Socioeconomics and Physician Distribution

Robert C. Bowman, M.D.

The nation has clearly been able to distribute physicians with a number of different interventions. This is a review of the successful approaches.

From William T. Butler's 1991 Address to AAMC:

Two major factors that influence career choice in medicine are

(1)   preexisting preferences and social ideologies, and

(2)   learning experiences during medical school.  

Therefore the admission office is the first gateway of opportunity, a point emphasized by Kay Clawson in his 1989 chairman’s address. We will only perpetuate the trend toward specialization, which began in the 1950s and 1960s, if medical schools continue to admit students narrowly trained in biological sciences at the expense of broader education…

Let us affirm – in this new “season of accountability and social responsibility” - a vigorous commitment to leadership that will ensure the public’s trust of academic medicine in the seasons of the twenty-first century. As Hippocrates observed, “For extreme diseases, extreme methods of cure…are most suitable.

Upon us is the season to prescribe an extreme cure.

From Academic Medicine’s Season of Accountability and Social Responsibility

William T. Butler, M.D.  Revision of Chairman’s Address Given at 102^nd Annual Meeting of AAMC November 1991, Academic Medicine 67(1992) 68-73

Posted with permission of AAMC at Academic Medicine's Season of Accountability and Social Responsibility

Overview of Physician Distribution

Physician distribution involves multiple areas including previous experiences, education, medical education, and health policy. For the nation to have more physicians to distribute, it will take all of the following:

1. Improvements in education resources and distribution of education in several states in addition to improved accountability
2. Admissions of more medical students who have a higher probability of distribution (generally students of lower socioeconomic levels),
3. Adequate physicians choosing primary care to fill urban and larger rural positions (as during managed care) to prevent physicians that are more likely to distribute from being recruited by those with greater resources,
4. Adequate support for rural physicians, including allowances for tuition and liability and other overhead costs
5. Adequate support for rural facilities
6. Potential rural physicians to believe that there is a stable to steadily improving future in rural practice
7. A general consensus on the part of US citizens that the above are important and worth some degree of sacrifice to accomplish (convenience mostly and some dollars).

For the nation to have declining rural physicians and distribution, any one of the above can fail and result in poor distribution for the nation.

To do this efficiently and effectively, it will also take the following:

1. Medical experiences in primary care and underserved practice during medical training that will address adequate exposure to primary care (6 months of a quality experience) and increased intensity of experiences rather than inadequate or passive learning
2. Superior medical education leadership working to coordinate efforts on a statewide basis across as many levels as possible from elementary to secondary to college to admissions, to training to practice, to health policy and research

States, schools, and programs following this format have demonstrated improved distribution. Some have even decreased class size because they have met state needs.

Just One Change

The simplest change to accomplish that would likely improve distribution and also physician quality and physician leadership in the United States is to raise the bar in medical school admissions such that the students admitted have people skills and orientation that are equal to the current academic preparation levels of today's medical students. This is also consistent with the addresses of several medical education leaders for more than a decade (Butler, Cohen, Clawson). It makes little sense to expect these changes in the young adults that have already been shaped by a lifetime of previous experiences and education. It makes perfect sense to have students, parents, advisors, and educators know that academic performance and speeded intellect (tests with more questions than time allows forcing quicker decisions) alone will not suffice regarding admissions to medical school. When this is the known route to admissions, students will be different and far more likely to be comfortable working with people and medical careers involving people.

• Not to change the influences prior to admissions is to invite catastrophe.
• Efforts to change the current set of influence prior to admissions is to promote excellence in medicine and health care.

The following efforts involve studies on the birth origins, career choices, and distribution decisions of medical students. These studies are based on the 2004 AMA Masterfile and represent a cross-section of physician careers and locations as of 2002 and 2003. The major cohort studied involves 1987 - 2000 medical school graduates, the heart of the active US physician workforce. Other studies in prior years illustrate changes pertinent to distribution.

Disclaimers and Limitations of this work, the AMA Masterfile, and Workforce Interpretations

The author is the Chair of the STFM Group on Admissions and also the Group on Rural Health. He is also involved with the Rural Medical Educators Group of the National Rural Health Association. The author has had the benefit of access to the AMA Masterfile and current AAFP data through Ed Fryer and the Robert Graham Center. The author updated practice locations of family physicians by comparing his existing files, AAFP internet data, and the above sources. The author does not represent this work as the policy of any group or organization. Previous Masterfile versions were purchased by the UNMC Department of Family Medicine. The coding work, including birth origins, is also the work of the author. . Physician workforce research has been approved by the UNMC IRB 404-04-EX. Previous work was also under IRB approval. The author has approval for $17,000 funding from the Federal Office of Rural Health Policy which may assist in future database efforts and publications. No federal or state or medical school individual or group has requested this work or pressured any of the efforts of the author.

The work does not consider other sources of health care workforce in rural areas. Physician leadership for over a century from Flexner and Osler to Butler and beyond have supported the concept of having the best quality physicians in all locations. There was always little reason for physicians to accept limitations in distribution, now there are no reasons.

There are great similarities between distribution and service to inner city areas. They are obviously connected by socioeconomics. Inner city locations cannot be discerned by secondary means. It would be a major surprise to find that distributional schools and students were different in the characteristics discussed from those serving inner city underserved locations. The principles commonly used in diversity recruitment are important to considerations regarding distribution. The peer work by black and Hispanic students to encourage those at earlier education levels begs major replication nationwide in all low income and rural medical education situations. An understanding of the enormous pressures facing minority students or any low income first time college student now entering medical school escapes most of us who have not had the great privilege of discussing some of these issues. The body of literature on education opportunity and the fine example of persistence and dedication in the face of great odds is also inspiring.

The author also discusses ethnicity and income and education in the hope of better understanding. There is no disrespect intended toward any students who do not choose distribution. This work is intended to assist those evaluating students. It is the hope of the author, as with all dedicated physicians and leaders, that all students would have the great qualities discussed in all specialties and locations and from all origins. Medical education has demonstrated that it can change academic preparation. It can also change people preparation.

Note: The Masterfile has limitations that should be noted. These include a cross section of recent locations and specialty choices. Certain types of physicians are known to change specialty over time in much greater numbers. This is less common in primary care and the least common in family medicine. The choice of the years 1987 - 2000 involve considerations of the heart of the US physician workforce, those most likely to be active. There are limitations on self-designated data. Generally those listing internal medicine, family medicine, and pediatrics from earlier graduation years have not moved on to other fellowships and specialties. Delays in reporting and graduation make it difficult to report subspecialist locations past 1998 graduates or primary care locations and designations past 2000. The locations in the 2004 data do not reflect previous locations or training. The end result for practice location reflects recruitment to rural areas for more recent years and retention for other years. This is suitable for career choice observations but not full scale physician workforce analysis. There is an equilibrium between rural and urban practice types that is relatively stable, not moving from rural to urban as many believe (Nebraska primary care studies, FP Graduate studies). Family medicine distributions in various rural and urban locations in each state have been stable over many years (Bowman, Patterns of Workforce http://www.unmc.edu/Community/ruralmeded/patterns_of_rural_workforce.htm with links).  This reflects who family physicians are as well as relatively little economic change regarding various categories of communities.

This work does not reveal any problem with the MCAT test itself. It is the use of the MCAT and other standardized tests at the college and medical school level that represents a grave concern regarding distribution. Efforts to game the system of standardized tests in the US may also influence admissions, again with lower income students and students in less prestigious colleges and high schools less able to play the game due to income or access limitations.

Introduction to Socioeconomics and Physician Distribution

Recent studies by the Jefferson Longitudinal group provide a direct link between socioeconomic origins and choice of family medicine, the only specialty that distributes according to the US population. Studies have long noted the higher choice of family medicine by rural background and inner city students, areas with lower property values and income and education levels. With the connection between students who will distribute based on income levels there are new considerations in physician workforce.

Socioeconomic levels may be reflected by other student characteristics such as physician age and birth location in addition to specialty choice by income levels. Age, birth location, and specialty choice are available for over 98 % of US allopathic physicians. The type of medical school and the average MCAT score for the medical school also characterize the students admitted along socioeconomic and distributional lines (tables later, Bowman MCAT Correlations). Students who are older, students born in less urban US locations, students born in the same state as the medical school, and students in schools with even slightly lower MCAT scores distribute better. Students who are more likely to be admitted to allopathic medical schools are also less likely to distribute well. Students less likely to be admitted do tend to have a higher attrition rate, but no differences in physician performance measures (Cooter, Jefferson Studies). Students with the highest incomes and scores and urban origins may actually not do as well on USMLE 1 board scores as compared to their grades and MCAT scores (Veloski, Jefferson Studies). The lower income student groups have less predictable outcomes in many ways except for two key areas, their ability to distribute to areas of most health care need in the nation and their ability to perform just as well as their privileged peers as physicians (Cooter, Jefferson Studies).

Socioeconomic measures, admissions probabilities, choice of family medicine, test taking ability, and distribution outcomes all relate to one another in a consistent way that has not been studied in great detail, especially on the national level.

The common theme for distribution is admissions of students of lower socioeconomic origins. Even when not choosing family medicine such students have greater choice of rural practice locations.

Distribution and Physician Specialties

The geographic distribution of physicians can be influenced by specialties that have rural markets.

Locations of Allopathic Medical School Graduates from the 1987 - 2000 Classes

Data on more recent graduates is not significantly different.

Graduating more physicians or more office-based primary care physicians who are not family physicians will not address physician distribution.

Family Medicine Physician Distribution

Accountable Health Policy for Career Choice and Distribution

Distribution can also be influenced by displacement. Increasing numbers of internal medicine and pediatrics physicians that primarily occupy urban locations will serve to displace family physicians to large rural and rural areas. With adequate numbers of primary care and family medicine graduates, there is maximal distribution of physician workforce. In the absence of adequate numbers of primary care physicians, the family physicians will not distribute as well. In the absence of adequate numbers of family physicians, there is a greater probability of urban and large rural locations for all of primary care. The larger markets with greater resources can attract graduates that might have chosen rural locations in times of greater numbers of graduates.

Adequate numbers of primary care and family medicine graduates have not been the rule. The 1970s had increasing numbers due to new support from Medicare and Medicaid, new emphasis on primary care, and the creation of family medicine. The managed care period was the only other period with significant increases. During this era the students and schools least likely to distribute well had 30 - 50 % increase in choice of family medicine and primary care.  In the 1970s there were fewer family physicians and general practitioners out in practice compared to managed care. The managed care period maximized distribution, peaking in 2001 for new entrants into rural practice.

This is exactly what Newhouse and other economists have predicted (Newhouse, Where Have All the Doctors Gone?). At no other time in physician workforce history were there enough primary care and family medicine physicians graduated to test this hypothesis. Just as Newhouse noted, family medicine had a unique distribution that was important to consider.

State level markets can be filled with a coordinated effort. Such an effort maximizes retention of the students, medical students, and residents that will choose family medicine and rural locations.

These involve coordination of the steps between various stages of physician development, including college, admissions, curricula, transition to graduate medical education, graduate experiences, coordinated recruitment efforts, retention efforts, and practice support activities. Arkansas, North Carolina, West Virginia, Iowa, Nebraska, Minnesota, and the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) states have long had success with a coordinated effort. The admissions efforts are particularly critical so that there are enough students entering that will choose distributional careers.  The most successful distributional medical schools and programs have used socioeconomic indicators in the admission of medical students. Successful methods include partnerships with lower income students or their schools, small and rural college admissions programs, and special admissions tracks.

Most US distributional efforts impacting later stages of practice support, recruitment, graduate education, or medical school curricula. These later interventions are rendered less than effective by the failure of education and admissions to advance and admit enough of the students that have a higher probability of distribution.

Socioeconomic Determinants of Distribution

The students with lower income or less urban origins and those from schools with the lowest MCAT scores are the ones most likely to choose rural locations. An analysis of distribution needs to consider socioeconomic and test-taking determinations. Test-taking ability in standardized tests is known to have income, education, and parent education bias (ACT site, Bowman MCAT Correlations). The MCAT is no different in its socioeconomic bias involving urban and higher income students (Bowman MCAT Correlations). Primary care students also have lower MCAT scores compared to those who will not later select primary care (Veloski). This may well be the impact of lower income, older, and rural students that tend to choose primary care in greater numbers. Lower income, older, and rural students are admitted in lower ratios, again a function of lower MCAT scores. Studies also have repeatedly noted the increased validity problems of the MCAT and standardized tests regarding evaluation of those of lower income levels. The following statement is consistent with socioeconomics and admissions observations and research:

When education distribution, resources, or outcomes are poor, the students

admitted have the highest income levels, the most urban origins and interests,

and the best test-taking ability. These are all characteristics associate

with the lowest rates of distribution.

It is also important to understand the impact of instate vs out of state admissions. As out of state admissions have increased over the decades, the students have tended to have higher MCAT and income levels. Out of state students generally have lower choice of family medicine and rural practice. This impact is most marked in allopathic public schools and less in osteopathic and allopathic private schools.

Birth Origins, Admissions, and Distribution

The allopathic medical students that are not as likely to distribute were born in the most urban counties or outside of the 50 states (territory or foreign). Those students most likely to distribute are the least likely to be admitted to allopathic medical schools. Admissions decisions involving those most likely to distribute is the most difficult. Such students have a wider variety of backgrounds, less preparation, and a higher attrition rate. However they also have a much higher distributional capability and those graduating have the same performance as physicians as other graduates.

Admissions of the students who will distribute has been decreasing for decades. The impact of this slow steady decline has been masked by temporary workforce changes during managed care.

Health Policy Regarding Distribution

Solutions to Maldistributions: Beginnings in the 1960s and 1970s

Changes in the 1960s and 1970s give important clues regarding distribution. These include the initiation of Medicare, Medicaid, family medicine, and medical school expansion.

It is difficult to separate the individual contributions of these new creations. The creation of family medicine brought back a physician specialty that would distribute. Medicare and Medicaid brought increased reimbursements to areas with lower income levels, more poor patients, and more elderly.

Total FPGP percent of physicians doubled from 1965 - 1975.  Initially the new specialty of family medicine had over 30 % of graduates choosing rural locations before settling in to a fairly constant 22 % rural graduation rate as a discipline. The early increased choice of rural practice was another indication that family physicians were capable of markets that were not previously able to be filled without a distributional specialty.

The early popularity of the specialty, changes in medical education schools and training, and the support of Medicare and Medicaid fueled a growth pattern not seen in family medicine or primary care until the recent managed care era. The evidence for the impact of federal programs involves increases in not only family medicine, but also a 50 % increases in choice of internal medicine in the classes graduating 1965 - 1975. Family medicine and internal medicine appear to be complimentary during this and other growth periods. With increases in internal medicine (from 12.4 % of medical students to 18 %) and family medicine (4.5 to 13.9 %) leading the way, total primary care (all types internal medicine, pediatrics, family medicine, general practice) career choices rose from 26.7% in 1965 to 41.1 % of allopathic graduates of 1975.

The actual magnitude of the increase in primary care choice from 1965 - 1975 is likely to be underestimated. The primary care increase to 41.1 % also does not include the 5 percentage points of  graduates who self-designated emergency medicine in later years. These ER docs most likely would have been primary care practitioners during their early medical careers. Primary care numbers would have also deteriorated over time as internal medicine and pediatrics graduates moved on to other specialties. The actual increase in adjusted figures from 1965 to 1975 would be more like 28 % to 50 %, a dramatic change in the career choices of US medical students.

Primary care percentages from 1975 - 1985 stabilized at values from 36.1 to 41.1 % of graduating classes. Major specialties losing ground when comparing the graduating classes of 1965 to 1975 include ophthalmology (from 4.8 to 3.1 %), orthopedics (6.1 - 3.9 %), psychiatry (8.1 to 5.0 %), and general practice (cut in half from 4.3 to 2.2 %).

The impact of the student birth origins should not be overlooked regarding the improving primary care and rural practice location rates in this era. The medical student composition during the 1970s included 27 % from rural backgrounds (towns of less than 10000), twice the composition of today's allopathic medical schools (AAMC GQs). This data and the later decline of rural born admissions is confirmed by birth origin studies. Rural born admissions at US allopathic medical schools have declined from 18 % during this period to 12.4 % in 1987 to 9.8 % in 1999 (Hart Use of RUCA, Hart WWAMI RUCA site).

There were areas relating to distribution that had not yet had time to make impacts. Allopathic medical schools beginning operation in 1961 to 1971 had no distribution increases compared to older medical schools. This fact that these medical schools were planned and implemented before the creation of family medicine is an important consideration. Those allopathic medical schools planned and implemented after this time had much improved distribution of graduates. The osteopathic schools have maintained their excellent distribution without interruption. International medical schools have had limited distribution capabilities until recently. International schools with predominantly US citizens of lower income and test taking ability have also distributed US physicians well.

The combination of increasing reimbursement patterns in areas of most need, new emphasis in medical education regarding the new specialty of family medicine and primary care, and adequate numbers of distributional students in allopathic medical schools greatly enhanced physician distribution. The nation currently has taken the opposite approach:

1.      Questionable financial viability of low paying physician specialties due to continued declines in reimbursements in comparison to unlimited overhead cost increases from liability and tuition.

2.      Medical education emphasis away from primary care and family medicine

3.      Continued steady declines in admissions of students who will distribute.

4.      National "crisis-oriented" reports and regular media expressions regarding difficulties in family medicine and primary care.

5.      General public preference for costly convenience care rather than continuity care.

Medical School Expansion Era

The major event in medical education was medical school expansion. From 1971 to 1981 the allopathic graduating classes doubled from 8000 to 16000 a year and students born in the most urban counties rose to prominence in US medical school admissions. There were slightly increased admissions of older students during this time period. Admissions of less urban and underrepresented minority (URM) students were relatively flat during the 1970s.

The end result of the decade was that both the percentage and the probability of rural and URM student admissions during this time of great opportunity basically was cut in half compared to those of urban origin. This decline in rural born admissions probability was confirmed in direct state to state comparisons of rural and urban born students (Bowman Probability Tables) as well as methods comparing admissions by various rural-urban county coding methods. Scatterplots of income levels of these various county types compared to family medicine choice or admissions ratios are linear. Those born in counties or ethnicities of the lowest income levels consistently have the lowest admissions levels and the highest choice of family medicine (Bowman Medicine Education Social Status).

Comparing the 50 states by ability to admit rural born medical students, the college continuation rate of a state was the most important variable predicting rural born admissions to medical school in equations explaining 44 % of the variance. The college continuation rate of the state of a medical school also contributes to linear equations involving choice of family medicine. The proportion of US students attempting admissions from rural areas have been unchanged from 1991-1999 but the percentage admitted has declined. 

There was a bright note during later medical school expansion. The new allopathic medical schools beginning operation since 1971 had a 55 % increase in graduation of physicians who were in rural locations in 2004 (10.2 % for pre 1973, 16.1 % for new). These distributional schools include Mercer (1973 start), Northeast Ohio, Wright State, Eastern Virginia, U of South Carolina, Marshall, Morehouse, Oral Roberts (now closed), and East Tennessee State. Duluth also began operation during this time period. These are the same schools that have the highest choice of family medicine and primary care choice in allopathic medical schools. These schools were much more likely to have significant family medicine influences from their creation. Unfortunately they also shared the common characteristic of a smaller class size.

Admissions and Distribution

The urban born students most likely to gain admission in the US are the ones least likely to choose family medicine (in table) and rural practice (not shown).

*Foreign born include mostly students of Asian ethnicity. According to the US census 70% of US Asians live in Code 1 and only 5 % in rural areas. Including foreign born in the counties where they were raised would increase admissions ratios for code 1 by nearly 2 points to 9.0 or 2 to 6 times any other origin.

Because so many US medical students have foreign birth, more accurate calculations must use census data on college student age groups. When comparing 18 - 24 year olds in the United States with medical students admitted from their respective groups, black and rural students are admitted in the lowest ratios, about 250 per 100,000 college age students. Black, rural, Mexican American, and Vietnamese medical students have the lowest income origins and have the highest choice of family medicine (18 - 30 %). Asian students have a rate 9 times higher at 1967 per 100000.

* FP and Rural FP Data from Graham Center and Masterfile for FP Grads and Rural FP Grads 2001 – 2003, used as numerators divided by known AAMC data on allopathic graduates for 1998 - 2001. Ethnicity is missing from 30 % in the AMA Masterfile. Asian students are known to represent higher parent income, higher education origins, and greater college preparation

The rate of admissions for the highest income Asian students, those of Indian-Pakistani origin, is even higher since there is a greater matriculant rate compared to Asian students as a whole. This is also the fastest growing group of Asian students, with Asian students the fastest growing group admitted to US medical schools. The major factors are not likely to be Asian so much as socioeconomic relationships. White medical student parents have the same distribution of income (AAMC Minorities in Medicine) that is likely to be even more shifted to the higher income levels for whites in urban areas. Indian-Pakistani students have the lowest choice of family medicine at 2.3 %.  Vietnamese have the lowest income levels and have perhaps the broadest income distribution of any medical student ethnicity and choose family medicine at 24% (Bowman Ethnicity and FP Choice). No Asian group has special consideration for admission but clearly there are many Asians with lower income levels and education barriers than many students who do obtain special consideration.

Rural Born Admissions

Rural born admissions have been given special consideration in as many as 47 medical schools. These considerations are important in some rural students gaining interviews (Basco). The rate of rural born admissions has declined in every US medical school except Morehouse. The rate of decline was highest in schools in states with 40 - 50 % of the population in rural areas. The rate of decline was significantly lower in medical schools with a rural mission. States with special admissions programs involving tracks had greater admissions or rural born medical students. The presence of actual admissions tracks in a state together with the college continuation rate of the state explained 44 % of the variance in rural born admissions in states across the nation. Variables involving school mission for rural health mission, presence of specific rural medical educators, and stated preference for rural background students did not contribute to regression evaluations.

Combining Characteristics

Young, urban, out of state or foreign born medical students, in allopathic private medical schools have family medicine choice approaching zero. Older students who were born instate in metro areas not in counties of over 1 million and attending any allopathic public school have family medicine choice of nearly 50 %. Age is a particularly good multiplier of existing distributional tendency characteristics in students.

Birth Origins and Distribution

Table of Birth Origins of Allopathic Medical Students 1987 - 2000

Basically distribution and family medicine choice breaks down into birth origins. The 49 % of medical students born in counties over 1 million share origins with 49 % of the US population and chose family medicine at 12 %. Other metro areas admit only 23 % of US medical students even though these counties have reasonable income levels and 29 % of the population. This less metro group has a choice of family medicine at 18.4%. Those born in adjacent and lower income metro and rural areas with 23 % of the population only provide 10 % of US medical students. This most rural group chooses family medicine at rates from 22 - 30 %, again related to the income levels of the counties of origin. The relationship between the income levels of the county of birth and admissions and between the income level of the county types and choice of family medicine is unquestionably linear.

Subtracting 49 % in the most urban areas and 23 % in code 2 and 10 % from the rest of the nation leaves 82 % of US medical students explained. The "missing" portion of allopathic medical students includes 14 % that were born in foreign countries, 1.8 % born in territories, and 1 % with missing birth data. This combined group shares the same low probability of choice of family medicine and likely shares the most urban origins and the highest income levels.

Changes in Medical School Admissions

The group increasing the most during the medical school expansion era was those born in counties of over 1 million. This group of students is the least likely of US born medical students to choose family medicine or to distribute.

In the last 15 years the group rising to prominence in US medical school admissions is foreign born medical students. This is the least likely of all students groups to choose rural practice and family medicine. The predominant origin of such students is Asian.  Asian medical students have increased from 400 to over 3200 out of 16000 allopathic graduates a year (AAMC Minorities in Medicine).

The groups declining most in US medical school admissions are males, rural origin students, and white students. This combination is particularly high probability for choice of rural practice. The probability of admission changes before, during, and after medical school expansion.

Basically the probability of a student born in non-metropolitan areas of the nation gaining admission to medical school declined more than half during the period of medical school expansion, with some slight improvement in admissions after expansion. This improvement coincides with specific emphasis and training (3000 by 2000) regarding admissions of students of lower income origins who were underrepresented minority students. The decline in percentage of minority student admissions during this time resulted in efforts to remedy this area. The rural student declines were not as noticed since these students were not as easily identified. As noted in the ratios of admissions, rural born students share the lowest admission ratios with black students. Special admissions considerations should include ethnicity and income considerations.

Gender and Ethnicity Considerations

Throughout the choice of family medicine and rural practice, males tend to distribute at a 5 - 12 % higher rate than females. Without intensity of training or special admissions or both to equalize distribution, these are important factors in assessing distribution.

Non-white family medicine residents have half of the rural location rate compared to white graduates in studies on 2001 - 2003 graduates. Again this is related to birth origins. Over 89 % of non-white FP graduates were urban in origin compared to 77 % of whites. Mexican American and Native American FP graduates (very few) had greater rural origins than whites. The birth origins are almost completely urban (over 90 %) for Black and Hispanic (not Mexican American) and Asian family practice graduates (96%) of 2001 - 2003(Bowman Birth Origin and Ethnicity). These family medicine graduate birth origins all represent lower urban origin levels than medical students who did not choose family medicine, particularly in white students.

Medical School Types and Distribution

Medical School Type and Distribution as of 2004 Data (1987-2000 Graduating Classes)

Data on self-designated specialty missing in 12 % osteopathic, 6 % international, 1 % allopathic.

Physician workforce needs also involve areas beyond primary care, particularly geriatrics and behavioral health. Combining office-based primary care, geriatrics, and behavioral health into an "Essential Workforce" category can be useful.

Essential Workforce involves 1987 – 2000 graduates in family medicine, general practice, geriatrics, office-based primary care, all obstetrics and gynecology, public health, and all psychiatry. These are essential specialties to continue to maintain the health quality and access indicators in the nation. They also continue to be the specialties in most consistent shortage in the nation.

All inclusive primary care includes 1987 – 2000 graduates who have designated internal medicine, pediatrics, medicine-pediatrics, family medicine, or general practice as their primary specialty.

Office-based primary care includes 1987 – 2000 graduates who are office-based in primary physician activity in the above all inclusive primary care cohort.

The FP GP group from the previous table is included for comparison.

Allopathic private schools and distant international schools graduate the lowest percentages of family physicians and rural physicians. They also have the lowest rates of essential physician workforce and office-based primary care. There are 3 allopathic private schools that provide substantial diversity and service to underserved urban areas through graduation of black physicians. These schools are in the highest quintile of allopathic private medical schools with higher rates of primary care, family medicine, and essential workforce. Outside of these three schools, allopathic private schools have no advantage in equity for minorities or women. They do graduate more physician researchers, but this is concentrated in the top research schools.

The following table involves a division of medical schools into quartiles or halves based on choice of family medicine over 1987 - 2000. It includes research statistics and also the most recent “match” by type of medical school.

Does not include osteopathic graduates choosing osteopathic family medicine.

The Research group includes those who have designated their primary activity as medical research. Because of delays in the time that it takes physicians to report their research careers, data was used for 1987-1996 graduates to give a higher and more realistic representation. Only 28 medical schools had over 1% of graduates as medical researchers. In the allopathic private group, 10 schools graduated half of the medical researchers in the entire group. The allopathic public and private schools graduating the most researchers also graduated the least family physicians.

A nation that exclusively rewards medical schools who graduate specialists and researchers is not likely to distribute physicians well.

When considering birth origins and ranking states as to the percentage of physician researchers originating from a state, states such as Wyoming and Utah and similar states with better education investments and outcomes have research physician rates (1.5 - 2.8 %) comparable to the elite research medical schools. These states also have some of the higher family medicine graduation rates.

Medical Schools Categorized By Choice of Family Medicine

The socioeconomic tie most evident is students from urban influence 1, the highest income area of the nation. Older students, rural born students, and those with lower MCAT scores are also likely to have origins involving lower income and education origins.

More recent comparisons of FP Match, MCAT, and age composition:

The osteopathic rates noted in the FP Match reflect only those attending ACGME programs. The actual osteopathic graduation rate for family physicians is much higher as seen in other tables.

Medical Schools and Distribution

In terms of numbers, allopathic public schools provide the largest portion of the workforce. Duluth has been the standout among all allopathic schools, consistently graduating 50 % into family medicine, 22% into rural family medicine, and 30 % into all rural locations. Only a small class size of 60 keeps it from leading other categories.

Allopathic private and distant international schools provide the least essential workforce, primary care, family medicine, and rural physicians of all types.

Osteopathic schools provide the highest concentration of essential, family medicine, and primary care workforce.

Ranking Distribution

Medical schools and family medicine residency programs have been ranked by percentage and total rural graduates in the United States at http://www.unmc.edu/Community/ruralmeded/ranking_rural.htm

Distributional Specialty Rankings: Family Medicine

In the last 5 years of FP graduates, three osteopathic schools (Des Moines, Western, Philadelphia) have led the nation in total number of family medicine and general practice physicians. Osteopathic schools in Kirksville and Kansas City also are top ten contributors. The other top 10 FP GP contributors are Ross, American University, Indiana, Iowa, and Illinois. Iowa has one of the smallest class sizes of the top ten group. Ross led all medical schools with 90 allopathic FP graduates in 2003 and has continued to expand class sizes over the past few years. Among the osteopathic schools West Virginia leads in rural family medicine percentage at 20%. Again, only small class size prevents West Virginia osteopathic from leading the nation in more categories. West Virginia is also one of the youngest osteopathic schools.

Newer Allopathic Medical Schools

The newest allopathic medical schools beginning operation since 1973 have increased distribution of physicians, averaging 16% of graduates currently in rural locations as compared with 10% of the classes of older medical schools. This 6 percentage point difference is a constant for the class years graduating each year from 1987 - 2000. Again the contribution of family medicine to the planning and operations of these medical schools and their admissions may be a key feature. Mercer (1973 start), Northeast Ohio, Wright State, Eastern Virginia, U of South Carolina, Marshall, Morehouse, Oral Roberts (now closed), and East Tennessee State. Duluth persists as a 2 year branch feeding into the University of Minnesota and has the highest distributional indicators of allopathic public schools.

The managed care intervention

“Who ever wishes to investigate medicine properly,” Hippocrates counseled physicians 23 centuries ago, “should proceed thus: in the first place to consider the seasons of the year, and what effects each of them produces…” as quoted in Butler, Academic Medicine's Season of Accountability and Responsibility.

Managed care was an entirely different season in medicine with very different impacts upon career choice and distribution.

The following table demonstrates the impact on career choice by type of medical school and on the career choices of those most and least likely to choose family medicine.

The schools with the least probability of graduating family physicians and the highest proportion of urban and foreign origin students prior to managed care had the greatest improvements in graduation rates during managed care. Studies of these groups of students comparing peak managed care to trough prior to managed care reveals a 50 - 60 % increase.

FP Likely is students born in counties of less than 1 million in the US.

FP Likely is students born in counties over 1 million or outside of US 50 states.

Instate born is different than actual instate as determined by the variety of state and medical school policies, but there is a +0.82 correlation between the two and the relationships of this group is the same in comparison with instate admissions.

The impact of the managed care era was to distribute physicians effectively by increased choice of primary care, family medicine, and rural family medicine. This impact was greater on the groups of students who were the most numerous, the most urban, and previously the most unlikely to choose family medicine. Older students were more resistant to career change, as noted in previous studies (Xu, Older students).

North American International Medical Schools

North American International graduates are similar to allopathic public school graduates in distribution with a slight edge in family medicine and essential workforce. This suggests a similar composition of students admitted. Indeed some schools have as many as 70 % US citizens who have often attempted allopathic schools prior to international.

North American medical schools outside of the US have a much great distributional value. Canadian medical school graduates have the highest choice of rural practice but very few total graduates locating in the US. Canadian schools are followed closely by graduates of Ross, St. Georges, American University, and schools in Mexico with large number of US citizens. The rates of distribution for schools including high percentages of US citizens is actually higher than US public allopathic schools. This is consistent with lower MCAT scores and socioeconomics.

The three main Caribbean schools have been increasing in size and impact. They rate in the top 10 of all medical schools in the world in graduating ACGME family medicine residents. Ross is the top source of such graduates for 2003 with 90. Ross has an annual graduating class bigger than 6 allopathic medical schools that graduate the most rural physicians. Only the US allopathic schools with the highest class sizes reach this top 10 list.

Distant International Medical Schools

There are a few medical schools in the Philippines and in India that have high ranking rural location percentages when examining their graduates choosing the US for practice. The admissions policies of these medical schools and the characteristics of their graduates have not been well studied. Generally distant schools are not major contributors to US rural workforce. Although there are special programs to assist international graduates with locating in the US, the numbers are small. The impact of such graduates is limited. Often the graduates do not live in the towns where they practice (KY Office of Rural Health). Such international graduates have the lowest percentages in rural areas of all medical school groups in 2004. This cross section study involves both location in rural areas and retention. Visa policies and medical license procedures are more important determinants for distant international graduates. There is also a concern regarding the US taking the health and education resources of other nations. Obviously there are reasons for choosing the US for medical studies. There are nations that will not be damaged by the loss of a few graduates. However there are a few nations that desperately need all of their physicians. Some of these nations are active combatants involved in the global war against terrorism. This war is all about trust in government. Health and education and economics are the primary determinants of trust in government. If the US allows the loss of such resources in the nations in most need of them, it is really not fighting this global war. Again this involves a decision of the citizens of the US regarding their own needs as compared to that of others less fortunate. We should be willing to make some sacrifices for other nations beyond military actions and relief programs.

Socioeconomic Admissions Efforts

The United States has been successfully and preferentially admitting students who are more likely to distribute for years. These programs include targeted admissions of rural background and lower income students. Few of these programs have been replicated. It seems that the nation has chosen exploration of new methods over replication of methods that actually do distribute physicians.

The Physician Shortage Area Program at Jefferson is the most well known. This program with 14 medical students a year now boasts 21 % of the rural family medicine graduates in Pennsylvania that graduated from the states medical schools even though the program only involved 1 % of medical students. A partnership with college health advisors and selection of rural and older students is a key component. Males and females distribute equally in PSAP.

Duluth selects students based on rural background, rural practice interest, and family medicine interest. Questions used to screen students include questions about overcoming obstacles and comprehension of rural practice and rural lifestyles (Duluth Twenty Questions). Duluth has one of the smaller metro locations and this may also influence who chooses this medical school. Other schools in smaller metro and rural locations have similar high rates of rural location and distribution.

Socioeconomics Plus Intensity of Training

Duluth students make up the majority of the Rural Physician Associate Program, a 9 month rural preceptorship involving 60 students a year at the University of Minnesota. Traditionally half of Duluth's 60 students join 30 students from the much larger U of MN. In recent years there has been declining interest from the U of MN students, with difficulty finding 30 interested in rural practice. Overall U of MN plus Duluth graduates together place the state's public medical schools in the top 10 in graduation of family physicians. The combination of admissions and intense training results in much better rural location rates, retention, and females distributing equal to males in Duluth plus RPAP. Syracuse and other schools have implemented RPAP-type programs with success.

Rockford has a special admissions track that involves selections based on rural and service oriented criteria. All but the final choices are influenced by rural community admissions committee advisors. Rockford's RMED program selects students specifically not from prestigious colleges and accepts a much wider range of MCAT scores. Not uncommonly Rockford students with the lowest MCAT scores, including scores as low as 7s, have been some of the highest ranking students. Such is the situation in the US where students with great potential have never had the opportunity to shine. Rockford's effort involves a 4 month rural preceptorship. Rockford has had success in gaining support from hospitals and preceptors by pointing out that their students are more likely to go and stay in rural communities similar to their birth origins and training locations.

Longer term rural experiences are less of a burden upon preceptors and may actually contribute to workforce efficiency in shortage areas.

Nebraska began a special admissions program that admits 10 of 120 medical students each year from rural high schools. The selections of this Rural Health Opportunities Program is a partnership between the colleges, the health advisors, and the dean of admissions, a former rural family physician. These RHOP selections and alternates attend one of two small rural state colleges for 4 years before moving to Omaha to begin medical school. RHOP graduates have higher choice of primary care and rural location in the 4 years of graduates out in practice, including a rural general surgeon. No specific track for curricula exists but all medical students at Nebraska take a 2 month rural family medicine preceptorship and have a 1 month first year experience. They have extensive contact with family medicine faculty throughout training. Nebraska also has the widest variety of rural and underserved medical education choices for graduates including a combined internal medicine/family practice track, an accelerated family medicine track, 5 rural training tracks, and an inner city track.

Intensity of Training Plus Older Students

Graduates of accelerated family practice programs in Nebraska do have rural preference in practice location and rural born bias in selections. The other 10 programs involving 150 accelerated graduates across the nation reveal that these biases actually mean little in accelerated programs. The accelerated programs involve no rural training locations, no rural bias in location preference, and no rural bias in birth origins. The rural location rate for all accelerated graduates is 50 %, twice that of family medicine as a whole or compared to family medicine graduates in the home states of the accelerated programs. Again the intensity of the training, a likely result of back to back M-3 and PGY-1 years, and a higher proportion of older medical students is a great boost. Female accelerated graduates distribute to the same degree in numbers and sizes of small towns. Urban born students have a slightly lower rural location rate, but a proportionally much higher rural location rate than other urban born family medicine residents. Accelerated graduates had stellar academic and leadership accomplishments and in many medical schools reversed the severe problems with match rates at university-based programs.

Accelerated programs were initially designed for older graduates and successfully facilitated the distribution of these graduates to an even greater degree. In Nebraska the rural location rate was 78 %. Rural training track graduates in the state had a higher rural practice rate and distributed to somewhat smaller towns, but had an obvious edge in rural location of training and rural origins. Accelerated programs often allowed non-medical spouses to complete training or degrees prior to leaving urban areas, a boost for rural communities in need of other types of workforce.

There were 7 accelerated programs in the United States (out of 11 total with secondary data) that were in the top 50 family medicine residency programs ranked by rural graduation rate. Rural training tracks and FP residency programs in rural locations dominated the other positions. At maximum output, there were only 30 - 40 graduates of accelerated programs a year, and a similar output in the RTT programs, but the rich contributions of both programs will be missed. Accelerated programs were terminated and it is likely that only the Nebraska program survives as a track. Declines in rural born admissions, federal graduate medical education changes, and lower choice of family medicine by students has also been hard on rural training tracks with over 30 % expected to close operations. Without the intensity and specificity of the training of acclerated and rural training track programs, both rural recruitment and retention will suffer. Smaller communities in particular will likely be impacted.

A few osteopathic medical schools are beginning to combine medical school and graduate training in similar ways. Given the older and lower socioeconomic admissions at osteopathic schools, their orientation toward rural and family medicine, and their already stellar rural graduation rates, the outcomes of these programs should be even more remarkable.

Changing Admissions Toward Socioeconomics and Ethnicity

Admissions based on ethnicity designations alone for the intention of improving health access no longer make sense. Those of higher income and urban origins seem to be able to access professional education at similar levels. Lower income students are admitted in lower ratios and may face greater barriers than designated minority students. Even within various designations there are inequities. Asian students receive no special consideration for admission as a group even though Vietnamese parents have some of the lowest income levels of all medical student parents. Indian-Pakistani students are admitted in the highest ratios and have the highest income levels. Distribution is also involved. Vietnamese students choose rural locations at higher rates and choose family medicine at rates nearing 30 % compared to 2.2 % for Indian-Pakistani students. Moving more toward income-based determinations in special admissions could increase the numbers of students that would distribute. This could be done in a way that would meet more stringent admissions legal requirements (Kreiter).

Declining numbers of Native Americans and other underrepresented minorities choosing family medicine also suggest that higher income minorities are gaining entry to US medical schools, and are not as likely to distribute well. Native Americans choosing family medicine had the highest rural location rates of any group at over 47 %. The impact of their loss is great in terms of distribution and in the great needs in reservations in rural areas. Changes in Native American choice of family medicine may reflect a continued loss of rural and reservation origin students. This is consistent with the increasing distribution of Native Americans. Again confirmatory studies are needed in this area.

Questions Regarding Title VII

Studies supporting the Title VII programs have had variable results. Even supportive works have demonstrated minimal results. Evaluations involving diversity and inner city practice locations and retention are much more complex. It is interesting that the nation is willing to support Community Health Centers that provide distribution services, but is unwilling to support the sources of physicians for CHC and other underserved programs and locations.

Title VII does represent one of the only sources of infrastructure for the programs that do facilitate distribution however. The leaders in distribution medical education in the US have been trained in departments, residency programs, and fellowships supported by Title VII funding. Socioeconomic admissions are a key concern of Area Health Education Center programs. The focus on survivability may limit such efforts however. There is no future in a program that focuses on admitted more medical students that will distribute. The money involves efforts at later stages unlikely to impact distribution.

Studies comparing the impact of Title VII investments compared to creation of new medical schools (osteopathic or distributional allopathic) should be done to help the nation evaluate efficient graduation of physicians who will distribute.

Flawed Workforce Research

When considering the impact of birth origins, managed care, and choice of family medicine, the Title VII studies and the "Lifestyle" Career Decision studies may have significant flaws. The major flaw is that both types of studies have timing bias. Rates of primary care, family medicine, and rural location all improved during managed care. Studies ending at this period are biased by this trend. Studies beginning during this period (Lifestyle) are also biased by the subsequent changes due to the end of managed care influences. At other time periods the relationships between the various specialties have not varied.

A 7 state study of Title VII was also not representative of family medicine, with a higher % of rural physicians, family physicians, and rural family physicians in the 7 states studied. These rates all increased over the time course of the study in all parts of the nation, not just the 7 states. The studies did not consider the composition of the students or individual state characteristics. These are serious omissions.

The students most impacted by managed care were the urban and higher income students, the ones most likely to be determined "lifestyle" oriented. Controlling for student types, career decision impacts unique to the time period, and timing bias is essential in workforce studies. The "Lifestyle" decision studies are based on student surveys regarding career choice. Students likely to answer such questions are also more likely to feel unprepared for careers that are more intense. Declining intensity in medical education training (fewer babies, more passive role) makes more sense as an interpretation. Although studies note that college students have changed in major "lifestyle" ways. These studies have not specifically involved medical students. With so many career options involving "lifestyle" and income considerations equal or better, it makes no sense for "lifestyle" to have impacts on students. Again studies of who changed decisions would be helpful. Many career choices are limited not by student choice, but by available position. Also Emergency Medicine is relatively new and still has a "honeymoon glow." Studies involving career choice must involve understanding of national impacts, student origins, income levels, types of schools, changes in various specialties, and changes in medical education.

Long Term Considerations

At the current growth rate, family medicine numbers will have increased 56% over a 50 year period from 1970 - 2020. This represents a relative decline to the US population projected at 63% increase and a major decline relative to total physicians at 270% increase. Schoolteachers are projected to increase at 64 % if enough can be found to supply positions. Again rural and inner city areas are the ones most in need of educators. Many positions in such areas are filled with rookies and those near retirement. A nation that supports health care to the exclusion of education needs may soon not be able to do either.

Higher education data on underrepresented minority students is similar in impact. URM student numbers are increasing but are not keeping up with US population increases. Lower income origins for higher education and medical education result in similar obstacles, lower admission, and less distribution of physician resources to those most in need.

Delayed Recognition

The effect of changing admissions has not been recognized for a number of reasons.

• A key reason is the lack of evidence-based information involving admissions. Without outcomes data on careers and performance tied to medical school and pre-medical school performance, it is difficult to make good admissions policy.
• The major reports guiding our medical schools are also not as helpful as they could be. Most medical education reports are collected year to year and the changes have been subtle but progressive over time. This includes declines in rural admissions from 27% to less than 15%, declines in instate and older student admissions, and increases in admissions of those of higher income.
• Admissions-related research is not well-supported and admissions data is not widely available to researchers. Medical schools with the means to study admissions more thoroughly have little reason to do so. Those with much less resources cannot afford such efforts.
• New federal requirements branding annual educational evaluations such as the AAMC GQ as “research” have raised additional obstacles that may make these important evaluation tools worthless. In some schools less than 25% of students return useable information with even less in critical areas such as abuse of students.
• Another reason for poor recognition of admissions changes is the screening effect of managed care. During the managed care era, primary care and family medicine enjoyed 50% increases in career choice in many medical schools and student groups that normally did not choose such careers. This masked the longer term effect that had eroded student choices for years.
• Also we seem to be divided into various camps with perspectives and biases that keep us from seeing important patterns that impact health access and are likely to impact costs and quality as well. 

Stratification

The data suggest that the nation is stratifying health care into haves and have nots. Education research suggests much the same. With education and health care so critical regarding trust in government, this has important ramifications for the future. Many of the issues that most divide us in the nation are prevalent in those of lower education and income, including domestic violence, abortion (rates of 30 per 1000 live births in highly educated and over 1000 per 1000 live births in the least educated), and adverse outcomes in pregnancy (conception status in education a greater determinant of birth outcomes than later interventions). In many cases the interventions in education and early childhood would save tremendous health care costs, improve outcomes, and result in less divisiveness in the US.

Summary

Socioeconomic indicators linked to family medicine and primary care such as birth origin, in-state admission, state educational opportunity, and use of the MCAT suggest that a comprehensive solution to the nation's physician workforce problems must involve the integration of education and health professions education.

Regardless of policy, research, or probability, medical school admissions involve one decision at a time for each candidate. Setting the bar too high means exclusion of the family medicine, primary care, rural, and other diverse physicians most needed across the nation. Setting the bar too low means that more students will fail. This may be even more of a problem in schools that are not equipped to support their needs. The Jefferson studies illustrated the risks inherent in admissions that distribute more effectively, with higher school failure rates in the lower income origin students. There was no difference in performance by the end of medical school and residency. Admissions committees must do their own studies to obtain the best mix of physicians, but clearly the usual measures used in medical school admissions may not be the best for those from different origins.

In the final analysis, medical students will choose to distribute according to  socioeconomic level, experiences from birth to admissions, and geographic origins. The limitations of admissions for those of lower socioeconomics do not suddenly begin in high school or college, they begin before birth and continue throughout life. Progress can be made, but only with consistent and dedicated leaders and sustained national interest.

Currently the nation seems to be doing all that it can to discourage physician distribution.

• Primary concerns include significant erosions of education investment in many states that are often caught between recession, "no new taxes," poor distribution of education resources (Carey, Funding Gap 2004), and massive increases in health care costs (which also have gone up because of lack of education, etc.). New studies indicate that the US needs 20 % of total college graduate workforce to choose education just to maintain current levels of education as the baby boom echo reverberates through the US with higher numbers entering K - 16 education (Snyder) This has important impacts upon admissions of minority and lower income medical students needed for distribution and access. 
• The nation has declining admissions of students who will distribute.
• There is a constant steady dilution of the intensity of medical school experience in general and in preparation for underserved primary care practice in particular.
• There is less than adequate respect for careers of service involving teaching, nursing, and family medicine. This low level of respect seems to consistently turn into lower pay and shortages.
• There are constant indicators of declines in reimbursement.
• The nation has continued for more than 2 generations with the prospect of continued unlimited overhead cost increases from liability alone, not to mention mounting costs of new technology, information systems, continuing education, and efforts required to maximize quality. Those considering careers involving the necessary front line patient care specialties of primary care, mental health, and women's health are waiting and watching for signs of change. Nothing short of major liability overhaul or complete protection from liability costs will suffice to reassure medical students such that they can consider lower paying physician specialties.
• Tuition costs need to be addresses for college and medical school in a way favorable to those of lower income. Australia has a system that defers payments and repays education expenses at a later date based on the income derived from this investment in education. This has improved access to higher education for those of lower income levels (Rasmussen, ASHE). These are of course, the key to physician distribution and may be the keys to adequate numbers of teachers, counselors, nurses, public servants, and other service careers that may draw from the same declining pool of graduates.
• Medical schools and residency programs are stacked on top of one another in the most urban parts of the nation. Better distribution of medical training can help in distribution of physicians after training and also improve economics and education in more rural areas.

The efforts that have resulted in improved physician distribution highlight the hit or miss policies of our nation. These are not Republican or Democratic or liberal or conservative issues, they are American issues.

Restoration of underserved areas is an all or nothing phenomena. A city, state, or nation must work in a multidimensional comprehensive fashion to make progress. Failure to address a single area involving education or health or economics will result in lack of progress and frustration and additional cost.

States investing more in restoration may be frustrated as their investments graduate and locate in states with higher growth rates, more resources, or superior recruitment investments. Unless most states make the necessary multidimensional investments, it is difficult for the nation to make headway. If states that are successful in distributing graduates decrease their class sizes, this also does not help the nation to address chronic problems.

Areas of chronic poverty, ignorance, and poor health persist and impact us all through violence, taxes, illegal activities, legal and prison costs, insurance premiums, and security costs. The impact on our children and their children will be intensified and magnified. The disease known as poverty spreads in unmistakable and deadly ways. It spreads to past generations who end up raising one or two additional sets of kids. It streams into future generations impacted through education or poor health. Poverty also leaps over the barriers of insulation that we set up in neighborhoods and schools, catching fire in families driven to poverty through peer contacts that destroy families through drugs, abnormal and illegal behaviors, and violence. Anyone familiar with personal rehabilitation programs realize the importance of involving multiple generations and contacts for true recovery.

The practices, programs, and policies that distribute students share some common themes. A primary theme is risk taking. Establishing such programs and admitting such students involves risk. Another theme is valuing potential and people over performance measures. Students gaining entry because others valued them as people may be more likely to value others that they serve later in life. In a final analysis there really is little risk in choice of physicians who will distribute. We usually know all that we need to know about those less likely to distribute. Their access to income and education and the most prestigious colleges produce a uniform product with predictable outcomes and abysmal distribution. What we know about those who are likely to distribute is much less, difficult to compare, and even more difficult to predict. What is known is that 4 – 10 % will fail, depending upon personal characteristics and the support that they have available and will pursue. Their potential is vast in terms of performance and in distribution. The reward for working with such students is enormous, for classmates, for faculty, for academic leaders, for states, for the nation, and for underserved communities. Upon review the riskier behavior is not making efforts to distribute physicians. It is in these admissions and programs that the future directions of health, medicine, and medical education can be cast. Successful efforts to restoring communities, states, and nations depend upon these efforts. The recovery time is all a matter of how long people have chosen to ignore the recovery process. In the worst case scenarios, nothing short of a military action will suffice. In the best case, a flood of dedicated individuals in health, education, and service careers who understand the recovery process will suffice. Not to choose distribution is to choose education failure and societal decline.

For many years the US has worked to tame the rivers of the country that would periodically rise up and consume the progress of many decades. We learned to look upriver and influence the streams and creeks and smaller rivers feeding into the main systems. It took many years of explaining the necessities to people who often did not want to invest through taxes and did not want to give up their land or way of life. We made a decision as a nation to do it and had the fortitude to virtually end these disasters. It is interesting that the politicians that helped the nation tame rivers and electrical distribution were also involved in wars on poverty, and had great successes.

The rivers of underserved are still rising up. They rise up in unpredictable ways that damage themselves and others. The streams that overflow consume our state budgets in increasing health costs, social costs, and program costs. The persistent maldistributions in our society make it much more difficult to govern. The costs for adequate education in underserved groups are 40% higher and successful only with accountability and dedication (Carey, Funding Gap 2004). Such national efforts are less and less likely with passing years until changes are forced upon a nation. The health and legal and prison costs have eroded the means for the education expenditures that might help reverse the problem.

The multidimensional challenges of the underserved burden caring professionals enormously. Many professional students have a taste of careers involving the underserved. Their brief unsatisfactory exposures may do a great disservice to the nation. Those choosing such careers are rewarded with lower salaries, less professional respect, and fewer supporting resources. These are early and obvious observations. Without working with dedicated and experienced caregivers and efforts that work for long term changes, students are likely to see the failures rather than the successes. Without a more consistent approach to physician distribution, current career choices are likely to continue.

References

Note: The following have all had influences. Some are subtle and some are more direct. These are all referenced for consideration and for better understanding of this important area. The major influences are directly referenced in the text. Integration of two or more references may be required for understanding the referenced areas.

Association of American Medical Colleges (AAMC) Data Warehouse

AAMC GQ

AAMC Minorities in Medicine

Advisory Committee on Student Financial Assistance. (2001). Access denied: Restoring the nation’s commitment to equal educational opportunity. Washington, DC: Author.

Albanese, M. A., Snow, M. H., Skochelak, S. E., Huggett, K. N.,&Farrell, P. M. (2003). Assessing personal qualities in medical school admissions. Academic Medicine, 78(1), 313-321.

Albanese, MA   2004 CGEA Meeting Presentation regarding scores and diversity

Baicker K and Chandra A   Medicare Spending, The Physician Workforce, And Beneficiaries’ Quality Of Care, Health Affairs, 10.1377/hlthaff.w4.184 http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184v1 

Basco, W.T., Jr., Gilbert, G.E., & Blue, A.V.(2002). Determining the Consequences for Rural Applicants When Additional Consideration is Discontinued. Academic Medicine, 77, S20-S22. http://www.aamc.org/students/mcat/research/bibliography/basco002.htm

Bland CJ, Meurer LN, Maldonado G. Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature.Acad Med . 1995;70:620 -41.

Boulger, JG. (1991). Family medicine education and rural health: A response to present and future needs. The Journal of Rural Health, 7(2), 105-115.

Bowman RC    Before Admissions: Physician Career Predictions http://www.unmc.edu/Community/ruralmeded/before_admissions.htm

Bowman RC    Birth Origins, Ethnicity, and FP Graduates http://www.unmc.edu/Community/ruralmeded/birth_origins_ethnicity_FP.htm

Bowman RC Career Predictors: MCAT sensitive or not http://www.unmc.edu/Community/ruralmeded/career_predictors.htm

Bowman RC  Ethnicity Gender and Rural Practice Choice

http://www.unmc.edu/Community/ruralmeded/ethnicity_gender_and_rural_pract.htm

Bowman FP Graduate Studies - Details on coding and variables http://www.unmc.edu/Community/ruralmeded/bowman_fp_grad_2004.htm

Bowman RC MCAT Correlations http://www.unmc.edu/Community/ruralmeded/mcat_correlations.htm

Bowman RC Medicine Education and Social Status, graphics on income, ethnicity, family medicine choice  http://www.unmc.edu/Community/ruralmeded/medicine_education_social_status.htm

Bowman RC Patterns of Rural Workforce http://www.unmc.edu/Community/ruralmeded/patterns_of_rural_workforce.htm

Bowman RC  Probability of Admission Tables http://www.unmc.edu/Community/ruralmeded/probability_of_admission_tables.htm

Bowman RC Ranking Medical Schools and Residency Programs for Rural http://www.unmc.edu/Community/ruralmeded/ranking_rural.htm

Bowman, RC, & Crouse, BJ. (2003). Community-driven Medical Education: The Rural Component. The Journal of Rural Health, 2003    19(3), 214-217.

Bowman, RC, & Penrod, JD. (1998). Family practice residency programs and the graduation of rural family physicians. Family Medicine, 30(4), 288-292.

Brooks,RG; Walsh,M; Mardon,RE; Lewis,M and Clawson,A. “The Roles of Nature and Nurture in the Recruitment and Retention of Primary Care Physicians in Rural Areas: A Review of the Literature,” Acad. Med., August 1, 2002; 77(8):790-8.Butler WT Academic Medicine’s Season of Accountability and Social Responsibility Academic Medicine 67(1992) 68-73 Chair's address 1991

Butler WT Academic Medicine’s Season of Accountability and Social Responsibility Chairmans Address, AAMC Academic Medicine 67(1992) 68-73

Callahan, C., Erdmann, J. B., Hojat, M., Veloski, J. J., Rattner, S., Nasca, T. J., et al. (2000). Validity of faculty ratings of students’ clinical competence in core clerkships in relation to scores on licensing examinations and supervisors’ rating in residency. Academic Medicine, 75, S71-S73.

Carey, Keith   Funding Gap 2004 by Keith Carey, The Education Trust, page 16 accessed at http://www2.edtrust.org/NR/rdonlyres/30B3C1B3-3DA6-4809-AFB9-2DAACF11CF88/0/funding2004.pdf

Clawson DK. The Education of the Physician. Academic Medicine 65(1990):84-88.

Cohen JJ Our compact with tomorrow's doctors, Academic Medicine, 2002;  77:475-480

Colloton JW.  Academic Medicine’s Changing Covenant with Society Acad. Med. 64(1989): 55–60.

Colquitt,W. L., Zeh, M. C., Killian, C. D.,& Cultice, J. M. (1996). Effect of debt on U.S. medical school graduates’ preferences for family medicine, general internal medicine, and general pediatrics. Academic Medicine, 71(4), 399-411.

Cooter R, Erdmann JB, Gonnella JS, Callahan CA, Hojat M, Xu G, Evaluation & the Health Professions, Economic Diversity In Medical Education / September 2004 http://ehp.sagepub.com/cgi/reprint/27/3/252

Cooter, R., Bross, T. M., & Erdmann, J. B. (1998). Factors influencing students’ borrowing that may affect their specialty choices and other after-graduation behaviors. Academic Medicine, 73(1), 71-76.

Council on Graduate Medical Education TR. Physician Distribution and Health Care Challenges in Rural and Inner-City Areas. Washington, D.C.: U.S. Dept. of Health and Human Services, Health Resources and Services Administration; 1998:1-74.

Coutts-van Dijk LC, Bray JH, Moore S, Rogers J. Prospective study of how students' humanism and psychosocial beliefs relate to specialty matching. Acad Med.1997; 72:1106 -8.

Crowley AE and Etzel SI. Graduate Medical Education in the United States. JAMA 256(1986):1585-1594.

Crowley AE. Graduate Medical Education in the United States. JAMA 248(1982):3271-3275.

Ebert RH. Has the Acute General Hospital Become and Inappropriate Environment for the Education of the Primary Care Physician? J. Lab. Clin. Med. 117(1991):438-442.

Fryer GE, Dovey SM, Green LA. The effect of accredited rural training tracks. Am Fam Physician, July 1, 2000; 62:22. http://www.aafp.org/afp/20000701/policy.html

Fryer GE, Stine C, Krugman RD, Miyoshi TJ. Geographic benefit from decentralized medical education: student and preceptor practice patterns. Journal of Rural Health 1994:10:193-198.

Fryer, GE, Stine, C, Vojir, C, & Miller, M. (1997). Predictors and profiles of rural versus urban family practice. Family Medicine, 29(2), 115-118.

Funkenstein DH Medical Students, Medical Schools and Society During Five Eras: Factors Affecting the Career Choices of Physicians 1958-1976. Cambridge, Massachusetts: Ballinger Publishing Company, 1978.

Greenhalgh T, Seyan K, Boynton P "Not a university type": focus group study of social class, ethnic, and sex differences in school pupils' perceptions about medical school BMJ  2004;328:1541 (26 June), http://bmj.bmjjournals.com/cgi/content/full/328/7455/1541

Hanushek EA, Kain JF, Rivkin SG New Evidence about Brown v. Board of Education: The Complex Effects of School Racial Composition on Achievement

http://www.ssc.wisc.edu/irp/pubs/dp128404.pdf

Hart Gary WWAMI Rural-Urban Commuting Areas (For Residential & Commercial/Geographic Zip Codes: Version 1.1)http://www.fammed.washington.edu/wwamirhrc/rucas/descript.html

Hart Gary Use of RUCA codes  Categorization A http://www.fammed.washington.edu/wwamirhrc/rucas/00F02640-005B90E7.-1/use_healthcare.html  

Harth, S. C., Biggs, J. S. G., & Thong, Y. H. (1990). Mature-age entrants to medical school: A controlled of sociodemographic characteristics, career choice, and job satisfaction. Medical Education, 24, 488-498.

Head, R.E., and D.L. Harris. "Characteristics of Medical School Applicants: Implications for Rural Health Care." Family Medicine. 21(3):187-190, May-June 1989.

Hippocrates .On Airs, Waters, and Places In The Genuine Works of Hippocrates, Frances Adams, ed. Vol.I. New York: William Wood & Company, 1849, p. 156.  From Butler

Hojat, M., Borenstein, B. D.,& Veloski, J. J. (1988). Cognitive and non-cognitive factors in predicting the clinical performance of medical school graduates. Journal of Medical Education, 63, 323-325.

Hojat, M., Gonnella, J. S., Veloski, J. J., & Erdmann, J. B. (1996). Jefferson Medical College Longitudinal Study: A prototype for evaluation of changes. Education for Health, 9, 99-113.

Hojat, M.,Veloski, J. J.,& Borenstein, B. D. (1986). Components of clinical competence ratings of physicians: An empirical approach. Educational and Psychological Measurement, 46, 761-769.

Huckle, P., & McGuffin, P. (1991). Familial factors in going to medical school. Medical Education, 25(1), 13-15.

Janeway R. Medical Education and Societal Expectations: Conflicts at the Clinical Interface. J. Med. Educ. 61(1986): 104-111.

Kassebaum DG, Szenas PL (1993). Rural sources of medical students and graduates choice of rural practice. Academic Medicine 68;3:232-6.

Kassebaum, DG, Szenas, PL, & Schuchert, MK. (1996). Determinants of the generalist career intentions of 1995 graduating medical students. Academic Medicine, 71(2), 198-209.

Kassler WJ Wartman SA Sillman RA.Why students choose primary careers Academic Medicine 66(1991):41-43

Kreiter, C. D., Stansfield, B., James, P. A., & Solow, C. (2003). A model for diversity in admissions: a reviewof issues and methods and an experimental approach. Teaching and Learning in Medicine, 15(2), 116-122.

Lieu TA, Schroeder SA, and Altman DF, Specialty Choices at One Medical School: Recent Trends and Analysis, Predictive Factors. Acad. Med. 64(1989):622-629.

Madison DL, Combs CD (1981) Location Patterns of Recent Physician Settlers in Rural America" Journal of Community Health 6:4 267-274 Summer 1981

Madison, Donald L Medical School Admission and Generalist Physicians A Study of the Class of 1985,  Academic Medicine Vol 69 Number 10 October 1994 p 825 - 831

Martini JM, Veloski JJ, Barzansky B. Medical school and student characteristics that influence choosing a generalist career.JAMA . 1994;272:661 -8          Lower mcat   

McGaghie WC Assessing Readiness for Medical Education Evolution of the MCAT  JAMA September 4, 2002 Vol 288 No 9

McGaghie, W. C. (1990). Qualitative variables in medical school admission. Academic Medicine, 65, 145-149.

Medical Marketing Service I. AMA Physician MasterFile: Medical Marketing Service, Inc; 2000 and 2004, access to 2004 data via Robert Graham Center for collaborative work

Mellinkoff SM  On the Imbalance between Medical Specialists and Generalists. Pharos 54 (1991):30.

Mitchell, K. J. (1990).Traditional predictors of performance in medical school. Academic Medicine, 65, 149-158.

Montague,W., & Odds, F. C. (1990). Academic selection criteria and subsequent performance. Medical Education, 24, 151-157.

Newhouse JP, Williams AP, Bennett BW, Schwartz WB Where have all the doctors gone?  JAMA Vol 247 No 17 May 7, 1982 http://jama.ama-assn.org/cgi/content/abstract/247/17/2392   Nowacek, G., & Sachs, L. (1990). Demographic variables in medical school admission. Academic Medicine, 65, 140-144.

Petersdorf RG. Three Easy Pieces. Acad. Med. 65(1990):73-77.

Peterson BR Admissions & Recruitment Policies of Underrepresented

Student Populations at Texas A&M University: A Bourdieudian Analysis

http://www.ashe.ws/paperdepot/2004%20d05%20petersen%20institutional%20recruitment%20and%20admission%20policies.pdf

Politzer RM, Harris DL Gaston MH and Mullan F. Primary Care Physician Supply and the Medically Underserved. JAMA 266(1991):104-109.

Rabinowitz HK The Role of the Medical School in Rural Graduate Medical Education: Pipeline or Control Valve?  The Journal of Rural Health Volume 16, No.3, Summer 2000

Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP, Critical factors for designing programs to increase the supply and retention of rural primary care physicians, JAMA 2001; 286: 1041-1048

Rabinowitz, H.K. "Estimating the Percentage of Primary Care Rural Physicians Produced by Regular and Special Admissions Policies." Journal of Medical Education. 61:598-600, July 1986.

Rabinowitz, HK, Diamond, JJ, Hojat, M, & Hazelwood, C. (1999). Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania. Journal of Rural Health  15(2), 212-218.

Rabinowitz, HR. (1998, August). Evaluation of a selective medical school admissions policy to increase the number of family physicians in rural and underserved areas. The New England Journal of Medicine, 480-486.

Rasmussen CJ  Addressing the Continued Socioeconomic Gap in Higher Education: Insights from Low-Income Students In Australian Universities http://www.ashe.ws/paperdepot/2002Rasmussen-Addrs.pdf

Relman AS. Shattuck Lecture – The Health Care Industry: Where Is It Taking Us? NEJM 325(1991):854-859.

Roberts A, Foster R, Dennis M, Davis L, Wells J, Bodemuller MF, Bailey C. An approach to training and retaining primary care physicians in rural Appalachia. Academic Medicine 1993;68:122-5.

Rogers DE. American Medicine: Challenges for the 1980s. Cambridge, Massachusetts: Ballinger Publishing Company, 1978.

Rogers DE. Medicine and the Social Contract. Pharos 54(1991):17-19.

Rosenblatt, RA, Whitcomb, ME, Cullen, TJ, Lishner, DM, & Hart, LG. (1992). Which medical schools produce rural physicians? JAMA, 268(12), 1559-1565.

Rosenblatt,RA; Schneeweiss,R; Hart,LG; Casey,S; Andrilla,CHA; and Chen,FM. “Family Medicine Training in Rural Areas,” JAMA, September 4, 2002; 288(9): 1063-64.

Rosenthal T Outcomes of Rural Training Tracks: A Review--Tom Rosenthal, M.D. The Journal of Rural Health Volume 16, No.3, Summer 2000

Rosenthal T Rural-based Graduate Medical Education--Tom Rosenthal, M.D. The Journal of Rural Health Volume 16, No.3, Summer 2000

Rosenthal TC (1997) Rural physicians, rural networks, and free market health care in the 1990s. Arch Fam Med, 1997 Jul-Aug

Rosenthal TC, Maudlin RK, Sitorius M, et al. (1992). Rural training tracks in four family practice residencies. Acad Med 67(10): 685-91.

Rosenthal, M. P., Marquette, P. A., & Diamond, J. J. (1996). Trends along the debt-income axis: Implications for medical students’selections of family practice careers. Academic Medicine, 71(6), 675-667.

Saver, BG, Bowman, R, Crittenden, RA, Maudlin, RK, & Hart, LG. (1998). Barriers to residency training of physicians in rural areas. Rural Health Research Center, University of Washington School of Medicine, Department of Family Medicine.

Schroeder SA Comments: Optimal Outcomes

Schroeder SA, Zones JS, Showstack JA, Academic Medicine as a Public Trust. JAMA 262(1989):803-812.

Searle, J.,&McHarg, J. (2003). Selection for medical school: just pick the right students and the rest is easy! Medical Education, 37, 458-463.

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  .

Snyder DP Edwards G Folsom C The Strategic Context of Education in America 2000 to 2020, http://www.davidpearcesnyder.com/new_page_3.htm

Staff of Postsecondary Education Opportunity. (2000a). College participation for students from low income families by state, 1992 to 1998. Postsecondary Education Opportunity, 97, 1-5.

Staff of Postsecondary Education Opportunity. (2000b). Higher educational opportunity by family income 1998. Postsecondary Education Opportunity, 94, 1-10.

Staff of Postsecondary Education Opportunity. (2001).Trends in college participation by family income 1970 to 1999. Postsecondary Education Opportunity, 106, 1-8.

Staff of Postsecondary Education Opportunity. (2003). A nation at risk, again. Postsecondary Education Opportunity, 131, 1-10.

Stageman J Summary Report--A Three-Four Program: A new Model for Rural Training --James Stageman, M.D. The Journal of Rural Health Volume 16, No.3, Summer 2000

Stageman JH, Bowman RC, Harrison JD An accelerated rural training program J Am Board Fam Pract 2003; 16: 124-30 Department of Family Medicine, University of Nebraska Medical Center, Omaha 68198-3075, USA

Supplying Physicians for Future Needs. In Report of the Steering Committee of the Task Force on Physician Supply, p. 17. Washington DC. Association of American Medical Colleges, 1990.

Supplying Physicians for Future Needs. In Report of the Steering Committee of the Task Force on Physician Supply, p.23. Washington DC: Association of American Medical Colleges, 1990.

Thorndike quoted in Chesney AM, Hale W, Thorpe ES Jr, Palmer CE. Evaluation of the Medical Aptitude Test. J Assoc Am Med Coll. 1936;11:15-32.).  From McGaghie

Veloski, J. J., Rabinowitz, H. K., Robeson, M. R., & Young, P. R. (1999). Patients don’t present with five choices: An alternative to multiple-choice tests in assessing physicians’ competence. Academic Medicine, 74, 539-546.

Veloski, J.J., Callahan, C.A., Xu, G., Hojat, M., & Nash, D.B. (2000). Prediction of Students' Performances on Licensing Examinations Using Age, Race, Sex, Undergraduate GPA, and MCAT Scores. Academic Medicine, 75, S28-S30.

Verby JE, Newell JP, Andresen SA and Swentko WM, Changing the Medical School Curriculum to Improve Patient Access to Primary Care. JAMA 26(1991):110-113.

Verby JE, Schaefer MT, Voeks RS The impact of a long term preceptorship on clinical confidence of senior medical students Minnesota Medicine May 1982 p 297- 300

Wheat, JR, Brandon, JE, Carter, LR, Leeper, JD, & Jackson, JR. (2003). Premedical Education: The Contribution of Small Local Colleges. Journal of Rural Health 19(2), 181-189.

Women, Minorities, and Persons with Disabilities in Science and Engineering at http://www.nsf.gov/sbe/srs/nsf99338/frames.htm

Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. Am J Public Health 1997 May;87(5):817-22.

Xu G, Hojat M, Brigham TP, Veloski JJ. Factors associated with changing levels of interest in primary care during medical school. Acad Med. 1999;74:1011 -5

Xu G, Rattner SL, Veloski JJ, Hojat M, Fields SK, Barzansky B. A national study of the factors influencing men and women physicians' choices of primary care specialties. Acad Med.1995; 70:398 -404.

Xu G; Veloski JJ; Barzansky B   Comparisons between older and usual-aged medical school graduates on the factors influencing their choices of primary care specialties. Acad Med, 1997 Nov; Vol. 72 (11), pp. 1003-7.

A more complete set of higher education references is at my web site at http://www.unmc.edu/Community/ruralmeded/understanding_higher_education.htm

Robert C. Bowman, M.D.,

UNMC Department of Family Medicine Director of Rural Health Education and Research

Chair of Society of Teachers of Family Medicine Group on Admissions

Chair of Society of Teachers of Family Medicine Group on Rural Health

Past Chair, Rural Medical Educators Group of the National Rural Health Association

983075 Nebraska Medical Center

Omaha, NE   68198‑3075

(402) 559‑8873 or fax at ‑8118

Email:   rbowman@unmc.edu

http://www.unmc.edu/Community/ruralmeded/

www.ruralmedicaleducation.org