Failure To Launch - Counties with the lowest probability of admission, some reasons, and discussions of why Florida ranks among these counties.
Divisions in Physician Career and Location Choice Related to Age at Graduation - Changes in the United States mean that physicians layer out by socioeconomics, age, and scores into three different career types: those that emphasis people, direct patient care, and generalist focus; those that those that distribute and those that do not.
Current Active Health Care Policy Decisions - Increasing GME positions generically is a very bad idea. Specific changes and their likely result, based on the decisions of the latest 40% of physicians.
Health Care Workforce Estimates - National data is revealing regarding distributions of various professionals. The directions are also clear. Other than family medicine, there will not be much contribution for rural and for underserved areas at the higher percentage levels that make a difference, beyond the current 5.4% underserved and 11% rural.
Family Medicine Standards and Constants - There are reasons for optimal distribution and primary care delivery. In fact it is very hard to keep a family physician from becoming a family physician. Research demonstrates a 25% maximum and a 6% minimum FP choice. Those graduating more than 25% or less than 6%, are working hard to do it.
Physician Careers By MCAT Groups - certain schools graduate certain types of physicians
Medical School Expansion 2004 - 2017 - updated version, now over 24,000 expected per year from US sources and 32000 total added each year from all sources in the world, this is over 7000 more than the previous stability for decades
Flaws in the Concept of Controllable Lifestyle - updated, the very thought that a physician career can be less intense is a strange concept at best. There are many reasons for career choice changes over time such as health policy, different types of careers in careers, poor assumptions and poor design of the career surveys and more. Studies 6 years earlier would have had very different outcomes.
Primary Care Retention - Updated primary care tables added in this piece now - family physicians remain in primary care while other physicians, nurse practitioners, and physician assistants fall away over time under the influences of current health policy and major medical centers
Office Based Proportions in IM, FP, Pediatrics - some stay, some go, but those most committed to primary care remain as office based generalists.
Top Workforce Outcomes Rankings - family medicine leads in Optimal Workforce Outcomes, not much competition
Recent Black Family Physicians - US Born, Foreign Born, Higher income or lower, is there at difference in physician distribution to rural, underserved, academic, or military careers for US MD Grad Black Family Physicians? The early returns are in for 1997 - 2003 FP Grads. The real overall difference may well be choice of FP.
Admissions: To Do No Harm - Access to medical school faces a new barrier. Just registering for the MCAT is a challenge. One more barrier in a whole series that shapes future physicians. Time for changes!
Shaping a Nation: Physicians Who Serve - Handout for STFM Predoctoral Conference When the nation chooses physicians that are different than the 70% admitted from the top 30% in status, they have different distribution and career choice. But do they also have advantages in service orientation, empathy, awareness, physician satisfaction, and other areas that might impact costs and quality?
Distribution: The 70-30 Distributions That Complicate Physician Distribution - Education, admissions, training, health policy also see The One Per Cent Solutions that Resolve Distribution Problems
Medical School Type and Distribution: Initial Database Description and Rural Application Graphics - new definitions of medical school type are needed based more on their admissions policies, also new database definitions are provided, with application to rural distribution
Market Forces Admissions and Health Policy Versus Distribution of Physicians and Health Care - market forces shape who gets the best education, college, and medical school admission, just like health policy shapes distribution.
Distribution as Related to Birth: Birth in a Medical School County or City - those most closely associated with medical schools and major medical centers for the first 30 years of life rarely distribute.
Comparing Probability of Admission and Population Composition
Changes in Specialty Choice 1987 - 1999 - review of each major specialty with changes during this time period and likely explanations. More flaws in controllable lifestyle exposed.
Physicians in Poverty Discussion: Major Medical Center Locations - the distributions of physicians vary with increasing levels of poverty in the United States. This first work considers the locations of 71% of US physicians, those in major medical centers. Primary care levels are not well sustained with increasing poverty levels. Not a surprise given Medicare and Medicaid declines in dollars, amounts, and percentages devoted to primary care. Generalist pediatrics and family medicine that normally increases across then nation for urban underserved areas (both) and for rural areas (family medicine) decrease with increasing poverty levels within major medical center locations. Further cuts in Medicare and Medicaid are not likely to enhance generalist career reputations in major medical centers.
Distributional Medical Schools - who serves America outside of major medical centers- those admitting students from outside, training outside, and graduating the specialty that distributes outside and remains
Distributional Medical Schools: The Lost Lesson of Specific Forms of Government Support - osteopathic public medical schools lead in all categories of distribution to rural and to underserved populations and in primary care and family medicine choice and in most retained instate to practice. Why so few?
Medical Schools and Distribution for tables comparing origins, income levels, and outcomes
Major Medical Centers - understanding health policy, primary care, and distribution requires understanding major medical centers, concentrations of physicians, and why the nation cannot focus on major medical centers and still distribute health care to rural and underserved areas.
Birth Origins and Distribution Tables - Different medical student types have different distribution. Medical schools with different students have different distribution.
Medical School County Birth - those born in counties with medical schools are more likely to be admitted but are less likely to choose family medicine and to distribute to rural and underserved areas. Could it be that this is a proxy for children of physicians or professionals? Most medical students were born in a city or county with a medical school.
Birth Country and Career Choice - where physicians come from can influence where they go and where they stay, also divided into foreign born US MD Grads and those born in other nations and attending medical schools in other nations.
Medical School Type and Distribution - some schools distribute, others do not - comparisons by rural, underserved, office based, major medical center, and other factors
Multiplier Impacts Involving Birth Origins, Age, Choice of Family Medicine - why admitting more urban, foreign born, Asian, and highest income medical students will not distribute physicians outside of major medical centers
Family Medicine The Distributional Specialty - data on family medicine, the chief component of physician distribution
Rural Interested Senior Medical Students - are compared to the literature, to survey findings on 1995 seniors, and to actual outcomes regarding medical student choices. The analysis integrates birth origin, Community Health Center, and primary care career choice studies.
Choice of Family Medicine Regression - Schools admitting the most exclusive students and states that fail to present a broad range of students to medical school admissions committees will not be graduating family physicians. Newer medical schools and those in more western locations graduate more family physicians and distribute physicians more equitably.
Distribution of Physicians - Table listing medical schools and their physician distribution levels, also MCAT, early research graduation rates, and graduate retention instate. Those that do well should expand. Those that are not doing well in distribution should consider special programs to admit more distributional types of students, or not expand.
Family Medicine Contributes More - the significant contributions of family medicine are too often ignored, studies comparing physicians over longer time periods reveal the advantages of a specialty that goes and stays and stays in family medicine
Matters of Perspective - why medical education leaders are missing the point about distribution
Birth Origins and Distribution Tables - updated tables on the student characteristics involved in distribution
Ethnicity Gender Admissions and Distribution - tables comparing admissions, choice of family medicine, distribution, rural, underserved, military, teaching, major medical center location
Awareness and Future Physician Leaders - the students who are most likely to gain admission to medical school are the least likely to be aware of health access and other problems. The path for diverse and disadvantaged students is challenging but such physicians are more likely to distribute and to be aware of the serious health and education problems facing the nation.
MCAT and Physician Distribution or lack of distribution - graphic and tables regarding physician distribution based on 1987 - 1999 graduate practice locations and career choices as of 2005.
Admissions By Income Quartiles the students most likely to gain admission are not the ones that will distribute, includes admissions ratios and student numbers, based on AAMC income data and census data
Medical School Admissions By Income - changes in the income origins of US physicians predict lower choice of family medicine and lower physician distribution. This pipeline table compares the highest, middle, and lowest income students from high school to college to medical school to choice of family medicine. Not good stats to view for a holiday.
Multidimensional Choice of Rural Practice Compare by Birth Origins, Age, School Type, Region of the Nation
Distribution of Physicians includes info on rural choices, family medicine, MCAT scores, office poverty, by school, age of the class, and other factors important in distribution
Medical School Type and Distribution - comparison of various medical school types and subtypes by distribution
Geriatrics Distribution in the United States - sources and distribution levels for the 1987 - 1999 medical school grads
Managed Care and Choice of FP - Medical school graduates of 1995 - 1997 had the best choice of family medicine and the best physician distribution in the nation's history. Those born in urban areas, those born instate, and younger students were the most likely to have increased choice of FP.
COGME Links at http://www.cogme.gov/pubs.htm Rural, Minorities in Medicine, International Medical Graduates, Physician Education, Improving Access to Health Care, Physician Workforce Reform, Women and Medicine, Physician Workforce Funding Recommendations, COGME Recommendations, Changing the Governance of Graduate Medical Education to Achieve Physician Workforce Objectives Physician Distribution and Health Care Challenges in Rural and Inner-City Areas, GME Payment Reform, Proceedings of the GME Financing Stakeholders Meeting, Collaborative Education to Ensure Patient Safety, Process by which International Medical Graduates are Licensed to Practice in the United States, Preparing Learners for Practice in a Managed Care Environment, The Effects of the Balanced Budget Act of 1997 on Graduate Medical Education
Those who wish to consider the impact of neglected infrastructure or how colleges gatekeep admissions by income levels may do well to review Winner Take All Economics by Robert H. Frank or others. The studies apply to higher education and make sense for medical education and medicine where 1 or 2 medical centers dominate a market or a few insurance companies dominate a state market or as the nation reduces down to 2 pharmacy chains. One size attempting to fit all is problematic for physicians, health policies, and other areas. New NY Times article in the Real World of Wages, Trickle Down
The studies track the most recent graduates in their current locations. The studies involve equilibrium conditions, not just first practice outcomes. These studies involve the AMA Masterfile with locations using OfficeMax software. The major contribution involves extensive coding of the birth origins of the physicians with 97% of this data available for allopathic graduates from US schools. There are new frames of reference that assist with health policy evaluation such as Comparing Medical Students By Class Year and categorizations of major medical centers, rural, urban, and underserved locations.
For more on the interaction of education, admissions, and distribution see Growing Up America
The growth of the US population (63 % from 1970 - 2020) is outdistancing
The growth rate of rural areas at 10 % in the last decade is less than metro at 16 % but rural populations are still increasing. The rural born student admissions to medical school are decreasing, down from 27% to 11% even though 23% of the US population is in rural areas. The growth rate of physicians is 270 % from 1970 - 2020 without expansions. This is 4 times the rate of US population growth (63%), the growth of family physicians (56% and falling), or the growth of schoolteachers anticipated (64 % 1970 - 2020 NECS data). See Birth Origins and FP Choice regarding the loss of service oriented professionals (FP, schoolteachers, public servants)
Health care access is a function of numbers of physicians and physician distribution. The key components of physician distribution involve medical student choice of family medicine, the only specialty that distributes geographically and socioeconomically to those most in need of physicians. When attempting to graduate more family physicians, medical schools should pursue older medical students, those born in rural areas, those born in less dense or lower income urban areas, and those born in the same state as their medical school (allopathic public school).
Several national studies have raised questions regarding the quality of education and also medical education. Concerns have been raised about the capacity (enough patient volume available) to train physicians in areas where most medical schools reside. These are basically the most metro areas of the nation. 97% of medical education is in metro areas. 90% of medical students were born or raised in urban areas. 90% of physicians choose to practice in urban areas, unless they choose FP then 78% choose urban areas.
Increased numbers of primary care and family physicians are also important regarding health care quality and cost issues. Baicker and Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries Quality of Care, Health Affairs April 2004 http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf
or Starfield's efforts with Phillips http://www.aafp.org/afp/20040801/editorials.html
or Starfield, Barbara. Primary Care: Concept, Evaluation, and Policy. New York, Oxford University Press, 1992.
Health Affairs has new articles by Starfield, Hsu, Xu and others. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97
or Phillips, Dodoo, and Green at http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.111/DC1
However the major flaw of most economic works is failure to consider distributions, child development, and early education. The nations that have more primary care, generalists, and family physicians also invest more in children, which make all facets of a nation more efficient including health care, education, economics, and more. Top health and education outcomes have only been reached by nations that invest the most in children.
There are also concerns as to whether the increasing numbers of urban and foreign born medical students can effectively serve a more and more diverse population involving a wider and wider range of income levels, cultures, and geographic areas.
Rural Medical Schools: A Different Kind of Education
Older graduates, those born in rural areas, and newer medical schools with older graduates have been the most resistant to changes in primary care health policy. Already at high levels of distributional choice, they are influenced, but not to the same degree. Managed Care Comparison Table
There is also the consideration of types of training
Sources of the Current US Physician Workforce - who provides rural, essential, and other types of physicians
Frontier Family Medicine Choices by medical school name and type
Rural Coding RUCA 2.0 and the US pop and poverty by state
The 1990s represented a "perfect storm" of reimbursement and training and support and accountability and popularity for career choice with great improvements in distribution to rural and poverty areas.
Such a perfect storm allows RTT and accelerated and other programs with distributional students to shine.
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and the distribution of state education resources as they impact health care
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