Physician Distribution in the United States

Robert C. Bowman, M.D.

Physician distribution is about admissions of students with origins outside of major medical centers, a focus on specialties that distribute outside of major medical centers, and the health policies that facilitate physician distribution outside of major medical centers. The distributional medical students were born and raised outside and choose family medicine the highest levels. Distributional training involves training outside of major medical centers and a focus on primary care, family medicine, rural, and underserved careers. The distributional specialty is family medicine where over 50% locate practices outside of major medical centers. General internal medicine and general pediatrics both have 70% inside of major medical centers and all other specialties have 75% or more in major medical centers (MMCs).

Super Centers with 200 or more physicians at a zip code have 12% of the population and 45% of the physicians. In the highest income areas in the United States, nearly 78% of the physicians are found in zip codes with 200 or more physicians. Graduate medical education positions are also stacked into the highest income locations, as is research funding.

The health policies that facilitate distribution shift funding and support to health care delivered outside of major medical centers. It took the nation 13 years of investments from 1965 - 1978 to create the potential for primary care in rural and in underserved areas. The urban underserved and rural locations in most need of physicians are dominated by family physicians. Only in the zip codes with 200 or more physicians are family physicians found below the 14% national average for family medicine. Family medicine choice doubles distribution to the following careers and locations controlling for other variables such as origins and medical school type in logistic regression: rural (3 X), urban underserved (1.8), teaching (2.2 X), military (1.8 X), predominantly rural and minority counties (2.4 X), whole county primary care shortage areas (3 X), isolated rural locations (4 X), and isolated underserved locations (4 X). Declines in family medicine and primary care represent significant problems for the nation in physician distribution. Primary Care Retention The worst losses involve the remaining permanent form of primary care, family medicine.

Health policy is the most important determinant of family medicine choice Five Periods of Health Policy and Physician Career Choice

Admissions of highest income, youngest, foreign born, and highest scoring medical students together with health policy that facilitates major medical center location leads to greater concentrations of physicians within Major Medical Centers (with more developing).

Types of Medical Students by Distribution Tendencies

Distributional Types and Lower Admissions Probabilities(Humble Origin, bottom 70% origins)	Non-Distributional Types and Higher Admissions Probability(Elite, Top 30%, Major Medical Center)
uRural born	uUrban born
uLow or Middle Income	uHighest income
uBorn in the United States	uForeign born current or recent
uInner City	uElite, schools, colleges, medical schools
uOlder, especially with barriers of income	uYounger, especially with no barriers
uNot born in a county with a medical school	uBorn in a county with a medical school
uDiverse/different backgrounds, combinations	uCombinations of the above
uBarriers involving income, education, parent occupation, family structure, environment, no funds for standardized prep and depend upon local, state, and federal government for additional college and career assistance	uParent socioeconomics, occupation, family structure, environment, tens to hundreds of thousands spent on child development, education, standardized testing and college preparation, top colleges where 74% are highest income quartile
uDisadvantages at critical age 0 – 8 stage, constant challenges after, velocity of learning constant, (Hart, B., and Risley, T. Meaningful Differences in the Everyday Experience of Young Children) so it takes years longer to catch up	uMajor advantages at age 0 – 8 stage, can maintain advantage with less effort, on track for graduation by 25 – 27 years of age, tens of thousands spent on children beyond public investments
uLower scoring on standardized tests at age 8 to admissions, often a pattern of improvement from admissions to USMLE 1 to clinical, medical school may be the first level playing field of their lives. See also Education	uHigher scoring on standardized tests until admissions and then possibly some decline from MCAT to USMLE 1 in relation to others catching up (strong in Asian and somewhat in Hispanic types, both the most concentrated next to MMCs) Veloski, J. Callahan, C Xu, G Hojat, M Nash, DB Prediction of students performances on licensing examinations using age, race, sex, undergraduate GPAs, and MCAT scores.Acad Med S28-3075 (10 Suppl)

For tables of class compositions and distributional outcomes see Medical Schools and Distribution

Health Policies

Distributional or favoring physicians and practitioners outside of major medical centers	Non-Distributional or favoring physicians and practitioners inside of major medical centers
uSlow steady consistent increases in reimbursement for physicians outside of major medical centers such as primary care and family physicians	uAbrupt or steady increases in reimbursement to physicians inside of major medical centers such as subspecialists and hospital support physicians
uSlow steady movements of health care funding to lower or middle income populations including improved health care coverage, eligibility, rural and small hospitals, Community Health Centers not in major medical center zip codes	uPolicies that continue to move funds into major medical centers. Major medical centers are particularly good at maximizing revenue streams, even those targeting location outside of major centers and served areas (bonuses, designations, Community Health Centers, and now J-1 Visa)
uDespite attempts to impact training and location, medical students, residents in training, National Institutes of Health dollars, and Graduate Medical Education dollars rarely leave major medical centers	uLow levels of federal and state funding for medical education, forcing medical schools to retain and maximize existing resources, barriers regarding Medicare regional carriers and delays in policy implementation involving those who might establish training outside
uLimitations of graduate medical education positions such that more are encouraged to choose family medicine, the only career that locates outside of major medical centers with 57%, 70% for direct patient care family medicine.	uUnlimited GME positions for the physicians that locate in major medical centers (all except FP) that move funding to major medical centers, faculty to major medical centers, and keep physicians in major medical centers
uExpansion of medical schools during periods of emphasis of primary care, family medicine, and restoring equity in the nation	uExpansion of medical schools during periods of emphasis of subspecialization and the lowest choice of family medicine in decades
uAccreditation and training funding that allows flexibility in how curricular objectives are accomplished. Focus on more active student and resident participation in health care decisions, procedures, and patient management. Replication of established models that have proven their ability, not forcing replications to some different hybrid form. Partnerships between government and major medical centers and middle and lower income populations, especially involving training in rural and underserved areas and Community Health Centers.	uAccreditation and training funding that forces medical schools and residency training locations to be in the most urban areas by size or subspecialist or revenue stream restrictions. Health policy punishes leaving major medical centers for training by loss of revenue or lack of GME funding. There are no real incentives for Community Health Centers or anyone outside of major medical centers to participate in training. There are many incentives now for non-academic and private physicians to cherry-pick the least complex Medicare, Medicaid, and previously indigent patients who once were teaching patients.

Executive Summary

Physician distribution involves distribution of physicians to rural locations, to primary care, and to lower income locations and populations. Physician distribution is a key measure of health access in the United States.
Physician distribution is a relatively simple matter in its most basic form. Students have a tendency to make career choices based on their birth origins, their standardized test scores, and the characteristics of the medical school that they attend. (Birth Origins and Distribution Tables, Birth Origins Articles, Distribution of Physicians, Comparing Physician Distribution and the MCAT)
Physician distribution requires different policy in health and education and schools that admit the most different students in income levels and birth origins and ages. The distributional medical schools have different mission, different location, different primary care emphasis, and different focus on underserved populations. (Community Driven Approach: Linking Resources with True Needs, Models of Rural Medical Education)
For the nation to have sustained levels of distribution, there must be retention. This retention involves Primary Care Retention as maximized in family medicine and it involves retention in rural and underserved areas for maximal service and efficiency.
A cure for the chronic malady of maldistribution exists. This cure also is likely to result in long term benefits for just about every citizen or resident in the United States and also many in some of the poorest nations, but only in the long term and only if every state and every community makes the appropriate plans and sacrifices. It is impossible to separate the cures for maldistribution and the resolution of violence and terrorism from the local to the global level. (Maldistribution Cured, Restoration of Communities, Nations, People, Service Orientation)
The nation has successfully distributed physicians in two periods of history impacting the graduating classes from 1965 to 1978 and from 1991 to 1997. These were periods involving the most massive health investments in primary care, in low income populations, and in rural practitioners and facilities. It is also possible that US investments in education after Sputnik contributed to better preparation of a wide range of candidates for medical school during the first period of distribution. (Managed Care Comparison Table, Managed Care and Choice of FP, open graphic above for impact of health policy)
The US is currently distributing physicians at the poorest levels in decades. Recent studies of Community Health Centers and Family Physicians reveal large and persistent vacancies for family physicians. Rural practice choice is falling down after stability during managed care and health reform years. With current directions in education, health care policy, and health care; there is no improvement in health care access in sight for many years.
Without the brief and intense interventions involving managed care and health policy in the 1990s, the nation would be entering the 28^th consecutive year of decline in primary care choice and physician distribution instead of the 8^th. There would also be massive divisions in the nation far beyond what exist today and even more crippling health care costs. Although the nation has admitted more Black and Mexican American medical students, Black and Mexican American population growth continues at an even greater level. In other words the nation has made little progress in admissions equity. In fact the nation has widening gaps in admissions related to social class, income, education, and population density level that all result in poorer distribution of young professionals, education, health, and other services and economic contributors in the United States. (Admissions Ratios and US Medical Students, Admissions Ratio By Birth Origin, Changing Patterns of Admission)
Measurements of year-to-year graduating class decisions and locations are the best predictors of physician distribution. Sequential comparisons over years and decades compare long term changes that are related to admissions and education as well as short term impacts regarding health policy. (Comparing Medical Students By Class, Class by Class Comparisons of Primary Care)
Without a detailed ability to track physicians and without investments in different studies involving physician workforce, the nation will continue to fail to understand physician distribution. The typical studies fail to capture cumulative changes because most involve brief changes over the past 1 – 2 years and most continue to proceed from a medical school focus. Efforts at the medical school level and beyond are far less important in distribution than the preceding period from birth to education to admissions.
Longer term changes in admissions that are important include massive increases in urban born, foreign born, Asian, and higher income origin students and a number of declines. These include declines of rural born medical students from 27% in the 1940s to less than 10%, instate born students from 60% in 1980 to 38%, declines in whites, declines in males, and declines in admission of students whose parents made less than $40,000 which were cut in half from 1997 to 2002. Medical students from parents of over $100,000 in income have doubled each 5 – 7 years since the 1997 matriculants. All of these changes are associated with poorer distribution. Changes in Admissions in Allopathic Medical Schools
The major differences in the extremes of physician distribution involve health policy regarding primary care and underserved practice. Even increases in nonphysician primary care practitioners are not likely to improve health access since all are impacted by the same investments in health as indicated in health policy, or the lack thereof. It is also far easier and more rewarding in income and lifestyle for nurse practitioners and physician assistants to switch to non-primary care areas. (Managed Care Comparison Table, Managed Care and Choice of FP, Reimbursement and Physician Distribution)
The family physicians that are more likely to distribute across geography and income levels Family Medicine Physician Distribution are also more likely to be delivering important primary care services where most needed longer after graduation. Family physicians do not have a tendency for years of inactivity as do many non-physicians. Family physicians remain steady in their specialty at over 96% levels, do office based practice at 97 - 92% levels, are retained in family medicine at 96% levels, and are retained in the same state as their medical school at 44% higher levels compared to allopathic public school physicians not choosing family medicine. From pediatrics and across non-physicians and to general internal medicine there are steady declines in the percentage and volume of true primary care services delivered per practitioner trained. Family medicine also includes significant women’s health, mental health, geriatrics, urgent, and emergent care and are often the sole source of such services in rural areas and also many underserved areas. Efficiency and Family Medicine
The choice of family medicine and the students admitted vary by medical school type. Medical school type can be an important factor in physician distribution, or failure to distribute. The MCAT, student characteristics, and career decisions are similar across school types. (Medical School Type and Distribution)
In the absence of health policy impacts or during periods of poor or declining support of primary care and underserved health care, there are only socioeconomic indicators of distribution. These are impacts involve education and medical school admissions. Those of the highest socioeconomics distribute the least. The most relevant measures of socioeconomics include higher income, higher parent education levels, higher levels of parent professional degree, higher population density origins, and higher standardized test scores. (MCAT Correlations, MCAT and Family Medicine, Socioeconomics and Physician Distribution)
Measures that predict distribution of physicians and all young professionals include various education measures from preschool levels to the Medical College Admission Test score. Elite scores and elite origins predict admissions to college and medical school, poor retention in their state of origins, and poor distribution to rural and underserved populations. Those of the highest socioeconomics are increasingly dominating college and medical school admissions. (Education, Retention of Family Physicians, Admissions and ORIGIN)
Family medicine is the only specialty that distributes in the same geographic and socioeconomic pattern as the US population. Those not choosing family medicine tend to favor urban, subspecialty, and higher income careers and locations. Choice of family medicine is related to state and federal health policy, to education and medical education investments in a state or community, and to the birth origins of the students. Choice of family medicine facilitates physician distribution, especially in distributional student types. (Facilitating Physician Distribution)
The students, schools, and policies in education and health policy that result in more family physicians also result in better distribution involving primary care, all rural careers, psychiatry, women’s health, and office-based primary care in poverty locations. (see thumbnail graphic above)
Non-Distributional Students - Those likely to have an academic focus from birth tend to choose subspecialties, research, and urban locations. They have the highest probability of medical school admission at up to 10 times the average student in the United States. Their parents are more likely to be the most educated and are the most likely to read to them as preschool children, they live in the highest income locations, their schools are likely to be elite public or private schools, they have consistently the highest standardized test scores at all levels, they have the most college preparation, their parents are more able to enter or afford the most prestigious colleges and they can access the elite medical schools. Their parents, education, scores, advisors, relatives, parent contacts, and background ensure that they can access the most elite subspecialties and locations and more often than not they choose to do so. (Admissions Ratios and US Medical Students) Non-Distributional students are the most likely to become influential physician leaders in the nation and have the least awareness of serious health and education problems facing the nation Awareness and Future Physician Leaders
Distributional Students - Those who have humble origins involving income, ethnicity, lower population density, and barriers of education and status are more likely to choose service-oriented professional careers. They are more likely to be first or second generation in their family to attend college. They are admitted to medical school in the lowest ratios from half the probability of average US students for rural and for Black students to one-seventh for Mexican American females. They must decide early and have supportive parents and others to gain admission. When combining gender, race, rurality, and poverty, basically the probability of medical school admission nears zero; the potential for medical school failure or delay increases greatly; and the probability of physician distribution to underserved primary care increases even more dramatically. Translating for family medicine, those of the most humble origins have 20 – 40% choice of family medicine, 30 – 60% choice of rural or urban poverty primary care locations, and 6 - 10% medical school failure rates. (Admissions Ratios and US Medical Students, Cohen Encourages Admissions to Look Beyond MCAT, Best or Brightest, Why not Both)
The MCAT is one of the best indicators of physician distribution (or lack of distribution) and socioeconomic level available. The MCAT is also a reflection of cumulative standardized testing and education policies acting over decades to favor those with higher socioeconomics or gifts of elite test taking ability. There is nothing wrong with the MCAT as a test, it is how the test is used by admissions committees. A focus on MCAT scores as a ranking system insures the poorest distribution. A focus on MCAT as a threshold with ranking by characteristics desired for family physicians results in maximal distribution. (MCAT Correlations, MCAT and Family Medicine, Socioeconomics and Physician Distribution)
New health policy considerations make choice of family medicine and other physician distribution choices impossible or force alternative decisions in the months or years just before a final location decision. The continued failure to address liability reform impacts those with lower volume procedures (obstetrics, scopes, colposcopy, assistant surgery) the most. Failure to finance college and medical education sufficiently not only excludes those most likely to choose distributional careers from admissions, it also makes it difficult for them to distribute after graduation. Declines in federal and state funding for primary care force family medicine departments and programs to focus on revenue generation and not on improvements in the admission and training of distributional students. The most distribution likely students (rural born, lower income, older) who do choose family medicine have two final obstacles before they can choose rural or low income areas of the nation. The military takes 150 – 200 out of each year’s final 3000 FP residency graduates. The military has long discovered the versatility of family physicians even if the rest of the nation lags behind. Academic family medicine also knows the value of family medicine and diversity. Most Black or Mexican American graduates have to endure years of intense recruitment to academic medicine before they can go underserved, especially those choosing family medicine. (Military Family Physicians, Level Playing Field for Military and Rural Support Programs, Ethnicity Gender and Rural Practice Choice)
Family medicine choice shares a significant correlation with physician distribution, education measures, health access measures, health costs, health care quality, and societal indicators. States, cities, counties, nations, and populations with greater choice of family medicine are more efficient, more effective, and more equitable. The state level measurements are some of the most dramatic. States with a higher percentage of family physicians have lower health care costs, increased quality of care, greater retention of physicians, increased high school graduation rates, less divisions between rich and poor, lower insurance premiums of several types, less medical liability claim cost, greater child health coverage levels, and increased per capita investment in education. This may not have to do so much with family medicine so much as having a population that has broader distributions of wealth and that places a higher priority on children and families and the future. Populations with higher choice of family medicine and other service-oriented professions tend to be those that are moving up in society from humble origins. Stagnant opportunities mean stagnant choice of service-oriented careers, especially for those in chronic poverty and the lowest levels of education. Such measures as distributional choice and first generation college attendance are also associated with family medicine and are measures of the future strength of our nation and its ability to restore itself and potentially other nations. (Service Orientation, Restoration of Communities, Nations, People)
States with lower levels of family physicians can be characterized as dependent states since they must attract their young professionals from other states and nations, particularly for health care and teaching. States with an elite focus on higher income and higher scoring students are inefficient and also graduate fewer family physicians. They have greater wealth and populations with higher income levels, but choose not to invest as much in education or else they distribute education funding poorly between rich and poor, between rural and urban, and between minority and non-minority school districts. Dependent states focus on advanced placement, college admissions, college funding, and professional school selections that involve test taking ability more and this tends to advance students who have higher income origins. Health care, insurance, prisons, housing costs, transportation, and welfare costs all are higher in dependent states. Abortion levels are higher and high school graduation rates are lower. Significant segments of the population have graduation rates below 50% when considering the entire population raised instead of statistics involving the last years of high school. This means that unemployment levels are higher. Where poverty and low education levels are allowed to fester on multiple generations, there is great hopelessness, violence, and distrust of government. Only a few miles away are people at the top of the socioeconomic scale. Washington DC is one of the prime examples with the highest and lowest abortion rates, the shortest and longest life expectancy, the highest and lowest education levels, and the highest and lowest admissions ratios in the nation. Washington DC, New Orleans, Milwaukee, Philadelphia, Detroit, and similar cities that have been denied the opportunity to increase boundaries and add to tax roles have been losing 5 – 15% of their population for decades. This represents people voting with their feet regarding the bankruptcy of current urban policies when they can no longer cover their decisions with rapid growth. The most rural and the most urban areas are grossly inefficient and the nation will soon have to deal with moving people to sustainable locations and away from the most population dense and coastal areas. Bright Future Rankings

Important Focused Questions and Issues Regarding Distribution

What is the impact of medical school class size expansion and distribution? If expansion includes distributional students and is coincident with health policy favorable to primary care, underserved areas, and distribution, then the distribution impact is significant. If distribution involves non-distributional types of students, there will be few or no improvements in distribution. The expansion from 1970 to 1980 largely coincided with greatly improved health care policy involving primary care, the poor, and rural locations. Office Based Primary care choice increased from 18% to 31% but actual primary care physician numbers almost quadrupled from the graduates of 1965 to those of 1978. Cost, Quality, Access, and Physician Workforce Expansion Expansion Good Bad Ugly and Best Medical School Expansion
What is the impact of medical school type on distribution? Elite medical schools do not admit distributional student types and in elite medical schools, even the distributional types do not distribute as well except for those choosing family medicine. The MCAT average of the medical school is a good indicator of distribution. The public allopathic schools with more older, rural born, lower income, and instate born students also have lower MCAT scores and have better distribution. Regarding family medicine and rural locations, the osteopathic schools and the allopathic schools in rural states and rural locations distribute the best and according to the rural born, older, and lower income medical students they admit. The best distribution to rural locations and family medicine involves Mercer and Duluth which clearly distribute beyond their student body composition and the background characteristics of their state.
What is the impact of locating medical school training in areas with lower population density? Even controlling for the rural population levels of the state, state income and poverty levels, student origins, and school MCAT, there is still a significant improvement in rural distribution with medical school location in a county with a lower population density level. The schools with more rural rotations and rural missions are also the schools that have distributional admissions. Medical school experiences beyond academic locations have the same quality. (Why a Rural Preceptorship Is Best, Community based preceptorships - Paul James, MedEdIQ)
What is the impact of longitude or east-west location in the nation? Even with the same socioeconomic controls for state, school and students; schools in the east do not tend to produce graduates who choose rural locations or family medicine.

Do medical students make career choices based on lifestyle? From the perspective of many, today’s medical students seem to be seeking an easier lifestyle, but this would be a mistaken assumption. It has never been harder to become a physician. Today’s medical students are very different than the college students characterized by generational studies and much more like the physicians of past decades. What remains influential are the important areas of prior contact The impact of origin and environment is strong and persistent. What has happened is that the nation’s medical students are increasingly born and raised in the most urban and academic lifestyles. Those born in such locations are the most likely to return. Any physician workforce studies involving the 1994 – 1998 graduating medical students also must control for the reversals of career choice based on health policy changes. These studies include physician lifestyle and Title VII studies.
What other factors must be controlled in studies of primary care workforce distribution? Such studies must also compensate for changes in military career choices and in choice of academic primary care. These two groups continue to absorb 6 – 12% of primary care graduates each, with the most distributional student types (white male rural born, black, Mexican American) even more likely to be taken before they can make rural, rural poverty, or urban poverty location choices. Both military and academic areas take more distribution likely family physicians out of circulation than the noted benefits of Title VII in studies (Krist - Journal of Rural Health). During WWII there was also increased choice of family medicine. After WWII there were 4 medical schools with significant and increased admissions of rural born students in the 1950s that are suspected to be related to the educational opportunities afforded rural born servicemen via the GI Bill. There is also indication that rural born admissions improved during the major national effort to admit 3000 Black, Mexican American, and Native students by the year 2000. This effort involved training of admissions committees and less focus on MCAT scores and prestigious education and more emphasis regarding the specific characteristics of the students. The reversals of affirmative action brought about by students, parents, and groups with higher income levels have brought about narrowing higher socioeconomic admissions with fewer rural born, lower income, Black, and Mexican American students. Admissions in Great Britain are influenced by socioeconomics. (Seyan K, Greenhalgh T, Dorling D The standardised admission ratio for measuring widening participation in medical schools: analysis of UK medical school admissions by ethnicity, socioeconomic status, and sex, British Medical Journal 2004;328:1545-1546 (26 June), http://bmj.bmjjournals.com/cgi/content/full/328/7455/1545 .) Higher income admissions are present in Canada along with lower choice of family medicine. In discussions with other faculty and in news accounts there are proposals in Australia to admit up to 30% of students privately instead of under 100% public criteria. Medical student parents in South Africa regularly protest quota systems which tend to limit Asian student admissions. Asian students in the US, South Africa, and Australia tend to have the most urban career and practice choices. They also have the most urban origins.

Physician Workforce Studies

Medical Schools and Distribution

Bright Future Rankings

Flawed Physician Workforce Beliefs