Family Medicine: the Distributional Specialty

Robert C. Bowman, M.D.

Family medicine is the major contributor in all of the physician distribution categories. When comparing graduates of allopathic medical schools in the United States for the 1987 – 1999 graduates, family physicians supply the most physicians in each of the following distributional categories:

In addition the distribution of family medicine gets better and better with specific selections and training such that 78% of the rural physicians graduating from a school such as Duluth that places a top priority on rural careers and family medicine.

Family physician contributions of mental health, women’s health, children’s health, public health, and the community role of physicians also increase with the distance from major medical centers. Because family physicians have more encounters per day than other types of primary care physicians, the workforce reflected above is a conservative estimate. (Mold, Graham)

The simplest consideration regarding physician distribution is whether physicians escape training locations in urban areas where 98% of medical education and graduate medical education occur. Over 75% of physicians outside of family medicine remain in major medical centers. Only 30% of general internal medicine and general pediatrics physicians escape major medical center zip codes associated with medical schools or zip code locations with 75 or more total physicians Over 57% of family physicians escape major center zip codes. This makes it possible for family physicians to dominate distribution to urban underserved, smaller urban, and rural locations. Scope of practice appears to be a factor as medicine-pediatrics escapes at the 50% level, but medical-pediatric numbers and low and grow lower over time as physicians subspecialize and return to major centers.

What medical students understand better than medical education leaders is that family medicine is an end point, not a transition. About 98% remain in family medicine and 90% remain in office based primary care. Longer term studies of physician workforce reveal some major advantages of family medicine involving retention: retention in specialty, retention in office based primary care, retention in the same state as their medical school, and retention in practices outside of major medical centers. (Family Medicine Contributes Much More)

Family physicians not choosing major medical centers or urban locations return to the same type of county for practice. They also concentrate away from major medical centers over time, especially when adjusting for military careers, academic careers, and birth origins associated with the least distribution. (Bowman Birth origins) Rural physicians over time transition to more rural locations. (Ricketts, Shepps Center presentation) Without significant prior life experiences in rural areas sometime between birth and first practice location, without significant maturity as in older age at medical school graduation, and without choice of family medicine, physicians will continue to concentrate in major medical center locations and urban areas. 

Family medicine is a career that requires significant trust in government, in training, and in personal abilities. Anything less than consistently improving health policy for underserved and rural patients has failed to improve choice of family medicine or physician distribution. During the two periods with supportive policy choice (class years of 1965 – 1978 and 1990 – 1998), both choice and distribution have greatly improved. (distributional policy) Anything less than the most intense medical education fails to prepare medical students for the most complex medical careers in rural and underserved areas. Distributional physicians are mature learners with significant life experiences who know what they want from medical training. Those who distribute can manage themselves and others around them. Distribution is not about income. The physicians choosing distributional careers have left income far behind. Distribution is about support of the kind of practice that family physicians, primary care physicians, rural physicians, and physicians in underserved areas desire to provide for their patients. Failure of distribution is about failure of public education, failures in admissions, and failure of government support of medical training and distributional practice.

Given current health policy regarding primary care, it is unlikely that other forms of primary care with more narrow scope can survive without the significant and multiple forms of government support associated with major medical center location. Those outside of major medical centers with lower reimbursement, higher overhead, less economies of scale, and other disadvantages survive by dedication and significant community support. Given changing economics and government budgets, declining distributional health policy, declines in education in rural and underserved areas, decreasing admissions of the dedicated humble origin types of medical students, and declining choice of family medicine; the nation faces serious and growing problems regarding distribution.

Physician Workforce Studies

The most effective rural medical education involves efforts at the earliest levels, those that orient and prepare and admit the students most likely to return to rural locations. The students most likely to choose rural careers by the probability of a rural location in 2005 are listed below for those choosing family medicine or not and also the multiplier effect or times factor. Increasing admissions of the student types that have less than 11% choice of rural locations will not improve rural workforce, especially in medical schools with low choice of family medicine.  

 

Rural Career Choices

% of Physicians

Multiplier

Rural Choices for 203,000 most recent  US MD Grads of 1987 – 1999

Without Family Medicine

With Family Medicine

Total in Category

Rural Physicians

Provided

Factor From Past 2 Columns

Born in lower income rural area

19.7%

46%

8.8%

20.0%

2.27

Born in a rural area

18.7%

44.7%

12%

30%

2.50

Born in a lower income urban area

11.9%

25.9%

11.7%

14.8%

1.26

Born urban and less than 1 million

11.1%

25.4%

22.2%

26.6%

1.20

Born in an urban area over 1 million

7.4%

19.6%

49.3%

38.8%

0.79

Foreign Born

5.5%

12.8%

14.4%

8.0%

0.56

Older and born in a rural area

20.4%

43.3%

2.8%

6.6%

2.36

Older and born in an urban area

10.4%

24.1%

19.9%

22.3%

1.12

Born instate in a rural area

22.2%

49.4%

6.2%

16.1%

2.60

Born out of state in a rural area

14.6%

35.9%

5.0%

8.2%

1.64

Born instate in an urban area

8.2%

20.4%

34.8%

30.7%

0.88

Born out of state in an urban area

7.8%

21.1%

55.5%

46.4%

0.84

See also Multiplier Impacts Involving Birth Origins, Age, Choice of Family Medicine

Admissions of students who were born in lower income rural areas in the same state as their medical school at a medical school is the best way to increase the rural physician numbers in a state. The medical schools that admit the most older, instate, rural born, and lower income students also have the greatest choice of family medicine. Admissions of these different students also means different Medical College Admission Test scores.

Increasing foreign born, out of state, or higher income urban student admissions only dilutes rural workforce contributions, especially when the school or state or nation has low choice of family medicine. All of the medical schools with the highest concentrations of these students have highest Medical College Admission Test scores and the lowest choice of family medicine, making distribution even more difficult.

 

Ranking students for interviews or admissions by MCAT scores ends up ranking the distributional students lowest and the nondistributional students highest. Setting a threshold of MCAT scores and then admitting based on the qualities most desired in a physician results in admissions of students much more like the populations in most need of service.

 

FP Grads 1997 to 2003 by RUCA code (Hart)

Urban /Urban Focused

Large Rural

Medium Rural

Isolated Rural

US population 1998

77.6%

9.3%

6.9%

6.1%

All FP Grads %

78.9%

9.1%

8.2%

3.8%

Accelerated FP (n=150)

50%

16.5%

23.7%

9.4%

Internal Medicine

89.6%

5%

2.8%

1.2%

See also Facilitating Physician Distribution with family medicine choice

Urban focused codes of 4.1, 5.1, 6.1, 7.1, 8.1, 10.1 are considered urban focused where 30 % commute and are included in Urban.  Accelerated family medicine residency graduates had 3 years medical school and 3 years FP residency and choose rural locations or urban poverty locations at levels of over 80% with an even higher 88% in the 10 public school programs. Internal medicine rural choices are 11% in rural areas when considering only the internal medicine physicians who have self-designated the office-based primary practice activity.

Data from 1987-2000 Allo Grads Ranked by Highest % Rural for Each Birth Origin Group Numbers from this Group % of all by Birth Origin Choosing Rural Location Usual Rural Location of All Students in this Birth Group Multiplier Effect of Specialty Choice All in Specialty from 1987-2000 Graduates  All Rural Doctors in this Specialty Contribution of this Birth Origin Group to the Rural Segment
FP Born Isolated Rural 344 48.9% 26.8% 1.8 27577 6812 - 24.7% 5.0%
FP Born Medium Rural 756 46.4% 24.5% 1.9 27577 6812- 24.7% 11.1%
FP Born Large Rural 1027 42.1% 22.4% 1.8 27577 6812 - 24.7% 15.1%
General  Surgery Born Isolated Rural 43 32.6% 26.8% 1.2 10993 1216 - 11.1% 3.5%
Medicine Pediatrics Born Large Rural 46 26.4% 22.4% 1.2 2214 292 - 13.2% 15.8%
General Surgery Born Large Rural 156 24.8% 22.4% 1.2 10993 1216 - 11.1% 12.8%
General Surgery Born Medium Rural 83 24.5% 24.5% 1 10993 1216 - 11.1% 6.8%
Ob-Gyn Born Medium Rural 112 24.0% 24.5% 1 14321 1536 - 10.7% 7.3%
Family Medicine Foreign Born (US allo) 57 23.6% 5.3% 4.5 10993 6812 - 24.7% 0.8%
Urology Large Rural Born 37 23.1% 22.4% 1 3206 287 - 9.0% 12.9%
Pediatrics Isolated Rural Born 43 22.4% 26.8% .8 20540 1671 - 8.1% 2.6%
Ophthalmology Medium Rural Born 33 22.3% 24.5% .9 5822 531 - 9.1% 6.2%
Family Medicine Born Urban 4180 21.7% 9.5% 2.3 27577 6812 - 24.7% 61.4%

Each group had to have 20 to qualify. FP distributes well, even better in other tables, and has an impressive multiplier effect that enhances the distribution of physicians choosing rural and underserved locations. Other specialties have concentration impact that greatly reduces their potential location to the most urban areas.   Distribution of Physicians

Without family medicine, the best distributions of urban born students are about 7% to rural areas. With family medicine even the urban born have 17% choosing rural.

 

Family Physician Graduates of 1997 - 2003 Nationwide  by Ethnicity and Gender rural by RUCA rural by nonmetro chc zip code Poverty Level of Zip over 20% Poverty over 18% military zip core metro county over 1 million less metro county < 1 million Residency Location to Practice < 60miles Residency Location to practice > 500 mi
white female 23.7% 21.4% 17.1% 23.7% 27.7% 4.0% 43.3% 35.3% 54.9% 26.5%
white male 28.3% 27.6% 13.7% 20.9% 24.7% 8.4% 33.8% 38.6% 47.7% 29.6%
black female 10.0% 9.3% 14.0% 30.3% 36.0% 2.8% 61.1% 29.6% 60.7% 26.1%
black male 11.7% 9.4% 16.9% 32.5% 38.6% 7.1% 57.8% 32.8% 57.5% 28.2%
mex am female 9.3% 6.2% 31.8% 46.4% 49.6% 2.5% 64.9% 28.9% 65.5% 23.3%
mex am male 14.6% 12.6% 27.6% 37.3% 40.8% 3.7% 59.2% 28.2% 59.3% 21.6%
asian female 7.7% 7.3% 20.0% 27.7% 31.4% 2.6% 69.8% 22.9% 58.5% 29.9%
asian male 7.6% 7.5% 17.9% 25.4% 28.8% 6.8% 70.6% 21.8% 54.4% 31.6%
puerto rican female     7.1% 43.4% 48.0% 6.8% 62.5% 25.0% 67.4% 26.1%
puerto rican male     5.9% 51.0% 53.1% 5.7% 28.6% 52.4% 60.0% 31.4%
other hisp female 13.2% 12.2% 21.1% 29.3% 30.1% 0.0% 64.9% 23.0% 57.4% 23.5%
other hisp male 9.2% 11.5% 18.4% 33.0% 34.0% 2.8% 59.4% 29.2% 47.2% 37.1%
native female 46.7% 40.7% 18.5% 44.8% 48.3% 0.0% 33.3% 25.9% 42.9% 17.9%
native male 36.4% 31.4% 30.2% 47.6% 50.0% 4.5% 31.4% 37.1% 45.7% 28.6%
other female 17.6% 16.3% 19.9% 30.5% 34.6% 3.6% 51.7% 32.0% 58.4% 25.7%
other male 25.3% 26.0% 18.2% 28.8% 32.6% 6.5% 35.4% 38.6% 51.6% 28.2%
Total 22.4% 21.3% 16.4% 24.9% 28.8% 5.9% 43.9% 34.8% 52.9% 28.0%

Males are more likely to be married and not surprisingly are more likely to be involved in military FP programs. Black males and rural males are lost to poverty and rural locations in this process.

Asian FPs are the most likely to live in counties over 1 million after graduation while white males and natives share the lowest core urban distribution in the low 30% level.

Family physicians are more likely to be retained near their residency location and within the state of their medical school.

 

 

Comparing Physician Distribution and the MCAT

Specific programs can address this. Rural Background

By size of town

 

 

 

 

 

 

 

 

 

Over time since 1900

Predictions based on adequacy of primary care from COGME and Colwill

 

Changing Primary Care Contributions 1970 - 2015  The nation has not exceeded the level required to improve concentrations. However the real bad news is that primary care, rural, and underserved contributions will be even lower from all other forms of primary care. Just as bad is that the nation is admitting fewer medical students who will distribute, Changes in Admissions in Allopathic Medical Schools, and these are also the most likely to choose family medicine.

By state, ABFP map

By community size, ABFP graph

Family Medicine Central: National Comparisons of Workforce

Physician Workforce Studies

www.ruralmedicaleduction.org

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