Patterns of Migration for FPs
Robert C. Bowman, M.D.

Family physicians provide the largest component of physicians to every location outside of major medical centers including rural careers, urban underserved, shortage areas, and Community Health Centers. This is possible because FPs accumulate over time away from major medical centers locations where 75% of physicians congregate. FPs prefer locations similar to their birth origins which tend to be different than other physicians and their training and scope focuses away from major medical centers. Considering that all professionals spend the college to residency graduation years almost entirely in the most urban areas of the nation, any movement away from major medical centers is quite remarkable. The rural and underserved distributions of other types of physicians are limited to rural birth and lower income origins. Family medicine is the only specialty that facilitates distribution beyond the limitations of birth origins to rural and underserved areas. (facilitating)

Pattern 1 Economics - Population growth patterns, physician recruitment packages, and government investments in health care shape family medicine workforce. Population growth involves the income and economics that shape support for physicians. Top growth states attract significant recent graduates. States such as North Carolina, Iowa, and Wisconsin have also invested significant resources to recruit FPs from other states and to retain their home grown FPs. Iowa has the top concentration of FPs in the nation and NC and IA have the most consistent gains in FPs from birth to medical school to residency to practice. States outside of the high growth and recruitment states tend to have declines in practice location numbers compared to those who did medical school or residency in the state. (FP workforce)

The supportive data also includes class year comparisons over time. The nation greatly increased family physician and primary care numbers and distributed them at maximal levels for the medical school classes of 1965 1978 and 1992 1997 with massive increases in reimbursements such as Medicare and Medicaid involving physician fees and support of those that hire FPs. The economic impact of such funding together with investments in education for the 1960s and 1970s also greatly influenced rural economics and the distribution of professionals, income, and population. (managed)

It is essential to discern the difference between physicians that need support and those that pursue opportunities. Opportunity physicians are more likely to be from out of state and are more likely to leave a state. Opportunity is not always income opportunity. Researchers and the top level subspecialists are the least likely to be retained. FPs follow different patterns. They fill in the gaps in care and health access. The concentration of FPs increases with decreasing density of income and physicians in urban and rural areas and decreasing density of population. Support is essential since FPs are the most likely to serve rural areas, more diverse populations, and those with less education and income. (mold, graham) FPs follow support for the kind of practice that they desire for their patients, those who are often most likely them.

Pattern 2 Proximity Within 60 Miles of Residency - These studies have been individual residency studies. (Dorner, Jacksonville) National studies do support location within 60 miles. The community based residencies and those in public medical schools tend to combine instate born residents with local training for high retention. Graduating residents may also follow connections made during residency. These family medicine tendencies can be used to direct FPs where they are needed or desired. Governments can use this to improve health access by residency placement. Hospital systems are well aware of the significant economic impact of FPs with estimates from hundreds of thousands of dollars to over a million a year. Even small programs that work to retain FPs can harvest hundreds of millions in economic impact over the practice life spans of a few FPs added each year. Investments in local child development, education, and the patients of family physicians may be one of the best ways to improve economics in rural or underserved areas.

Pattern 3 Same State Retention - FPs are more likely to be born in the same state as their medical school, a key factor in retention instate. Those who are instate, older, lower income, and born in rural areas are all more likely to become FPs and the addition of each of these characteristics, including choice of family medicine, adds to retention instate. The retention is greatest in the states and medical schools with the greatest choice of family medicine.

Pattern 4 State Policy Impact - Some states have the education, medical education, and health policies that are more supportive of lower income, middle income, rural born, and older students that result in more FPs. FPs also tend to accumulate in supportive states over time. Other states have a higher cost of living and concentrate physicians in major medical centers to a greater degree. These may make it difficult for family medicine to do well since overhead costs for the specialty are high, there are fewer middle income patients in these areas, health policy supports children and the poor at lower levels, and FPs find it difficult to practice the full range of family medicine. (Bright Future)

Pattern 5 Toward Birth and Away from Major Medical Centers - FPs tend to return to locations similar to their origins. Over 57% locate outside of major medical centers. Those not choosing urban or major medical center locations are found in practice in greatest numbers in the same type of urban influence code county as their birth county. Rural born graduates are not as likely to be retained within 60 miles, but are more likely to be retained instate and tend to return to the same type of county as their birth when choosing family medicine. Other specialties are limited to urban and major medical center locations and accumulate there over time. Studies demonstrate that rural physicians move even more rural over time. (Ricketts, NRHA conference) Most rural physicians are FPs or were born in rural locations.
 

Patterns of Rural Workforce - graphics on Pattern 1

Physician Workforce Studies

www.ruralmedicaleducation.org

 

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