Origins and Locations of Recent Family Medicine Residency Graduates

Robert C. Bowman, M.D.

10/23/2003 Draft, updated 10/29

The distribution of family physicians is a matter of great importance to our nation. No other physicians distribute as well (The United States Relies on Family Physicians, Unlike Any Other Specialty (April 2000) Graham Center). Family physicians are 3 to 5 times more likely to choose nonmetropolitan areas of the nation when compared to other types of primary care physicians (Ricketts nonmetro). Those in most need of care depend completely on the supply and distribution of family physicians.

The most reliable source of rural family physicians is students from rural areas. Some medical schools have made adjustments to admissions accordingly. Most have not. At least one nation, Australia, has made modifications in admissions and added rural-focused medical schools. This has increased the numbers of rural background medical students from 10% to 25% of matriculants. Allopathic medical schools in the United States have largely escaped responsibility for graduating the physicians needed for rural areas.

Osteopathic physicians are far more likely to choose family medicine and rural practice when compared to allopathic physicians. Graduates of public medical schools are more likely to choose both family medicine and rural practice. Recent difficulties with the accreditation of the newest allopathic medical school at Florida State, the forced merger of Duluth with the main Minnesota medical school campus, difficulties maintaining preceptorships, the increasing challenges facing rural training track programs, and the termination of the very effective Accelerated Rural Training Program at Nebraska illustrate just some of the difficulties facing those who prioritize the rural health mission.

The Effect of Accredited Rural Training Tracks on Physician Placement (November 1999)

Studies demonstrate that half of rural family physicians come from rural backgrounds and half from urban (reference). Little is known about those from urban backgrounds. The location decisions of family physicians are known to be influenced by the location of residency (dorner) and to some degree by medical school location. Gender is a factor with fewer females choosing rural locations (WAMI). Other influences include physician obligation programs such as the National Health Service Corps (50 FP docs a year) and various state programs. Some states receive little benefit from such programs http://www.ncsl.org/programs/health/forum/workforceprofiles/texas.pdf

.  International physicians also provide services in rural areas of the country, particularly in areas such as Appalachia  http://www.shepscenter.unc.edu/research_programs/Rural_Program/imgl.pdf. The effectiveness of international graduates is limited in the most rural locations as these physicians tend to locate in regional centers (ARC web site).

The relationship between family medicine and the choice of rural practice is a matter of some debate. Some hold that changes in primary care workforce, such as recent declines in the numbers choosing family medicine, will result in a decrease in the numbers choosing rural practice (Colwill - COGME, JRH). Others note that the numbers of family physicians choosing rural practice has been steady over the past 30 years, including the early years with few residents and continuing through two major decreases (Bowman, Medicine and Society, August, 1996, American Family Physician ). Studies by Rabinowitz note that 78% of the decision for rural practice involved two factors, rural background and expressed interest in family medicine at matriculation (Designing Programs - Rabinowitz).

The numbers of rural background students admitted to medical school have declined from 27% to 16% in past decades (Graph admiss2). Since there has been no change in the geographic distribution of those taking the Medical College Admission Test, rural background candidates have become less competitive. Admission committee members often comment that rural candidates have less polished applications. This involves applicants who lack career orientation such as shadowing, perform poorly on interviews, or  have deficiencies in their personal statements. This is not surprising considering that rural candidates have less access to important sources of career information such as health professionals (parents, friends of parents), health professional advisors, shadowing, and premedical school programs. Even when such preparation or feeder programs exist in a state, there is no consistent resource in the rural communities to identify, orient, and motivate potential rural candidates.

Without special considerations, the situation could be worse. The need for a special view toward rural admissions has been documented by Basco where a significant number of rural candidates would not have even received an interview. http://www.aamc.org/students/mcat/research/bibliography/basco002.htm

Declines in the number of rural background students are a concern for both family medicine and rural health. It may well be that it is family medicine that is dependent on rural background students for as many as 40% of residency positions. The influence of rural background has been noted by Kassenbaum (Kassenbaum also noted this decline (Kassenbaum DG, Szenas PL. Rural sources of medical students and graduates choice of rural practice. Academic Medicine 1993;68;3:232-6).   He also noted that there were not enough rural background students admitted to meet the needs of the nation. Madison noted:

A high service index (reflective of a demonstrated orientation toward community service prior to medical school matriculation) predicted strongly the choice of a generalist medical career. Less strong predictors of a generalist practice included the selection of a generous number of non-science-content courses as an undergraduate, lower socioeconomic family origin, and a record of leadership in one or more extracurricular activities during college. If an admission committee informs itself of "what finally happens" to those it admits, its decisions can contribute to achieving whatever policy its medical school adopts with respect to the mix of physicians it wishes to produce.   Acad Med 1994 Oct;69(10):825-31, Medical school admission and generalist physicians: a study of the class of 1985.  (148 graduates UNC included, review of AMCAS data) Madison DL Department of Social Medicine, University of North Carolina, Chapel Hill School of Medicine, 27599-7240. 

Medical leaders such as Jordan Cohen, have called for such changes in admissions, but few have paid attention http://www.aamc.org/newsroom/pressrel/2001/011104a.htm   Actually AAMC President William Butler called for changes much sooner (Butler, W. T. Academic Medicine's Season of Accountability and Social Responsibility, Acad Med 1992;67:68-73.). AAMC held a conference regarding rural medical education 14 years ago, but this effort deteriorated into a discussion of the merits of a merger of the primary care disciplines.  Organized efforts in this segment of medical education continue to remain in the hands of a few dedicated individuals.

Family medicine has responded with enhanced efforts regarding family medicine interest groups, including a national conference for residents and students, but little effort targets those with rural interest. More resources are devoted to international medicine than rural efforts even though 30% of AAFP members are in rural areas and another 10 - 15% have been in rural areas, originated from rural areas, or have family or other interests in such areas. About 30% of family medicine faculty have been in rural practice prior to full time teaching efforts http://www.unmc.edu/Community/ruralmeded/member/rural_faculty_survey.htm .

This current study continues to examine the sources of family medicine residency graduates and their location patterns.

Methods

Using a AMA and AAFP databases of family medicine residents as of September of 2001, data was collected regarding medical schools (AAMC, AAFP), locations of the graduates (AAFP data, census), and the graduates themselves.

Currently this database includes about 1400 or close to half of the graduates of 2002.

Results

Graduates of family medicine residency programs that choose rural practice are more likely to be male and from osteopathic or public medical schools that are not in the most urban locations in the nation.

Tables of gender and type of medical school

Rural Choices by Medical School Origin

Tables by medical school

Med School and Residency Influence By Type of Medical School

Rural docs (non-metro) were slightly more likely to have a practice site the same as their medical school state (35% vs 38.6%).  For both rural and urban docs, residency location much more important in attracting doctors to the state when compared with medical schools. Metro physicians stayed in the same state as their residency 64.5% compared to 46.7% of those choosing non-metropolitan practice sites.

Medical schools in Mexico are not graduating as many rural physicians, but this may be a reflection on the Hispanic influence. It is likely that graduates of these schools are serving the underserved, just not in rural areas. Sources of physicians for rural areas with Hispanic populations will continue to remain problematic without changes. Studies demonstrate that black graduates differ by only a few percentage points from white graduates regarding rural location of practice (Xu, G, et al. (1997). The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. American Journal of Public Health, 87(5), 817-822.public health). Further data on ethnicity is being compiled for comparison, but the numbers will likely be too small without data over a number of years.

Conclusions

The origins of family medicine are changing. Allopathic family medicine residencies are increasingly dependent upon osteopathic and international medical schools. Private allopathic have taken last place behind international schools as sources of residents. Some of these private school graduates may, however, be so dedicated that they are more likely to serve the underserved. This finding is also consistent with Pathman's research (Pathman).

The graduation of rural family physicians from allopathic residency programs continues to remain a constant despite changes the source of medical students regarding gender, background, type of medical school, and curricula. Clearly the smallest locations, even beyond the regional rural centers, continue to support family medicine residency graduates. However, the demand for rural physicians is greater than the supply.

With the decline in rural background admissions, it appears that rural curricula and incentive programs may be increasingly important, although such programs are potentially more costly than admitting the students who are more likely to choose and stay in rural areas. The smallest rural areas are difficult locations for international graduates and females. Admissions of those from rural areas may be the only source of such physicians.

Innovative efforts can stimulate improvements in known sources of rural background students. This is documented in Wheat's article regarding Small Colleges and Admissions in Alabama as well as other partnerships in Illinois, Indiana, Pennsylvania, and Nebraska. In order to implement such programs, it takes some time to improve the academics at many of these colleges. Early admissions programs can help in this process (Rural Health Opportunities Program). Also it takes much convincing to get admissions committees to take a chance on students with borderline scores and increased risks of academic failure, by traditional measurements. The problem is that many of these are nontraditional students. In any case, the overwhelming burden of medical school debt seems to be pushing committees toward taking less risks, with potential impact on not only access to care in rural areas, but also in inner cities.

The obstacles to rural medical education include more than admissions. The reimbursement problems for rural physicians and hospitals continue. Recruitment efforts continue to drain rural communities and continues more on a voluntary basis rather than through state support. States have also not supported efforts to gain funding for rural medical education programs. Federal graduate medical education efforts have also impeded program expansion and development, particularly regarding interpretations at the regional carrier level. Accrediting bodies in allopathic medicine have tended to impede the development and survival of medical school and graduate programs devoted to this area.

Osteopathic medical schools have done an excellent job in graduating physicians for rural areas. The marriage of osteopathic graduates with allopathic graduate programs seems particularly helpful. Osteopathic medical schools in the major urban areas do not contribute to rural workforce. The recent creation of newer osteopathic medical schools in less urban locations in Kentucky, Virginia, and New England bodes well for an increased supply of rural doctors.

It is likely that many who choose military careers would choose the rural pathway, given their origins and needs. An additional 50 rural doctors a year may be lost in this way, although military service benefits these physicians and this country. New incentives regarding benefits, retirement, or taxation could stimulate pathways of entry into rural practice after military service. Another impediment to rural workforce is restriction of military family medicine residents from moonlighting during their time as residents. Resident moonlighting is a significant source of workforce and recruitment for many rural communities. Moonlighting is also a great hands-on method of preparing even better doctors for military service, especially as medical education centers allow less and less hands-on training. Family physicians are used for triage in the military. Emergency rooms, often in rural areas, are a good source of such training.

International schools have a mixed picture regarding rural workforce. Some schools that cater to US students, such as Ross and American University, seem to be doing a good job regarding admitting students who choose family medicine and then rural practice. Recent expansions in these schools makes them an important source of family medicine residents. Other schools may be graduating students that will add to maldistribution and health care costs for this nation. J-1 visa physicians can certainly improve rural workforce in some states, but their location in regional centers, their specialty choices, and the volume of patients seen limits their effectiveness. Getting doctors to the smallest towns remains a function of rural admissions, incentive programs, and support for the smallest rural health systems.

Superselection, or admitting medical students that are likely to go and stay in rural areas,  is possible, given the efforts of Rabinowitz at Jefferson and Boulger at Duluth. However few medical schools seem willing to support such efforts. The study also indicated success in this area in Georgia and Arkansas. Recent articles regarding medical school admissions note that there needs to be an adequate supply of qualified applicants to be able to effect increases in medical school admissions. This principle also applies to rural graduates where improvements must come in rural high schools and small colleges. Rapid expansions of rural background admissions may actually admit students that are not as likely to return to rural practice. This could make things difficult in the rapid expansions in Australia unless care is taken regarding improvements in rural origin medical students and more time and effort with selections. Partnership programs in Nebraska, West Virginia, Indiana, and other locations may help improve the academics of colleges in rural areas that used to be sources of medical students. By giving high school students a choice to continue college in a rural area, there are less urban and spousal influences. Also the improved academics and admission in such schools can lead to increased numbers of other professionals needed in rural areas. Improved recruitment and retention should be attempted in a number of ways.

Rural Health Opportunities Program

Perennials vs Annuals

Admissions Committee Efforts

Principles of Recruitment and Retention of Rural Docs by Pathman http://www.tdh.state.tx.us/chpr/chprkeys.htm

Rural Practice, Keeping Physicians In (AAFP Position Paper)
 

Recommendations

The core value of rural medical education should be partnerships with rural high schools and small colleges and other sources of rural background students. http://www.arhaonline.org/PDF%20Files/RandRReport.PDF  These can be facilitated by rural faculty at medical schools working with rural and family medicine leaders. College Health Advisors are a key resource in past, present, and future efforts in this endeavor. Community Driven Approach: Linking Resources with True Needs

Rural hospitals have traditionally been instrumental in encouraging rural students regarding health careers and education. Hard times, regulations, and changes in schools have limited these efforts. Efforts to return them to this role should be a top priority. Improved financial status due to Critical Access funding, improved telecommunications, and the continual necessity of collaborative work can not only ensure survival for a few years, it can insure a steady increasing supply of physicians to ensure access, services, facilities, jobs, and leadership. Summer research fellowships have been successful in helping intellectually-oriented students into medical school. Summer service fellowships involving rural schools, hospitals, physicians, and health systems could do much the same for rural background students (Alliance Hospital, Terry Padden)

Family medicine should increase involvement with osteopathic and international schools and maintain efforts with allopathic public medical schools. Another consideration would be working closely with osteopathic graduate medical education to best prepare family medicine graduates across the nation.

www.ruralmedicaleducation.org

Top Priorities For More Rural Docs

Student Interest Group Package

The U.S. Primary Care Physician Workforce: Persistently Declining Interest in Primary Care Medical Specialties (October 2003)

Medicine and Society, August, 1996, American Family Physician Continuing the Role of Family Medicine in Rural Health. ... Family Med 1996;28:439. Bowman RC

A Case for the Development of Family Practice Rural Training Tracks - Bibliography