primary care. Health policy will continue to distort current forms of primary care practice away from primary care and back into major medical centers for. This includes all forms of primary care except family medicine, the specialty that remains in family medicine at 98%, in office based primary care at 90%, and outside of major medical centers with the majority of graduates.8 The nation has had different health policy which has maximized distribution and this health policy also maximized US MD Grad choice of family medicine.9 Because the decisions made by major medical centers and the nation involve health policy that impacts over 70% of the practitioners providing primary care, these decisions shape basic access to care for most Americans.
Not to Despair
Although the deck seems to be stacked against distribution, family medicine, primary care, rural, and underserved areas and populations; there is no need to despair. Health policy dealt with all of these areas for the few years that it remained in place, a successful natural experiment. Most importantly the changes that need to be made need only impact a small percentage. We need about 1 percentage point more urban underserved physicians and rural physicians in small and isolated locations. This can be accomplished by a few more percent of family physicians from US MD Grads, the richest and most efficient and most lasting form of physician distribution. All the above can be accomplished by “strongly encouraging” (forcing) medical students to choose family medicine, improving reimbursement for primary care and for those outside of major medical centers, and preferably a mix of both.
See The One Per Cent Solutions that Resolve Distribution Problems
1. Association of American Medical Colleges. Medical Student Education Costs and Student Debt Available https://services.aamc.org/Publications/showfile.cfm?file=version35.pdf&prd_id=121&prv_id=137&pdf_id=35 Accessed July 2006. Washington DC 2005.
2. Carnevale A, Rose S. Left Behind: Unequal Opportunity in Higher Education, Reality Check Series. In: Kahlenburg R, ed. New York: The Century Foundation Press; 2004:p. 106. http://www.tcf.org/Publications/Education/leftbehindrc.pdf
3. Carey K. Funding Gap 2004: The Education Trust; http://www2.edtrust.org/NR/rdonlyres/30B3C1B3-3DA6-4809-AFB9-2DAACF11CF88/0/funding2004.pdf accessed April. 2005.
4. Hart B, and Risley, T. Meaningful Differences in the Everyday Experience of Young Children. Baltimore: Paul H. Brookes; 1995.
5. Mullan F. The metrics of the physician brain drain. N Engl J Med. Oct 27 2005;353(17):1810-1818.
6. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Academic Medicine. May 2005;80(5):507-512.
7. Bowman R. Changes in Specialty Choice 1987 - 1999; 2006. Changes in Specialty Choice 1987 - 1999
8. Bowman RC. Primary Care Retention. Primary Care Retention
9. Bowman RC. Five Periods of Health Policy and Physician Career Choice; 2006.
Physician Distribution in the United States
Distributional Medical Schools
Changes in Specialty Choice 1987 - 1999