The indexes were generated by comparing the percentage of each group found in each location to the percentage composition of the group in the US workforce. For example, rural born US born FPGP physicians have 9.1% rural underserved location and are only 2% of total physicians in the United States workforce. 9.1 / 2 is 4.56. The following are ranked from the top total underserved contribution to the bottom. Improving the distribution of physicians in the nation involves admissions or training that concentrates physicians in underserved areas and disperses physicians away from major medical centers.
| Total Under-served |
Group |
Urban Under-served |
Rural Under served |
All Rural |
Rural Not MMC |
Major Med Center |
Isolated Rural |
Isolated Under served |
Military |
| 18.4% |
Black,Hisp, PR, Native FP |
3.78 |
2.33 |
1.26 |
1.48 |
0.69 |
1.33 |
1.51 |
1.06 |
| 15.5% |
Rural Born US Born FPGP |
1.07 |
4.56 |
4.26 |
4.89 |
0.55 |
6.09 |
6.08 |
3.78 |
| 12.6% |
Foreign Born IMG Off IM |
1.97 |
2.48 |
1.47 |
1.71 |
0.82 |
2.00 |
3.63 |
0.28 |
| 11.8% |
Fam Practice Gen Practice |
1.70 |
2.48 |
2.28 |
2.64 |
0.67 |
3.36 |
3.43 |
1.06 |
| 11.3% |
Urban US Born FPGP |
1.83 |
2.15 |
1.89 |
2.19 |
0.70 |
2.91 |
2.93 |
2.00 |
| 11.1% |
White Family Physicians |
1.15 |
2.28 |
2.15 |
2.48 |
0.57 |
2.90 |
2.40 |
1.92 |
| 10.3% |
Historically Black School |
2.46 |
1.08 |
0.81 |
0.85 |
0.89 |
0.67 |
0.82 |
1.44 |
| 9.3% |
Bottom Quartile County Birth |
1.17 |
2.15 |
1.97 |
1.97 |
0.91 |
1.86 |
2.17 |
1.39 |
| 9.2% |
Osteopathic Low MCAT |
1.39 |
1.85 |
1.66 |
1.75 |
0.81 |
1.75 |
1.77 |
1.34 |
| 9.0% |
Office Primary Care |
1.47 |
1.70 |
1.53 |
1.69 |
0.84 |
2.00 |
2.13 |
0.72 |
| 8.4% |
Asian Family Physician |
1.67 |
1.27 |
1.08 |
1.24 |
0.80 |
1.79 |
1.53 |
1.19 |
| 8.4% |
Inclusive Primary Care |
1.40 |
1.56 |
1.39 |
1.53 |
0.87 |
1.82 |
2.00 |
0.94 |
| 8.2% |
Rural Born in US |
0.83 |
2.11 |
2.30 |
2.31 |
0.89 |
2.18 |
2.28 |
1.39 |
| 8.0% |
Foreign Born IMG |
1.40 |
1.41 |
0.98 |
1.04 |
0.99 |
1.18 |
1.63 |
0.22 |
| 7.8% |
School MCAT < 9.5 |
1.15 |
1.61 |
1.56 |
1.52 |
0.94 |
2.18 |
2.34 |
2.09 |
| 8.0% |
Foreign Born IMG Off FP |
1.33 |
1.37 |
0.94 |
0.99 |
1.00 |
1.18 |
1.60 |
0.22 |
| 7.7% |
Osteopathic High MCAT |
1.32 |
1.38 |
1.59 |
1.65 |
0.81 |
1.65 |
1.72 |
1.21 |
| 7.3% |
Office Internal Medicine |
1.27 |
1.30 |
1.09 |
1.13 |
0.96 |
1.18 |
1.55 |
0.50 |
| 6.8% |
Office Pediatrics |
1.43 |
0.93 |
0.90 |
0.90 |
0.95 |
0.73 |
0.63 |
0.72 |
| 6.7% |
Not Born MS City/County |
1.07 |
1.30 |
1.24 |
1.26 |
0.96 |
1.36 |
1.37 |
1.00 |
| 6.6% |
All Foreign Born |
1.30 |
1.00 |
0.78 |
0.81 |
1.01 |
0.82 |
1.03 |
0.50 |
| 5.7% | National Underserved Average of 3.0% Urban Underserved and 2.7% Rural Underserved | ||||||||
| 5.3% |
Off IM US Born |
0.93 |
0.93 |
1.05 |
1.01 |
1.01 |
0.82 |
0.80 |
0.61 |
| 5.2% |
US Born |
0.87 |
0.96 |
1.09 |
1.08 |
1.00 |
1.00 |
0.95 |
1.28 |
| 6.6% |
Foreign Born USMD Grad |
1.17 |
0.52 |
0.54 |
0.53 |
1.05 |
0.36 |
0.33 |
0.78 |
| 4.8% |
General Surgery |
0.65 |
1.07 |
1.22 |
1.21 |
1.04 |
0.86 |
0.54 |
1.59 |
| 4.8% |
Born in MS City/County |
0.93 |
0.74 |
0.80 |
0.78 |
1.03 |
0.73 |
0.70 |
1.00 |
| 4.0% |
Top Inc Quartile County |
0.82 |
0.56 |
0.70 |
0.67 |
1.05 |
0.68 |
0.56 |
1.12 |
| 3.9% |
Orthopedic Surgery |
0.53 |
0.85 |
1.07 |
1.00 |
1.05 |
0.43 |
0.49 |
1.51 |
| 3.1% |
School MCAT 10.5 - 12 |
0.74 |
0.31 |
0.36 |
0.33 |
1.13 |
0.21 |
0.18 |
0.63 |
Improving distribution is about concentrations. Increasing the numbers of physicians with higher concentrations of a desired underserved or rural location will be more likely to increase the workforce in this location. This can involve admissions, training, or health policy support. It takes additional work and expense to locate physicians against their desired career and location choices. Retention is also likely to be lower and services may be more compromised. Cost, quality, and access are more likely to improve with physicians that share common origins, background, and experiences.
Points
1. Those least likely to gain admission are most likely to distribute to the
most needed careers and locations
2. Physicians tend to return to birth origin locations, especially when choosing
a career with broad scope such as family medicine which allows the full
expression of birth origin tendencies
3. Accelerated graduates contribute at the highest levels of distribution
4. Understanding physician distribution requires understanding origins,
admissions, training choices, and health policy
5. Physicians most closely connected to major medical centers for the first 30
years of life are the least likely to leave these careers and locations
6. Obligations and health policy supports are important for distribution. J-1
Visa effects in international medical graduates in internal medicine, in
military careers, and in family physicians (NHSC, CHC, etc.) make important
contributions to career and location choice
By categorizing physician locations across the nation, the total contributions
to rural underserved and to urban underserved locations can be determined. Rural
underserved locations have about 2.7% of US physicians and urban underserved
locations occupy 3.0%. This is a total of about 5.7% for the 1987 - 1999
Graduates of all medical schools in the world in US locations as listed in the
AMA Masterfile for 2005, This is about 50% of the active physicians of the
nation and the most recent to graduate and distribute to equilibrium careers and
locations
The Total Underserved percentage in the table below represents the urban
underserved plus rural underserved contributions of the particular group. All
with greater than 5.7% are contributing to the distribution of physicians in the
nation above the national mean. Underserved locations are zip codes with 20% or
more in poverty or have a CHC, NHSC, or whole county shortage area designation.
Total Underserved %
Group of physicians
18.4% Black, Mexican American, Other Hispanic, Puerto Rican, or Native FP
15.5% Rural US Born FPGP
14.7% Accelerated family medicine residency grads (n=136 from 12 schools)
12.6% Foreign Born IMG in Office Based Internal Medicine
11.8% All Family Practice Gen Practice
11.3% Urban US Born FPGP
11.1% White Family Physicians
10.3% Historically Black Medical School Grad
9.3% Bottom Quartile County US Birth
9.2% Grad of Osteopathic Lower Half MCAT School
9.0% Office Primary Care - IM, FM, PD, MPD, GP and the office based primary
practice activity, a measure closest to actual primary care
8.4% Asian Family Physician
8.4% Inclusive Primary Care - any primary care type adding geriatrics to the
above and any primary practice activity (poor measure of PC)
8.2% Rural Born in US
8.0% Foreign Born IMG
7.8% Grad of School MCAT < 9.5
7.7% Foreign Born IMG Office FP
7.7% Grad of Osteopathic Highest MCAT half
7.3% Office Internal Medicine
6.8% Office Pediatrics
6.7% Not Born in a City or County with a Medical School
6.6% All Foreign Born
National mean of 5.7% here for the 294,000 in the 1987 - 1999 cohort from all
sources
5.3% Office IM US Born
5.2% US Born
4.9% Foreign Born US MD Grad - about 16% of US MD Grads now
4.8% Born in MS City/County - a likely proxy for children of professional
parents
4.0% Top Inc Quartile County
3.1% Grad of School with MCAT 10.5 - 12 - obviously other areas are emphasized
as these schools lead in MCAT, board scores, wealthy parents, foreign born,
youngest graduates, researchers, and fellowship positions, but distribution,
primary care, family medicine, and diversity are found at the lowest levels in
the nation for this 20% of US MD Grads. Much of the medical leadership of the
nation also arises out of this group with the least exposure to physicians
choosing distributional careers, primary care, or family medicine.
I don't have parent income, but I can use birth county income origins as a
proxy.
I don't have MCAT scores on individuals, but I can use school MCAT as a proxy
for national distributions. Higher MCAT is associated with lower distribution
and lower choice of FM and lower levels of income in a number of studies. Higher
MCAT is a measure of parent influences.
One other proxy that I have developed involves birth in a city or county with a
medical school. This appears to be a proxy for parents who are physicians or
professionals or at least professional and physician parents are concentrated at
the highest levels in counties or cities with medical schools in the United
States. Concentrations are also seen in certain populations. For example the top
quartile counties that have a medical school are just 51 counties, 1% of the
land area of the United States, 20% of the population, 47% of the Asian
population, 32% of the Hispanic population, 22% of the black population, and 17%
of the white population. These counties are also declining in percentage of the
US population as many are stagnant or losing population.
Admissions ratios are lowest for the medical students socially and
geographically distant and physician distribution levels are the highest.
MCATs, board scores, origins, and parents line up for major medical center
physician locations. Schools admitting under policies based more on the student
than their scores/parent influences admit older students, diverse students,
lower income origin students, and graduate more family physicians, who
distribute at the highest levels.
Family medicine is the only specialty with more than 50% of the specialty
located outside of major medical centers. This allows family physicians to be
the largest proportion of physicians in all other locations, including urban
underserved, urban served, rural, rural underserved, rural served, and all of
the various shortage designation types. Family medicine choice also doubles
teaching probability, a level not found in internal medicine or other career
choices.
Family physicians benefit from broad scope, enhanced privileges, increased
procedures, lower costs, and better income levels in states with fewer
physicians concentrated in major medical centers. These are also states with
lower health care costs and better quality of care, for a number of reasons that
may or may not related to family physicians. These are also states that do
better in a wide range of education, income, economic, social cost, prison, and
other outcomes.
Percentage of Physicians Compared to % found in underserved areas, both urban
and rural underserved types
| % of Physicians | Urban Under-served | Rural Under served | |
| US Population 2000 | |||
| 100.0% | National Averages | 3.0% | 2.7% |
| 29.7% | Office Primary Care | 43.5% | 50.5% |
| 15.3% | Fam Practice Gen Practice | 26.1% | 38.1% |
| 11.2% | Office Internal Medicine | 14.2% | 14.5% |
| 11.2% | White Family Physicians | 12.9% | 25.6% |
| 3.4% | Black,Hispanic,Native FP | 12.8% | 7.9% |
| 6.4% | Urban US Born FPGP | 11.8% | 13.8% |
| 5.8% | Office Pediatrics | 8.4% | 5.4% |
| 6.3% | Off IM US Born | 5.9% | 5.8% |
| 2.0% | Foreign Born IMG Off IM | 3.9% | 4.9% |
| 1.4% | Asian Family Physician | 2.3% | 1.7% |
| 2.0% | Rural US Born FPGP | 2.1% | 9.1% |
| 0.7% | Foreign Born IMG Off FP | 0.9% | 0.9% |
FPGP physicians are only 15.3% of the total physicians but
are 26% of the urban underserved physicians of the nation and 38.1% of the rural
underserved physicians. Family medicine choice more than doubles distribution
levels. Multiplier effects are seen for a variety of origins and for family
medicine choice. Again this is possible for specialties that give up major
medical center location. No other medical specialty does so and nurse
practitioners and physician assistants also concentrate in major medical
centers. Family physicians stay in family medicine at 98%, office primary care
at 90%, and outside of major medical centers above 50%. All other forms of
primary care collapse into major medical center careers and locations over time.
Family medicine remains at double rural and underserved national averages (>22%
rural and > 11% underserved) for all class years dating back to the creation of
family medicine.
International medical graduate physicians in office based internal medicine also
double urban underserved and rural underserved distribution. These levels
require J-1 Visa waivers for distribution. Bypass of waivers would result in
loss of rural underserved distribution although the urban underserved
distribution would remain. The lack of distribution for IMG family physicians is
worthy of study and may require examination of qualification procedures and
preferences.
Similar high levels distributions are found in obligated US born family
physicians.
Family medicine accomplishes distribution despite higher levels of military
obligations that take the family physicians most likely to be found in rural
underserved and urban underserved locations.
Asian and foreign born IMG family medicine contributions are limited by
concentrations in practice in California, a state with only 4% rural population
and lower levels of urban underserved location. Asian FP rural levels of 8% do
not seem like much, but this is double the California rural concentration. Asian
and foreign born family physicians are the fastest growing component. White,
rural, males are declining at the most rapid rates.
Different types of family physicians make different contributions to various
locations, usually according to birth origins.
Qualifiers - Family physicians who are youngest in age at graduation, those from
elite and highest scoring schools, those from highest income counties, and those
from international medical schools do not have the same 2 - 6 times multpliers
for distributional locations as found in typical family physicians.
Family physicians also have the highest levels of retention within the state
location of their medical school for practice. Admissions of medical students
born in a state (Instate birth) and choice of family medicine are the two major
factors in brain drain prevention in physicians. Osteopathic, older, and lower
income origin factors also increase instate retention.
Robert C. Bowman, M.D.
rbowman@unmc.edu
VISA Programs: Do They Help In Primary Care and Rural Areas?
Ranking Medical Schools and FP Residency Programs
- listings of actual medical school contributions to rural workforce
Sources of the Current US Physician Workforce - who provides rural, essential, and other types of physicians
Frontier Family Medicine Choices by medical school name and type
Rural Coding RUCA 2.0 and the US pop and poverty by state
Accelerated Family Medicine Training Programs
Rural
Recruitment and Retention Factoids
Physician
Workforce Studies