Physician databases such as the American Medical Association Masterfile can be used to determine the career and location decisions of physicians.1 When combined with census data and data from medical associations, this database becomes a powerful analytic tool. Birth origins data can be used to track physicians from birth to training to practice locations.
The 293,978 physicians from the 1987 – 1999 class years of graduates from all medical school sources set the standards for distribution with 9.8% in rural locations, 3.0% in underserved urban zip codes, 2.7% in rural underserved locations, 29.7% in office based primary care, and 14.2% in family medicine or general practice. About 73% are found in major medical center locations.2 This is about 50% of the active physicians in the United States that have finished training and that have distributed to representative careers and locations. Standards allow studies to identify the types of students, schools, career choices, and training that contribute to rural careers or underserved distributions. Major Medical Centers
Summary
1. Rural born medical students are more likely to be found in rural practice, primary care, family medicine, and rural underserved locations. Public schools and osteopathic medical students have the greatest levels of rural careers and underserved distribution. Different international graduates make different types of contributions.
2. About half of the medical students who were most interested in the smallest rural practices attended high school in rural areas and half attended high school in urban areas. Rural interested students were more likely to be older, married, and white. They were more likely to choose rotations away from major medical centers and they did volunteer work at twice the level of other students. About 68% chose family medicine, and 60% were interest in working with socioeconomically deprived populations in practice, the highest of any medical student group. Stability, service orientation, and maturity characterize those most interested in rural practice. Studies of rural physicians in the smallest locations reflect these characteristics of maturity, origins, service-orientation, and family medicine career. Rural Interested Senior Medical Students 1995
3. The physicians found in rural locations were more likely to be family physicians, rural born, male, Native, white, older, lower income birth county in origin, and attended osteopathic schools, public medical schools, or distributional allopathic schools. Family physicians are a consistent source of rural primary care for decades. Family physicians and distributional type schools (Historically Black, West Coast Distributional, Duluth, Mercer, lower MCAT schools) are the most efficient sources of physicians for rural locations that are also underserved. These are schools with significantly different missions, admissions, and training emphasis.
4. Rural born students who attend typical allopathic private schools and elite types of allopathic medical schools have lower levels of rural distribution. Rural born students from areas with greater population density and higher levels of income and organization have lower levels of rural distribution.
5. Rural born medical students choosing family medicine have 43% current rural location. Graduates of family medicine residency programs with rural training emphasis exceed this maximum indicator of birth origins influence, indicating the facilitation of training beyond origins contributions. Urban born family physicians have 20% rural location or twice the national rural workforce average of 10%. Rural born non-family physicians have 15 – 18% rural location, also exceeding the national average. Urban born physicians not in family medicine have 5 – 8% levels of rural distribution. Only family physicians and rural born physicians exceed the national average for rural distribution, indicating greater potential for maintaining or increasing rural physician workforce levels.
6. About 74% of the US MD Grad rural physicians were born in urban areas. Urban born physicians are 88.5% of total physicians. About 26% of rural physicians had rural origins, a group of 11.5% of physicians. Family medicine provides 30% of all rural physicians, the largest share of physicians for various lower income or underserved areas, 51% of Community Health Center physicians, 61% of rural Community Health Center physicians, and over 60% for the most rural and frontier areas of the nation. No other type of primary care can demonstrate levels of rural physicians or practitioners beyond the levels of rural born students who begin final training. With increasing years after medical school graduation, family physicians remain in family medicine, remain in primary care, remain outside of major medical centers, and remain in rural and underserved locations. All other types of practitioners collapse back into urban areas, major medical centers, and specialty careers outside of primary care. Family Medicine Central: National Comparisons of Workforce
7. The percentage of rural born admissions at a medical school has an almost perfect 0.926 correlation with the percentage of graduates of a medical school found in rural practice in 1995. This does not mean that all of the rural born graduates make rural choices, but the medical schools that graduate rural physicians admit more of the types of students found in rural practice (rural born, older, lower income, middle income, lower scoring, not born in cities or counties with medical schools), they graduate more of the types of physicians found in rural practice at higher levels (family medicine, general surgery, office based physicians), and they share medical school location with states with greater levels of rural population and greater levels of demand for rural physicians. Changes in admission indicate that those least likely to distribute are replacing the student types most likely to distributed.
Changes in Admissions in Allopathic Medical Schools
8. Declines in rural born admissions have exceeded declines in rural born population significantly and consistently for decades. Current rural born student admissions are below 10% or half of the 20% level of the rural population. Since 1940 the levels of admission have declined the most in the counties most distant and lowest in income level. Micropolitan rural areas with medical schools, major universities, or those with higher levels of professionals as in major corporations or research facilities have the highest levels of admission in the nation. A few counties in the Midwest share these higher levels of admission for reasons as yet unexplored but their efforts have been consistent for more than a decade and more than a few admissions a year. Larger rural counties and those with higher income levels compared to other rural counties have declined from 100% or the same percentage of admissions as compared to the percentage of the population to 70%. For medium rural counties in size, income, and organization the levels have declined from 80% to 50% levels compared to the population. For isolated counties and those adjacent to larger urban areas, the levels have declined from 70% to 30%. The larger rural counties have levels of admission that are similar to black females, Native Americans, and rural female students with about 1 medical student for each 300 US citizens or residents in the group who are of medical school age. The medium rural counties have levels of admission similar to black males and rural males or about 1 in 400 to 1 in 500. The lower income, isolated, and adjacent counties have levels of admission equivalent to Hispanic and Mexican American students or about 1 in 800 to 1 in 1200. Lowest quintile students in income or education and those with combination of low income, rural, and minority have the lowest levels of admission. This is a group with 20% of the population and only 2% of medical school admissions for a 10% probability or about 1 admission per 2000 students of medical school age. This group also includes inner city populations who also share the same low achievement scores, the same child development delays, the same low high school graduation rates, and the same low levels of college advancement. Males generally have more problems with admissions than females and males also are more likely to distribute to rural and underserved locations, making the gender changes part of an increasing problem for future rural and underserved workforce. In some states with fewer males admitted, females are the remaining rural born type of student and females have higher levels of rural distribution, an important exception to the increased male rural workforce factor. Physician distribution to populations in need will continue to be ineffective until child development, early education, and opportunity are realized in the most disadvantaged populations in the nation. State and federal budgets are likely to remain unbalanced until this inequity is reversed as well.
9. Medical schools with a rural mission have lower levels of decline in rural born admissions, although legal actions and medical school changes may have taken away this “benefit” in the past decade. Only a few special admission programs, a few special school efforts, and a few training programs remain.
10. States share similar rates of decline in rural born admissions except for states that have 40 – 50% levels of rural population currently. This suggests that states that have recently transitioned to urban dominant states have made changes in education, higher education, economics, and distributions of resources such that rural born students have a more difficult time gaining admission.
11. Medical schools with the highest MCAT scores have fewer admitted from rural areas but the rural born students that they admit also have lower levels of rural location. They also have lower choice of family medicine and higher choices of careers that require major medical center location.
12. A very few medical schools manage to obtain rural, underserved, or family medicine distributions out of all of the various populations of students that are admitted. Duluth and Mercer graduates of across the wide range of geographic and socioeconomic origins have similar rural, underserved, and family medicine workforce outcomes. The six osteopathic public medical schools also lead in distributions. Other osteopathic medical schools and some allopathic medical schools did well. Generally these were all schools that admitted students with a much wider range of origins, ages, and scores. This suggests that the distributional types of schools focused on the student more and their academics and parent influences less.
Distributional Medical Schools: The Lost Lesson of Specific Forms of Government Support
1. Medical Marketing Service I. AMA Physician MasterFile Available at
www.mmslists.com Accessed July,
2005. Wood Dale, Illinois 2005.
2. Bowman RC. Categorizing Physician Location. Rural and Remote Health. Omaha,
NE; 2007.
Decreases in rural background students from AAMC Data GQ, matched to senior student interest and eventual graduation of rural FP docs.
see Rural Background
see also Medicine, Education, and Social Status
Presentation Regarding Rural Background and MCAT Scores and Education Levels by State