Summary and Tables, Family Medicine Residency Graduates from 1997 - 2003
Robert C. Bowman, M.D. rbowman@unmc.edu www.ruralmedicaleducation.org
Newer summary and integration at Family Physicians Are Different
Each of the hyperlinks refers to a chart in this area:
Family Medicine Central: National Comparisons of Workforce
Decreasing Rural FP Physicians There is an overall decline in total numbers of rural FP graduates with all three categories showing decreases. Declines in those choosing isolated rural locations is a critical concern for the nation.
Gender and Ethnicity in FP Graduates 1997 There have been declines of FP grads who are white male, Hispanic male, and Native. White females are steady and Asian females are increasing, particularly international grad females from India, Pakistan, and China. Rural graduation rates of FP residents range from 5% for US born Asian grads to 50% for Native FP grads. Generally about 15% chose rural in allopathic private schools and international schools. Allopathic public is about 30 % and osteopathic 35 – 45%.
Increasing International FP Graduates from Near International Sources Over 90 Ross University graduates finished allopathic FP programs in 2003. American University and St. George's increased their contribution to 50 - 60 FP graduates each year in 2002 and 2003. The FP output of all international medical schools near the US, the ones most likely to include US citizens (50 – 70%) desiring to return to the US, tripled from 2000 to 2003.
Rural Medical Education Works Studies have long noted that increases in the number of physicians will result in better distribution of physicians. Within each specialty, there are limits regarding the population needed for support as well as facilities, equipment, and call coverage. For rural areas the supply of family physicians is a key area of concern. For small rural areas, selection of rural background students with interest in family practice (not other specialties even primary care) and specific types of rural fp training for best recruitment and retention.
States vary in their ability to retain and recruit across the entire spectrum from birth to medical school to residency. States with more comprehensive programs such as North Carolina, Wisconsin, and Arkansas do an excellent job of not only retaining the state investment in education, but also gathering such investments from other states. States with higher growth rates as well as states in the south and west also tend to attract FP graduates. Other states tend to donate physicians in at the residency and practice levels.
FPs of significant urban origin (Hispanic, Asian) tend to congregate in states such as California. Asian students chose family medicine at one-third to one-half the rate of other students. Only 5 % of US citizen Asian background FP/GP residents chose rural practice as compared to 15% of non-citizens. Asian background FP doctors from US and international medical schools have a strong preference for California. About 150 were born there, 273 attended California medical schools, 420 chose FP residencies in the state, and 721 began family practices in California. It is likely that Asian and URM background students have had little previous exposure to rural experiences. Additional regression studies involving a subgroup of the most urban FP residency programs documented an improved rural graduation rate when programs included a rural rotation Fam Med Residency Programs and the Graduation of Rural Family Physicians. These urban fp programs tend to have greater concentrations of Asian, Hispanic, and Black trainees. data from Bowman FP Grad Studies 2004 except as noted
Some states such as Texas have seen dramatic decreases in FP graduates in 2002 and 2003 from Hispanic origins. This is a time period coincident with affirmative action reversals in the state.
It may be that admission committees, under legal pressures and having concern for mounting debt, are less willing to admit students that are more likely to choose family medicine and rural practice.
Although the graduation rate of rural FP doctors remains about 750 a year, the numbers are falling for the rural and isolated rural areas which are most dependent on family medicine doctors interested in locating in rural areas (needs another year of follow-up for confirmation).
Declines in the numbers of rural background students admitted (some 2000 a year fewer) are likely to continue, with even more difficulty in future years. Declines in white males, those from rural backgrounds, and those from lower incomes, will compound this difficulty.
Recommendations
· Working with international schools to establish rural-based clinical education in the US might improve choice of FP and rural. Long term preceptorship education for international or any medical student is a way to address many of the obstacles plaguing today’s medical education.
· Scholarship and support packages that would level the playing field between military and underserved incentives might increase the numbers of rural fp docs each year by 5 – 10 %, some 50 – 100 rural family physicians.
· Increasing admissions of rural background students would increase the rural graduation rate by 5 – 10% also. Improvements in AHEC and outreach programs to rural communities would allow medical schools to increase this number.
Medical education must provide leadership training, outreach, support for rural health systems, and stimulus for improved rural education. The Flexner revolution did much for most of American health care, it is time to address the areas left behind by Flexner reforms.
1. The graduation rate of rural family physicians is related to the rurality of the state, admissions of rural background students, gender, type of medical school, and interest in family medicine at matriculation, and other characteristics (Rosenblatt, Rabinowitz, Bowman, others)
2. Rural med ed programs have demonstrated effectiveness in education outcomes and practice location.
3. Many rural medical education programs have been depleted over the years by rising costs and no increases in funding. Closures of smaller and rural FP graduate programs are on the increase. Research and educational evaluation studies have been the areas most impacted by funding attrition.
4. Community-based education has demonstrated equal or better educational outcomes (Verby, Gjerde, James)
5. Long term preceptorships have no equal regarding preparation for rural family medicine from the perspectives of the medical school, the student, the state, the rural community, and the rural practitioner.
6. Required rural experiences in residency, even in the most urban family practice programs, resulted in increases in those choosing rural practice locations (Fam Med Residency Programs and the Graduation of Rural Family Physicians).
7. Dispersed education has demonstrated improved distribution of family physicians, nurse practitioners, and physician assistants.
8. Nursing has long understood the value of training for 9 months in a rural area with a family practitioner, yet medicine has relegated this mode of training to a few models. Detailed studies and great rural needs have not improved this situation.
9. Groups of residency programs working together to provide 2 month rural experiences for residents in a continuous fashion (6 residents back to back for 2 months each) can improve education, gain funding for costs, and increase workforce and support in areas of great need (CORE program in Nebraska see Nebraska's Rural Family Practice Programs).
Remember that this is data that includes only graduating FP docs. Only 8% - 10% of other primary care specialties choose rural practice and these are usually in the large rural areas. see Decreasing Rural FP Physicians for graphs of fp and primary care distribution
Zip codes for each graduate were converted into RUCA codes and then method as per Hart
http://www.fammed.washington.edu/wwamirhrc/rucas/00C8994E-005B90E7.-1/use_healthcare.html
Urban focused: 1.0, 1.1, 2.0, 2.1, 2.2, 3.0, 4.1, 5.1, 7.1, 8.1, and 10.1 = 1 on my scale
Large Rural City/Town focused: 4.0, 5.0, and 6.0 = 2
Small Rural Town focused: 7.0, 7.2, 7.3, 7.4, 8.0, 8.2, 8.3, 8.4, 9.0, 9.1, and 9.2 = 3
Isolated Small Rural Town focused: 10.0, 10.2, 10.3, 10.4, 10.5 = 4
I converted this to a 1, 2, 3 or 4 for urban down to isolated rural. These are not linear variables.
|
Location |
FP Grad Count |
Per Cent |
1998 pop by category |
|
Urban Focus 1 |
18795 |
78.9% |
77.60% |
|
Large Rural 2 |
2160 |
9.1% |
9.30% |
|
Small Rural 3 |
1956 |
8.2% |
6.90% |
|
Isolated 4 |
913 |
3.8% |
6.10% |
|
Total in Database |
23824 |
|
|
|
Rural = 2,3,4 |
5029 |
21.1% |
22.30% |
On the right is the 1998 estimate of US population by the same coding. Family Medicine distributes well.
see Decreasing Rural FP Physicians for graphs of fp and primary care distribution
Due to some delays in data regarding osteopathic and international students, as well as the fact that osteopathic grads have osteopathic family medicine programs, the numbers of osteopaths would be higher for family medicine and rural family docs.
There were two data collection points, in Sept of 2001 for the 1997 - 2000 grads, and Nov of 2003 (with updating) recently for the 2001 - 2003 grads. I attempted to catch the entering workforce by the first practice location. I also wanted to know about any short term stayers such as NHSC or J-1. I have names on the more recent group for cross checking, but none for the earlier group so the data is "as is."
Percentage choosing rural practice by medical school origin.
In the following, graduates from these schools that chose family medicine chose rural practice in the highest percentages. Osteopathic and allopathic public schools do fairly well in this table, especially those in more rural states. Also in the left column is the percentage of the medical school students admitted that were considered in state students. Schools with higher percentages of in state students, and schools with higher percentages of students that were born in the state tend to graduate more family physicians. The center column is data from Rosenblatt’s study. The percentages listed represent the % of all students choosing rural (non-metro) practice locations. The rurality of a state has great influence in the rural graduation rates. The nonmetro % of the state population is in column 3. AnyRur is the actual count of rural family physicians from a medical school in 1997 – 2003 (areas 2,3,4 above)
|
|
PerInSt |
Rurality92 |
Rur%81-85 |
TotRurDoc |
AnyRur |
PerRFP |
|
WV Coll Osteo |
67.5% |
63.6 |
|
|
61 |
52.6% |
|
Mercer |
100.0% |
35 |
|
|
49 |
51.6% |
|
U NE Med Ctr |
97.5% |
51.5 |
12.1 |
77 |
83 |
48.0% |
|
U of Arkansas |
97.9% |
59.9 |
15.1 |
96 |
125 |
46.8% |
|
U MN Duluth |
88.0% |
32.3 |
|
30 |
81 |
45.8% |
|
U of Louisville |
91.2% |
53.5 |
10.7 |
72 |
69 |
45.7% |
|
U of South Dakota |
86.0% |
70.5 |
24.6 |
56 |
53 |
42.4% |
|
U of North Dakota |
67.3% |
59.7 |
17.9 |
36 |
49 |
41.2% |
|
West Virginia U |
90.9% |
63.6 |
12.3 |
49 |
40 |
40.4% |
|
U of TN |
91.5% |
32.3 |
7.7 |
70 |
46 |
37.1% |
|
Southern Illinois |
98.6% |
17.3 |
13.3 |
38 |
48 |
36.9% |
|
U Mississippi |
100.0% |
69.9 |
17.9 |
124 |
41 |
35.7% |
|
East TN St |
85.0% |
32.3 |
9.6 |
15 |
29 |
34.9% |
|
U of OK |
87.7% |
40.6 |
8.9 |
71 |
78 |
34.5% |
|
Ok St U Osteo |
84.3% |
40.6 |
|
|
33 |
34.0% |
|
U KS KC |
92.6% |
46.2 |
11.5 |
95 |
103 |
33.8% |
|
Med Coll GA |
98.9% |
35 |
9.2 |
79 |
76 |
33.5% |
|
Dartmouth |
13.6% |
43.9 |
7.5 |
18 |
26 |
32.9% |
|
Marshall |
93.9% |
63.6 |
11.9 |
17 |
23 |
31.9% |
|
East Carolina |
99.9% |
43.3 |
15.1 |
28 |
38 |
31.7% |
|
U MO Colum |
97.9% |
33.8 |
7.7 |
40 |
50 |
31.6% |
|
UHS Osteo MO |
28.5% |
33.8 |
|
|
79 |
30.7% |
|
U of Utah |
74.0% |
22.5 |
5.5 |
26 |
44 |
30.1% |
|
U of South Carolina |
95.9% |
39.4 |
11.1 |
19 |
30 |
30.0% |
Other tables listed below