Robert C. Bowman, M.D. rbowman@unmc.edu www.ruralmedicaleducation.org
The maldistribution of physicians is a chronic malady afflicting the nation that has somehow evaded effective treatment for the past 80 years. The 1995, 1996, and 1997 allopathic medical school classes in the United States all graduated over 750 rural family physicians and an additional 750 office-based primary care physicians who were in poverty locations in 2004. With maintenance of this level of supply, the US would have had more than enough physicians to address current and future needs; however, reversals in health policy have shifted physicians in other directions. Distributional graduates are half of peak levels and will soon reach the lowest levels in 40 years. It is almost as if Medicare, Medicaid, and family medicine training were never created.
Perhaps in the minds of today’s medical students, that is exactly what has happened. An exploration of the perceptions of 1990s students compared with students who graduated before them and after them can help in understanding the problem and the solutions.
Under the right conditions, students will choose the specialties and locations needed. Changes in choice of primary care have been related to health policy. The greatest increase in primary care choice was associated in the greatest change in health policy in the past century. From 1965 to 1978 the nation had an increase from 28% choosing primary care to 41 %. The implementation of Medicare and Medicaid in 1965 was followed by a tremendous increase in health care spending. Patients who could not afford routine care and primary care could now access care. The breadth of funding favored rural areas since there were greater numbers of both elderly and poor patients. With the creation of the family medicine specialty (1970) that could address the needs of all ages and all economic levels of patients, there now was a physician specialty that could distribute to rural areas. This opened up an entirely new market with hundreds of thousands of new patients. This was also an economic boost to rural areas, perhaps the last one provided by the nation. Soon the desert would begin to roll back the irrigated rural lands now producing health care.
In the 1990s again there was consistency in federal support with Congress sending a clear message of regular increases in Medicare and Medicaid support of primary care. In addition there were regular decreases in pay for hospital-based physicians and subspecialists. There was a clear state and federal message of broadening of health access for poor people with increase Medicaid eligibility. This also favored primary care physicians, especially those with greater percentages of Medicaid patients, the ones who also tend to have fewer paying patients. Office-based primary care physicians in poverty zip codes rose up to a record 5.6% for the 1997 graduates. The other providers in poverty locations that depend upon federal and state support include community health centers, family practice residency programs in rural and urban locations, other primary care training programs in urban areas, and family physicians in rural areas.
Since 1998 there has been an even clearer message to medical students: less support for Medicare and Medicaid, declining primary care support, increasing overhead costs with primary care physicians unable to adjust rates of pay to cover these costs, total health system dysfunction with subspecialty physicians more able to hire the assistants to insulate themselves from the mess, massive increases in medical school debt and tuition costs, confusing and crisis-oriented messages from primary care leadership, and declining support for rural hospitals, rural economies, and rural schools. Primary care has been "carved out" for punishment almost as much as psychiatry.
Although there have been changes in medical students between 1997 and in 2005 (fewer rural born and fewer lower income students, the major differences for the two periods of graduates involves health policy. Those graduating in 1997 had every reason to trust that they could practice high quality primary care even in the most challenging areas of the nation. Those graduating in 2005 and choosing primary care would have to be extremely naïve, extremely dedicated (likely both), trained in a foreign nation, or born in a foreign nation with either a.) poor understanding of our health system to choose primary care or b.) intent to retrain as a subspecialist after completing an obligation.
Despite the reversals in health policy, the lessons of the 1990s have not been lost. Career choice restrictions and supportive primary care health policy succeeded as never before. The most important group in physician distribution is the largest group of students: the 50% of allopathic medical students born in counties of over 1 million. This is the group most likely to practice at a location within 60 miles of their birth and least likely to practice in a county that is not a large metropolitan. This urban born group provides most of the rural and poverty physicians even though the percentages are smaller for each. The rural born, older, and other lower income students who will distribute are just too few in number. Also with fewer primary care physicians graduating compared to the positions available, the distributional students (rural, older, lower income) are often absorbed into urban, large rural, and less underserved practices.
When the majority of graduating medical students shifted career choice with 50% increase in choice of family medicine this filled urban and large rural positions. Some of the urban born and those born instate choose rural and poverty locations and the smaller numbers of rural born and older graduates also distributed more effectively. Perhaps more importantly there was the very real potential that a student could choose subspecialty training and not have a job after graduation, or might have a job but would have to be willing to move just about anywhere in location. This had a major impact on the students born in urban areas and this was the key to physician distribution success. Students who choose family medicine in greater numbers included those born in inner city locations. Black and Hispanic females increased greatly in FP during this period. There was no increase in overall rural physicians, but there was a 40% increase in rural family medicine. These all indicate a greatly favorable equilibrium shift toward the primary care positions and locations most in need during managed care/primary care reform.Five Periods of Health Policy and Physician Career Choice
The shift in national focus also involved residency positions. Primary care residency positions filled and programs expanded. Subspecialty programs faced shortages of residents. The overall effect was the same as limiting subspecialty graduate positions. Primary care programs had the luxury of developing in ways to attract more residents, instead of trying to be all things to all students in the attempt to fill positions. The primary care programs followed the interests of the directors of their programs. Instead of specializing into organs or technologies, primary care programs specialized in underserved populations. They developed special primary care programs for inner city locations working with community health centers. They developed rural training tracks, smaller family medicine programs in rural locations, and accelerated family medicine residency training programs. These programs graduated 80% into rural locations or urban poverty locations.
Family medicine training facilitated distribution. Urban born graduates choose rural locations at less than 8%, but urban born students choosing family medicine choose rural locations at 21%. Rural born graduates choose rural practice at 18% without family practice choice, but at 42% levels when choosing FP. Both urban and rural born students have half the rural choice of rural locations when choosing internal medicine or pediatrics as compared to family medicine. The poverty location choices of black, Hispanic, and Asian students also improve when choosing family medicine.
Is it the training that facilitates distribution or is it perhaps that those choosing family medicine are more likely to distribute?
The best answer is likely both. It appears that those choosing family medicine are different around the common theme of more humble origins. The scope of family practice training allows a better distribution to rural and underserved locations. The scope also includes significant training in mental health and women’s health.
The impact was not limited to managed care although the impact on limiting potential career choices was important. Five Periods of Health Policy and Physician Career Choice New revenues flowed into rural hospitals who could afford to recruit physicians more aggressively. Instead of operating in the red as in current situations, these hospitals had cost plus funding. The new reimbursement also favored family medicine, the specialty that is still more likely to care for poor, less educated, and rural patients. (Mold, 2002 Graham Center)
The common theme of distribution is breadth, not depth. This involves health care funding, education, health policy, public health, national efforts involving research, etc. Breadth builds a nation. Depth that steals breadth tears it down.
Understanding Higher Education and Income
Socioeconomics and Physician Distribution
Robert C. Bowman, M.D. rbowman@unmc.edu