Rural Workforce Past, Present, Future

 

Rural Health Workforce Issues

 

Changes in birth to admission, admission, training, career choice, and policy (neglect) will result in grossly insufficient physician and non-physician workforce for rural areas. The US has violated Basic Health Access Principles by moving steadily more exclusive (highest income, most urban) in the children who do well enough for medical school, more exclusive in the medical students admitted, most exclusive entering the workforce from other nations, fewer family physician graduates that triple rural distribution above origins (the most important rural workforce since FM turns any origin or training into rural workforce), and policy that sends 90% of the health funding related to physicians to just 4% of the land area.

 

Steady changes not only reflect problems for basic health access, the changes reflect deteriorations of US education in lower and middle income areas, rapidly risking problems with rural and lower income males, and all segments of the population left behind. 

 

Robert C. Bowman, M.D.   rcbowman@atsu.edu

 

Physician databases such as the American Medical Association Masterfile can be used to determine the career and location decisions of physicians. When combined with census data and data from medical associations, this database becomes a powerful analytic tool. Birth origins data can be used to track physicians from birth to training to practice locations.

 

A confirmation of the value of Birth Origins illustrates the relationship of admission to distribution for    Family Practice      Rural Practice    and  Underserved Practice   In each case, as the probability of admission increases for a type of physician, the probability of most needed health access decreases. The rate of family practice, rural, or underserved careers does not change. What happens is the more exclusive higher income and more urban children get more changes for admission to more schools and have backgrounds associated with top probability of admission. As they choose exclusive schools and exclusive careers, they end up in the most exclusive locations in 4% of the land area. They are following a design for birth to admission, admission, training, and policy that leaves 65% of the population in 4% of the land area behind.

 

 

Summary

 

  1. Rural born medical students are more likely to be found in rural practice, primary care, family medicine, and rural underserved locations. The relationship is linear however, not dichotomous. Those with most concentrated origins have the least rural distribution less than half of the national average, middle population density or origins are associated with average rural distribution and more rural origins have higher probability of rural distribution as physicians. Origins, training, and the career choice of family medicine facilitate rural location along with policy influences.  Public schools and osteopathic medical students have the greatest levels of rural careers and underserved distribution.
  2. About half of the medical students who were most interested in the smallest rural practices attended high school in rural areas and half attended high school in urban areas. Rural interested students were more likely to be older, married, and white. They were more likely to choose rotations away from major medical centers and they did volunteer work at twice the level of other students. About 68% chose family medicine, and 60% were interest in working with socioeconomically deprived populations in practice, the highest of any medical student group. Stability, service orientation, and maturity characterize those most interested in rural practice. Studies of rural physicians in the smallest locations reflect these characteristics of maturity, origins, service-orientation, and family medicine career.
  3. The physicians found in rural locations were more likely to be family physicians, rural born, male, Native, white, older, lower income birth county in origin, and attended osteopathic schools, public medical schools, or distributional allopathic schools. Family physicians are a consistent source of rural primary care for decades. Family physicians and distributional type schools are the most efficient sources of physicians for rural locations that are also underserved. These are schools with significantly different missions, admissions, and training emphasis.
  4. Rural born students who attend typical allopathic private schools and elite types of allopathic medical schools have lower levels of rural distribution. Rural born students from areas with greater population density and higher levels of income and organization have lower levels of rural distribution.
  5. Rural born medical students choosing family medicine have 43% current rural location. Graduates of family medicine residency programs with rural training emphasis exceed this maximum indicator of birth origins influence, indicating the facilitation of training beyond origins contributions. Urban born family physicians have 20% rural location or twice the national rural workforce average of 10%. Rural born non-family physicians have 15 – 18% rural location, also exceeding the national average. Urban born physicians not in family medicine have 5 – 8% levels of rural distribution. Only family physicians and rural born physicians exceed the national average for rural distribution, indicating greater potential for maintaining or increasing rural physician workforce levels.
  6. About 74% of the US MD Grad rural physicians were born in urban areas. Urban born physicians are 88.5% of total physicians. About 26% of rural physicians had rural origins, a group of 11.5% of physicians. Family medicine provides 30% of all rural physicians, the largest share of physicians for various lower income or underserved areas, 51% of Community Health Center physicians, 61% of rural Community Health Center physicians, and over 60% for the most rural and frontier areas of the nation. No other type of primary care can demonstrate levels of rural physicians or practitioners beyond the levels of rural born students who begin final training. With increasing years after medical school graduation, family physicians remain in family medicine, remain in primary care, remain outside of major medical centers, and remain in rural and underserved locations. All other types of practitioners collapse back into urban areas, major medical centers, and specialty careers outside of primary care.  
  7. The percentage of rural born admissions at a medical school has an almost perfect 0.926 correlation with the percentage of graduates of a medical school found in rural practice in 1995. This does not mean that all of the rural born graduates make rural choices, but the medical schools that graduate rural physicians admit more of the types of students found in rural practice (rural born, older, lower income, middle income, lower scoring, not born in cities or counties with medical schools), they graduate more of the types of physicians found in rural practice at higher levels (family medicine, general surgery, office based physicians), and they share medical school location with states with greater levels of rural population and greater levels of demand for rural physicians. Changes in admission indicate that those least likely to distribute are replacing the student types most likely to distribute to family medicine, rural, and underserved careers.  
  8. Declines in rural born admissions have exceeded declines in rural born population significantly and consistently for decades. Current rural born student admissions are below 10% or half of the 20% level of the rural population. When all entering the US workforce are considered, rural origins are only 6% entering. Since 1940 the levels of admission have declined the most in the counties most distant and lowest in income level. Micropolitan rural areas with medical schools, major universities, or those with higher levels of professionals as in major corporations or research facilities have the highest levels of admission in the nation. A few counties in the Midwest share these higher levels of admission for reasons as yet unexplored but their efforts have been consistent for more than a decade and more than a few admissions a year. Larger rural counties and those with higher income levels compared to other rural counties have declined from 100% or the same percentage of admissions as compared to the percentage of the population to 70%. For medium rural counties in size, income, and organization the levels have declined from 80% to 50% levels compared to the population. For isolated counties and those adjacent to larger urban areas, the levels have declined from 70% to 30%. The larger rural counties have levels of admission that are similar to black females, Native Americans, and rural female students with about 1 medical student for each 300 US citizens or residents in the group who are of medical school age. The medium rural counties have levels of admission similar to black males and rural males or about 1 in 400 to 1 in 500. The lower income, isolated, and adjacent counties have levels of admission equivalent to Hispanic and Mexican American students or about 1 in 800 to 1 in 1200. Lowest quintile students in income or education and those with combination of low income, rural, and minority have the lowest levels of admission. This is a group with 20% of the population and only 2% of medical school admissions for a 10% probability or about 1 admission per 2000 students of medical school age. This group also includes inner city populations who also share the same low achievement scores, the same child development delays, the same low high school graduation rates, and the same low levels of college advancement. Males generally have more problems with admissions than females and males also are more likely to distribute to rural and underserved locations, making the gender changes part of an increasing problem for future rural and underserved workforce. In some states with fewer males admitted, females are the remaining rural born type of student and females have higher levels of rural distribution, an important exception to the increased male rural workforce factor. Physician distribution to populations in need will continue to be ineffective until child development, early education, and opportunity are realized in the most disadvantaged populations in the nation. State and federal budgets are likely to remain unbalanced until this inequity is reversed as well. 
  9. Medical schools with a rural mission have lower levels of decline in rural born admissions, although legal actions and medical school changes may have taken away this “benefit” in the past decade. Only a few special admission programs, a few special school efforts, and a few training programs remain.
  10. States share similar rates of decline in rural born admissions except for states that have 40 – 50% levels of rural population currently. This suggests that states that have recently transitioned to urban dominant states have made changes in education, higher education, economics, and distributions of resources such that rural born students have a more difficult time gaining admission.
  11. Medical schools with the highest MCAT scores have fewer admitted from rural areas but the rural born students that they admit also have lower levels of rural location. They also have lower choice of family medicine and higher choices of careers that require major medical center location.
  12. A very few medical schools manage to obtain rural, underserved, or family medicine distributions out of all of the various populations of students that are admitted. Duluth and Mercer graduates of across the wide range of geographic and socioeconomic origins have similar rural, underserved, and family medicine workforce outcomes. Duluth contributions have remained while Mercer’s are declining. The loss of family medicine at Mercer is the reason. Generally these were all schools that admitted students with a much wider range of origins, ages, and scores. This suggests that the distributional types of schools focused on the student more and their academics and parent influences less. The older graduates least likely to be found at exclusive schools were most likely to be found in schools that contribute to health access. And older age contributes to most needed health access.

 

The 293,978 physicians from the 1987 – 1999 class years of graduates from all medical school sources set the standards for distribution with 9.8% in rural locations, 3.0% in underserved urban zip codes, 2.7% in rural underserved locations, 29.7% in office based primary care, and 14.2% in family medicine or general practice. About 73% are found in major medical center locations. This is over 40% of the active physicians in the United States that have finished training and that have distributed to representative careers and locations. Standards allow studies to identify the types of students, schools, career choices, and training that contribute to rural careers or underserved distributions.

 

Key questions can be asked in medical education regarding rural born admissions and rural .

 

  1. Are rural born medical students more likely to be found in rural practice?    2 times in US and international studies
  2. What are the characteristics of the medical students who are most interested in rural practice? Any not most exclusive in origins or exclusive in schools, family practice, older age graduation, those not from the most concentrated origins, especially not those with origins involving associations with combinations of concentration of income, people, physicians, health resources
  3. What are the characteristics of physicians found in the most rural locations? Less concentrated in origins, older at graduation, family physicians  
  4. Do medical students who are younger at admission have the same distribution as those of normal or older age? Youngest are least, older for most rural 
  5. Do medical students choosing family medicine have greater levels of rural distribution than predicted from rural origins? Family medicine choice provides a tripling of rural practice location controlling for origins, age, and training. Controls are important since lower and middle population density origins and older age and more normal training are all associated with increased probability of family medicine. Origins, age, training, and family medicine combine for optimal rural location rates.
  6. What is the role of family medicine in physician distribution, especially when compared to other forms of primary care over the three or more decades of workforce provided by the physician or practitioner? Family practice can turn any origin or any type of training into rural workforce. Those departing family practice depart primary care, rural, and underserved workforce. Any other career choice fails to multiply distribution and can result in concentration away from rural locations. 
  7. Is the level of rural born admissions to a medical school a predictor of rural practice locations of the graduates? The percent of rural origin admissions has a 0.9 correlation to the % of medical school graduates found in rural locations, but this is the result of a number of factors working together as discussed with rural origins only one of these factors. 
  8. Do declines in rural born medical school admission exceed declines in rural born population? Substantially, and only 6% of physicians entering the US workforce are rural origin when all are considered, including the most exclusive origin international graduates
  9. Do medical schools with a rural mission have lower levels of declines in rural admission? Yes
  10. Are declines in rural born medical school admissions greater for states that have recently transitioned from rural to urban states, suggesting political reasons for decline? Yes, declines are also seen in counties that are farming or manufacturing dependent as well as counties of lower income or lower organization level 
  11. Do some types of medical schools fail to gain rural distribution out of rural origin students? The myth of rural origin or underserved origin graduates not going to rural or to underserved locations is allowed to persist and even to multiply. No sadder situation exists than scientists who fail in science understanding. Because the most exclusive schools admit the most exclusive even with rural origin, and admit the youngest, and train the most exclusively in top concentrations, and graduate the fewest family physicians, their rural origin graduate contributions are the lowest; however controlling for origins, age, training, and career choice, rural origin physicians are still twice as likely to be found in rural locations. Studies that are anecdotal or that fail to have proper controls for origins, ages, career choice, training, and policy, are fatally flawed. Top researchers and top medical education leaders that do understand logistic regression and odds ratios and have ridden these concepts to prestige and top levels of research funding apparently fail to choose the proper methods of study for rural workforce. Studies to determine the dichotomous dependent rural practice location variable or the "risk" of rural practice are the same as studies evaluating the independent variables that determine the risk of heart disease. Family practice, older graduates, rural origins (and other birth origins outside of concentrations), and health access training multiply odds ratios probability of rural location just as smoking, cholesterol, family history, and hypertension multiply the risk of heart disease events. In addition, the rural workforce factors include complete populations of over 300,000 United States physicians for the best possible studies.
  12. Do some types of medical schools gain rural distribution above levels of rural admissions? Yes health access schools including some osteopathic and some allopathic public schools   West Virginia Osteopathic graduates 40% to rural locations and 22% to rural underserved locations. This is quite remarkable since the West Virginia workforce has only 16% of physicians in rural underserved locations. Duluth graduates contribute 64 times the rural primary care of the exclusive top 20 allopathic private research schools ranked by MCAT scores. Those that understand how to optimize health access by using all of the odds ratios in favor of rural workforce instead of an increasing focus on the most exclusive origins, training, career choices, and health policies with the consequence of declining levels of rural workforce, underserved workforce, and primary care.

 

A database coded with birth origins, shaped by workforce literature and association data, integrated with census data, and categorized by city, state, and county origins; medical school; type of medical school; career type; class year of graduation; age of graduates; and practice locations can help answer these questions.

 

 

Methods

 

The birth origins Masterfile was used as the database. About 97% of US MD Grads can be linked to a birth origin geographic location. Even international graduates can be linked to their country of origin or city of origin for an origin coding. Consistent relationships are found between origins, career choices, and US practice locations.

 

Birth origins, medical school training, and practice zip codes were compiled by categories such as birth income, birth geographic origin, instate birth compared to medical school, birth in a city or county with a medical school, younger or older age at medical school graduation, medical school, medical school type, medical school state and county location, career choice, and practice outcomes such as rural location, major medical center location, and underserved zip code. Physicians were also coded by the income level of their birth county. The counties were also divided into 4 quartiles of 50 million population each for per capita income level and physicians were assigned a birth county income quartile for 1969 census data, the approximate tim eof birth of the 1987 - 2000 graduates.

 

Medical schools were divided by state rural composition in 1992. The schools in states with 0 – 10%, 10 – 20%, 20 – 30%, 30 – 40%, 40 – 50%, and greater than 50% were compared. In addition schools with a rural mission, as defined by Rosenblatt,6 were compiled in an additional group for comparison. The rural born admissions for each group were compared over recent decades. Percentages of rural physicians, underserved physicians, family physicians, and office primary care physicians were generated for each medical school. Medical schools were also divided by types of admissions. These included Puerto Rican schools, Historically Black schools, Duluth and Mercer (top distribution), West Coast Distributional schools (UCLA, UC Davis, UC Irvine, U of Washington), the military school, early admissions schools, and medical schools by 6 different MCAT levels determined from matriculant averages for 2000 – 2003. This ranking of schools excludes schools with special admission, mission or training. What remains is a ranking by more exclusive selections and more exclusive training, also as verified by origins and by career and location choices. Again controls for origins, ages, career choices, and training type are important to consider. The MCAT divisions gives training rated more exclusive or more normal. The allopathic private school findings also confirm the most exclusive origins, training, career choices, and practice location choices. Removal of the allopathic private schools with broader origins, career choices, and practice locations (Creighton, Loma Linda, Oral Roberts, and Historically Black schools) only narrows the origins and practice locations.

 

Physician birth origins were also compiled using 1993 Urban Influence Codes at the county level. Counties in this coding system were kept constant over the decades. The percentage of medical students from each type of county was compared to the percentage of population in the United States in each type of county. The works of Calvin Beale, Thomas Ricketts, Gary Hart, and others are acknowledged. The same United States Department of Agriculture sites were used to divide counties into agricultural, manufacturing, and other types of counties.

 

The allopathic graduates of medical schools in the United States (US MD Grads) were considered in most studies. Studies dating back decades for birth origins required the use of the entire Masterfile. More detailed studies were available for the 1987 – 1999 graduates as of 2005 careers and locations. This is the group that will be remaining in the next decades with additional graduates added to this basic group.

 

Additional studies are listed in this report. The Association of American Medical Colleges identified approximately 300 senior medical students as interested in rural practices of less than 2500 people. This cohort was compared to 13,000 non-rural interested seniors who responded to the 1995 Graduation Questionnaire.

 

 

Results

 

Setting the Standards for Comparison

 

The most complex challenges involving physician distribution involve separations of the various influences. Even before birth, parent factors influence career choice and distribution. Birth origins are a reflection of a starting point. Birth data allows the contributions of origins to be considered for location and career choice. US MD Grads have about 95% birth origins, osteopathic physicians have 75%. International physicians have limited birth origins data and the data available suggests predominantly urban origins. When rural origins are present, the international physicians were largely born in the United States.

 

 

Rural Origins and Rural Location

 

Rural Location Factors

 

Logistic regression can help screen for the factors most related to rural location.

 

Logistic Regression Equations Characteristics of Rural Physicians Using Recent US Medical School Graduates 1987 - 1998 in 2005 Careers and Locations

 

B

Std. Error

Wald

df

Sig.

Exp(B)

95% Confidence Interval for Exp(B)

 

 

 

 

 

 

 

Lower Bound

Upper Bound

Intercept

0.744

0.027

784

1

0.0000

 

 

 

Family Practice

1.032

.016

3996

1

.00000

2.806

2.718

2.898

Rural Birth (RUCA)

.963

.018

2765

1

.00000

2.621

2.528

2.717

Age over 27 MS Grad

.292

.015

390

1

.00000

1.339

1.301

1.378

Allopathic Private School

-.506

.018

797

1

.00000

.603

.582

.625

Reduced Contributions for Exclusive Training

 

 

 

 

 

 

 

 

Enhanced Contributions for Origins Outside, Family Practice, Older Age

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intercept

3.150

.037

7251

1

.00000

 

 

 

Allopathic Public US

.275

.015

344

1

.00000

1.317

1.379

1.356

Foreign Born US school

-0.765

0.027

779

1

.00000

.465

.441

.491

Normal Age 26-29

-.298

.015

393

1

.00000

.742

.720

.764

Hospital Based Specialty

-.360

.027

183

1

.00000

.697

.662

.735

Reduced contributions for Specialists, Normal Age, Exclusive Most Urban or Highest Income Origins

 

 

 

 

 

 

 

 

Enhanced contributions for Public Schools

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intercept

4.331

.060

5222

1

 

 

 

 

Birth Top Quartile Income County

-.199

.020

97

1

.00000

.819

.787

.852

Birth Med School County/City

-.603

.016

1472

1

.00000

.547

.530

.564

Younger Than 26

-0.578

.037

249

1

.00000

.561

.522

.603

Top 20 MCAT School

-.657

.021

948

1

.00000

.518

.497

.541

Subspecialty

-.710

.045

255

1

.00000

.492

.451

.537

Each of the factors reduces rural distribution resulting in 3% rural.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intercept

-.049

.025

3.749

1

.053

 

 

 

Not Born MS County

.316

.018

305

1

.00000

1.371

1.324

1.421

Age 33 or over at MS Graduation

.380

.020

361

1

.00000

1.462

1.406

1.520

Lowest 30 US MD by MCAT

.473

.015

994

1

.00000

1.605

1.559

1.653

Rural Born (RUCA)

.746

.022

1143

1

.00000

2.108

2.019

2.202

Family Practice

1.011

.016

3792

1

.00000

2.749

2.662

2.839

 

Family physicians are three times as likely to be found in rural locations, rural birth contributes at 2 times, and 30 – 60% increases are found for birth outside of a county with a medical school, older age, and graduates of lower ranking MCAT schools.

 

The themes of outside origins resulted in most needed health access, family practice choice multiplying health access, and less exclusive and more normal related to health access are all supported.

 

Changes in Admission - Social Organization Changes, Economic Changes, Political Changes

 

Declining Rural Admissions By Urban Influence Coding   Birth origins in US physicians can be tracked to birth county and counties were coded using Urban Influence Coding (1993 Parker and Ghelfi). The percentage of the US physicians admitted from each county type was compared to the percentage of the US population in the county type for each time period 1940 to 2005. The most urban and most organized counties remained with admission ratios over 100%. The Urban Influence 2 county type maintained 100% or a 1 to 1 admissions ratio of medical students to population. The Urban Influence 7 counties separated from metro influences (many micropolitan) had the highest rural rates of admission and declined the least to 80%. Counties adjacent to metro counties but still with population more organized lost down to 50% or half as many admitted relative to population. Rural origins have a consistent 50% and declining probability of admission to medical school. The least organized counties with population spread throughout the county or counties adjacent to larger metro areas (compromised by adjacency) had the lowest admissions at 25%. Some caution is needed in the coding as some of the medical students may have listed the major metro city nearby as their birth origin which would result in fewer admitted from adjacent counties. The data on admissions changes is consistent with coding by race, ethnicity, and income levels. The foreign born medical students admitted to US medical schools were compared to foreign born population census figures. Over half are Asian. Asian medical students are about 22% of US medical students and Asian populations are about 4% for over 5 to 1. 

 

Social Organization Outline with Race and Ethnicity Changes   More detailed explanations regarding those inside of concentrations with higher ratios of admission and increasing probability of admission over time and those outside of concentrations (lower and middle income, first generation to college, lower and middle population density)

 

 

Declining Rural Admissions By Farming and Manufacturing Dependent   The rural origin counties were coded by economic factors and compared over time. Separations are seen with fewer admitted in the 1990s. These are numbers, not rates, so declining rural population does represent some of this change, but the abrupt changes since the 1990s suggest much more than population decline involved likely economics, education, and other distributions.

 

 

Decling Rural Admissions For States Switching From Rural to Urban Dominant with some Preservation by Rural Mission   States moving from majority rural to majority urban populations had the greatest decline in rural born admission in the past 30 years. Lesser declines were seen for states dominant rural or dominant urban. Medical schools with a mission for rural health had a lesser rate of decline compared to any group.

 

 

 

Older Age Graduates Demonstrate Rural Health Access Principles

 

Rural Interested Senior Medical Students

 

Basic Proofs Regarding Admission and Distribution

 

Birth Origins Confirmation Graphics    Family Practice      Rural Practice      Underserved Practice  

 

 

Basic Health Access Tables

 

 

www.basichealthaccess.org

 

 

www.physicianworkforcestudies.org

 

 

www.ruralmedicaleducation.org

 

Medical Marketing Service I. AMA Physician MasterFile Available at www.mmslists.com Accessed July, 2005. Wood Dale, Illinois 2005.

Bowman RC, Schuchert M. Rural Interested Senior Medical Students. AAMC Graduation Questionnaire. Washington DC: Data from the 1995 Association of American Medical Colleges Graduation Questionnaire; 1998.

Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? Jama. Sep 23-30 1992;268(12):1559-1565.

Ghelfi L, Parker T. A county-level measure of urban influence. Available at www/ers/usda.gov/publicatons/rdp/archives. Accessed April, 2005. Rural Development Perspectives  1997;12(2):32-41.

Basco WT, Jr., Gilbert GE, Blue AV. Determining the consequences for rural applicants when additional consideration is discontinued in a medical school admission process. Acad Med. Oct 2002;77(10 Suppl):S20-S22.

Boulger JG. Family medicine education and rural health: a response to present and future needs. J Rural Health. Spring 1991;7(2):105-115.

Council on Graduate Medical Education. Physician distribution and health care challenges in rural and inner-city areas. Rockville, MD: Dept HHS, PHS, HRSA; 1998.

Crump R, Byrne M, Joshua M. The University of Louisville Medical School's comprehensive programs to increase its percentage of underrepresented-minority students. Acad Med. Apr 1999;74(4):315-317.

Crump WJ, Fricker RS, Moore AN, Coakley VL. An innovative method for preparation for rural practice: the high school rural scholars program. J Ky Med Assoc. Nov 2002;100(11):499-504.

Jokela R. Rural Health Opportunties Program.  http://webmedia.unmc.edu/rhen//2004RHOPbrochure.pdf.

Rabinowitz HK, Diamond JJ, Markham FW, Rabinowitz C. Long-term retention of graduates from a program to increase the supply of rural family physicians. Acad Med. Aug 2005;80(8):728-732.

Rourke J, Dewar D, Harris K, et al. Strategies to increase the enrollment of students of rural origin in medical school: recommendations from the Society of Rural Physicians of Canada. Cmaj. Jan 4 2005;172(1):62-65.

Stearns JA, Stearns MA, Glasser M, Londo RA. Illinois RMED: a comprehensive program to improve the supply of rural family physicians. Fam Med. Jan 2000;32(1):17-21.

Wheat JR, Brandon JE, Carter LR, Leeper JD, Jackson JR. Premedical education: The contribution of small local colleges. J Rural Health. Spring 2003;19(2):181-189.

Swanson AG. AAMC longitudinal study of 1960 medical school graduates: a 20-year effort in 28 schools, 1956-1976. J Med Educ. Dec 1986;61(12):991-992.

Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.

American Academy of Physician Assistants. Data and Statistics.  http://www.aapa.org/research/index.html. Accessed October 26, 2006, 2006.

Goolsby MJ. 2001-2002 AANP national nurse practitioner practice site survey. J Am Acad Nurse Pract. Nov 2003;15(11):482-484.

Goolsby MJ. 2004 AANP National Nurse Practitioner Sample Survey, part I: an overview. J Am Acad Nurse Pract. Sep 2005;17(9):337-341.

Bowman RC. Head to Head: Physician Assistants in 2000 Compared to Family Physicians 1987 - 1999 Class Years.  http://www.unmc.edu/Community/ruralmeded/head_to_head_PA.htm.

Larson E, Hart LG. Historical Trends in Physician Assistant Education and their Contribution to Primary Health Care for Rural and Underserved Populations in the U.S. .  http://www.ruralhealthresearch.org/projects/100002096/.

FACTS - Applicants, Matriculants, Graduates, and Residency Applicants 2005. http://www.aamc.org/data/facts/. Updated Last Updated Date. Accessed August 2008.

American Osteopathic Association. Fact Sheet 2006.  http://www.osteopathic.org/pdf/ost_factsheet.pdf

Association of American Medical Colleges. Minority Students in Medical Education: Facts and Figures XIII Available at  https://services.aamc.org/Publications/showfile.cfm?file=version53.pdf&prd_id=133&prv_id=154&pdf_id=53, Accessed July 2006. Washington DC 2005.

Association of American Medical Colleges. Diversity in the Physician Workforce: Facts and Figures 2006.  https://services.aamc.org/Publications/showfile.cfm?file=version71.pdf&prd_id=161&prv_id=191&pdf_id=71.

Other bibliographies birth to admission at www.ruralmedicaleducation.org/education.htm