Multidimensional Choice of Family Medicine

Robert C. Bowman, M.D.

13.9%

is the current percentage of all physicians involved in family medicine for the graduates of 1987 – 1999 considering all physicians in the AMA Masterfile from all types of medical schools in the world. This cohort is 40% of the total workforce and represents the most recent graduates. Because family medicine is closely related to the types of students, income levels, and physician distribution, the factors in choice of family medicine are critically important to physician workforce. The following is a voyage of discovery about the concepts important in understanding choice of family medicine and physician distribution.

TIME - Considering the dimension of time, the choice of family medicine does vary.

 The following involve choice of office based family medical school by a number of factors.

Region of Medical School    Age of Student At Graduation    MCAT Score of School   Military Family Physicians

Comparing Medical Students By Class Year - the dimension of time can yield valuable clues about the impact of education, admissions, and health policy on choice of family medicine and physician distribution

Compare to MCAT and Choice of Rural Practice    Compare to Admissions Dimension

Medical School Admissions By Income - look earlier in the pipeline to see education and environment changes before admissions.

Matters of Perspective - comparisons of medical schools by types of students admitted by income, and how distribution and choice of FP disappears with increasing income, MCAT, and younger age

Health Policy - Although there have been articles that note rise and fall with economics (Bill Hueston in Family Medicine), the rise and fall variations involving family medicine appear to involve two key factors interacting over time.  Research on the Declining Family Practice Match

• Long term decline – Appears related to declines in US education, changes in distribution of wealth in the nation, and declining ability of lower income students to access college and medical school.
• Short term increases - The increase in family medicine and primary care graduates from 1965 to 1978 illustrate a peak in distributional health policy in the US with the creation of Medicare and Medicaid, the increasing support for federal funding for physicians and hospitals in underserved areas, funding for medical students, funding for medical schools, and the creation and support of family medicine and primary care.
• Short term declines in choice of primary care, family medicine, and poverty primary care choice were related to declines in federal support for Medicaid and Medicare.
• Repeated rise and fall in the 1990s - The same rise and fall with health policy accompanied managed care and health reform changes in the 1990s.

Family physicians have several advantages related to retention. They are more likely to be retained within the specialty of family medicine and delivering primary care. They are also more likely to be retained in state - like other types of physicians, about 98% of family physicians stick with family medicine. Family medicine is the most permanent choice made at the end of medical school. About 1% choose geriatrics or sports medicine and another 1% will choose another residency in the period within 5 years of graduation from a family medicine residency program. Some 90% of family physicians stick with office based family medicine. Only 50% of those taking an internal medical program and 76% of those taking a pediatric residency stay with office based general primary care when comparing the office based generalists with all those who trained in an internal medicine or pediatrics residency program.

The office based generalists are more likely to be delivering primary care, especially at zip codes away from major medical centers and teaching locations. The choice of family medicine for office based generalists is 

11.2% 

Types of Medical Schools rated by family medicine choice and by MCAT scores

 for text see MCAT and Physician Distribution             

     for graphic on how family medicine choice related to other distributional careers and the MCAT

Birth Origins and Choice of Family Medicine by Birth Origin for Allopathic US Graduates

 The areas with the greatest concentrations of people, wealth, education, and health facilities are less likely to be the birth origins of family physicians.

Birth Origin and Region of the Country

Region impacts distribution of population, income, education, and apparently physician distribution. Region also impacts distribution by ethnicity.

Family medicine is not a popular choice in eastern locations as compared to West and Midwest. Multiple linear regressions fully loaded and weighted for population distribution confirm a longitudinal bias in choice of family medicine.Birth Origins and FP Choice

Ethnicity and Choice of Family Medicine

In this determination, the universe is 1994 – 2000 graduates of US allopathic medical schools from AAMC data that is 98% complete for ethnicity. The numerator is the number of family physicians graduating from 1994 – 2000 by ethnicity and gender from the AMA Masterfile, a database that includes ethnicity on 80.5% of graduates.

Ethnicity Gender and Rural Practice Choice

 Choice of family medicine by admissions probability

The probability of admission increases with increasing income, population density of origin, and increasing college graduation rate of the county of origin. Students who are lower income, rural born, and minority are the least likely to gain admission but have the greatest probability of physician distribution upon graduation. Choice of family medicine facilitates the distribution of distributional type students, rural born or lower income in origin. see  table at Ethnicity Gender and Rural Practice Choice for probability of admission and choice of family medicine

Choice of Family Medicine within MCAT types of schools by Birth County Income levels of Students (1969 County Income in 1989 dollars)

The student birth origins were linked to county income levels. These were also compared to the medical school of the student by the MCAT score. As income increases and as MCAT increases, choice of family medicine declines. See also Admissions By Income Quartiles   There is some increase in family medicine in the higher income counties that are more urban. This may represent low income students within high income counties.

Choice of family medicine by age and rural origins

In the following, rurality is represented as the population density in people per square mile for the county of birth. Medical students are divided into a group of 8 – 10% who are up to age 25 at medical school graduation, the bulk of students graduating at age 26 – 29, and the 22% graduating who are considered non-traditional or older than 29 years. Choice of family medicine shares a linear and consistently increasing relationship with both age and rurality of origin. Population density is a reasonable proxy for income level and the % of the population that is college educated in the county also. Admissions probability for medical school has a strong relationship with college educated in a county. 

Choice of Family Medicine By Birth State, State of Medical School Attended (slotted states included for WWAMI, WICHE, Jefferson/Delaware), and Practice State

 The states with education and health policy difficulties demonstrate a decline in family medicine across the pipeline from birth to medical school to practice. Bright Future Rankings