Robert C. Bowman, M.D.
see also Five Periods of Health Policy and Physician Career Choice
updated version at Physicians in Poverty Series
Older web page below
The graphic did not control for various physician locations such as major medical center, urban served, or rural underserved. For more detail Physicians in Poverty Discussion: Major Medical Center Locations
The support factors of GME, FP and primary care residencies, and CHC efforts continue to be important in the zip codes with higher poverty that may only be able to support primary care physicians with special assistance from local, state, or federal government. More about health policy impacts at Five Periods of Health Policy and Physician Career Choice
A primary concern of the nation should be attempting to provide physician services for underserved and poverty areas. Direct data on physician practices is a difficult task, but there are proxy collections. These include use of zip codes where there are shortage facilities such as Community Health or Migrant Centers or zip codes with 20 % or more of the population in poverty levels. Zip codes with unique zip and no population can be assigned geographically to the closest zip codes with populations. Other census data can be attached to the zip code and also to the birth origins of the physicians. The zip codes with no population were matched geographically to the nearest zip code with a population.
The best concentrations involve zip codes with both a Community Health Center and a family practice residency at the zip code. Beyond the peak for either an FP residency or a Community Health Center, the basic concentration of primary care declines with increasing poverty level. Poor support of either and especially both, are likely to worsen health care access for lower income areas and populations.
When examining physician data in poverty locations it soon becomes clear that the physicians in poverty locations are not as likely to be office-based physicians. The physicians in poverty locations must have some other source of financial support. The practice activity costs of these physicians reveal that they are hospital-based residents, hospital-based physicians, and the kind of physicians that you would find in public health and academic settings (pediatric cardiologists, forensic psychiatrists). These physicians, although necessary, are not going to help poor people with health access issues. It is also obvious that the nation's low priority on primary care and mental health reimbursement restricts physicians from locating in high poverty or low density population areas of the nation.
When considering active office-based primary care physicians in poverty areas, the comparisons become more relevant to actual patient care needs and physician training. These are the physicians that actually depend upon local patients for their support, or lack of support. Family medicine does best where there are poor, but working poor with less support as poverty increases. The following considers all physicians by the per cent in poverty across the US. For example at all US zip codes with 17% - 19% of the population in poverty, about 16% of the total physicians are family physicians, 11% are office based general internists, and 6% are office-based general pediatricians for about 33% in primary care. The low poverty percentages tend to be high income residence locations. The % of primary care physicians dips in lower income areas of the nation, especially for family physicians. Pediatrics and internal medicine appear to be less impacted by poverty and this may involve other activities that support them in poverty zip codes.
When segmenting urban and rural, the IM and FP are no different in urban locations and the FP has a huge advantage in rural locations.
The highest levels of office based poverty location that I have detected so far are seen in family medicine physicians who have lower income origins, Native, Puerto Rican, black or Hispanic.
Family Medicine Graduates of 1997 - 2003 who attended allopathic medical schools and ACGME FP residency programs.
| Ethnicity and Gender | Poverty Location |
| white female | 25.8% |
| white male | 24.6% |
| black female | 35.0% |
| black male | 34.8% |
| mex am female | 45.6% |
| mex am male | 43.2% |
| asian female | 30.4% |
| asian male | 28.4% |
| pr female | 63.2% |
| pr male | 69.4% |
| other hisp female | 37.8% |
| other hisp male | 35.0% |
| native female | 43.3% |
| native male | 43.2% |
| other female | 29.2% |
| other male | 27.7% |
| Average | 27.9% |
Asian FP graduates who were born in the US are not different than whites born in the US in poverty location. Asian FP graduates born in other nations were much more likely to be in poverty locations.
Some of the highest rates of retention within 60 miles of the medical school location were in black and Hispanic females.
The rate for the nation in office based primary care for all allopathic graduates is about 4 %. This level in 2004 was lowest for the preMedicare graduates at 2 %, rises to 4.4 % for 1978 grads, slowly declines to 3.6 %, then rises to 5.4 % for those graduating during favorable primary care health policy in the mid 1990s, then the level has fallen precipitously in recent years to 3 % or perhaps even below. Again this is data by allopathic graduating class for office-based primary care physicians in poverty locations divided by all allopathic graduates for the year.
The student characteristics associated with poverty choice in primary care are older age, rural born, and lower income level. Those born in rural areas dominate with rural and urban primary care poverty locations more likely for rural born except in urban internal medicine poverty locations where there is a 1 percentage point advantage. Poverty location FP and Peds are much more likely for those born in rural areas.
Not only has health care policy turned against poverty location, the rural born numbers are moving south quickly as well, and so are lower income admissions.
Although many would point to CHC or various government programs, the fact of the matter is that choice of poverty location primary care is really about physician trust in government. When the government has been supportive, physicians have made the necessary choices, even when medical school have not necessarily gone along.
Right now it seems to be very hard for today's medical students to see a future in primary care, and the nations rural and low income peoples will suffer for this lack of vision.
By Medical School Type for 1987 - 2000 graduates
Updated Chart at
| All Docs | rural fp docs in pov | rural pc docs in pov | fp docs in pov | total pc docs in pov | fp docs in isol rural | pc docs in isol rural | All Office-Based PC | All Rural Physicians | |
| Allo Private | 78246 | 105 | 213 | 619 | 2584 | 94 | 204 | 51075 | 5458 |
| Allo Public | 140980 | 666 | 951 | 2166 | 5327 | 971 | 1242 | 100106 | 16967 |
| Osteo Private | 17950 | 107 | 133 | 338 | 533 | 201 | 242 | 10298 | 16201 |
| Osteo Public | 6891 | 73 | 98 | 168 | 253 | 66 | 77 | 3875 | 6335 |
| North Amer International | 16069 | 58 | 108 | 286 | 699 | 59 | 93 | 7372 | 11290 |
| Distant International | 51331 | 45 | 481 | 229 | 1847 | 68 | 388 | 21190 | 53209 |
| Caribbean | |||||||||
| Traditional Black | |||||||||
| Total | 311467 | 1054 | 1984 | 3806 | 11243 | 1459 | 2246 | 193916 | |
| All Docs | rural fp docs in pov | rural pc docs in pov | fp docs in pov | total pc docs in pov | fp docs in isol rural | pc docs in isol rural | All Office-Based PC | ||
| Allo Private | 25.1% | 10.0% | 10.7% | 16.3% | 23.0% | 6.4% | 9.1% | 26.3% | |
| Allo Public | 45.3% | 63.2% | 47.9% | 56.9% | 47.4% | 66.6% | 55.3% | 51.6% | |
| Osteo Private | 5.8% | 10.2% | 6.7% | 8.9% | 4.7% | 13.8% | 10.8% | 5.3% | |
| Osteo Public | 2.2% | 6.9% | 4.9% | 4.4% | 2.3% | 4.5% | 3.4% | 2.0% | |
| North Amer International | 5.2% | 5.5% | 5.4% | 7.5% | 6.2% | 4.0% | 4.1% | 3.8% | |
| Distant Inter | 16.5% | 4.3% | 24.2% | 6.0% | 16.4% | 4.7% | 17.3% | 10.9% |
By comparing patterns of distribution with the All Docs column %, the medical school types that make outstanding contributions to these important areas can be identified. Allopathic Private medical schools not only fail to meet any of these categories, they contribute much less than their 25% share in all categories other than total office-based PC.
National Center for Children in Poverty - midwest children poverty up 29%
(43% of the increase in child poverty in the nation), greatest rise in families
without college education
http://www.nccp.org/media/npr06_text.pdf
The US could adopt UK methods that were stolen from the US in previous eras
Underserved - Overview and Models