Birth Origins and FP Choice

Robert C. Bowman, M.D.

For changing composition of US allopathic students and graphics see Origins Changes

About Birth Origins

Medical students of different birth origins choose family medicine at different percentages. This is more than just rural and urban. The best indicators are socioeconomic. Students from all but the highest income, most urban locations choose family medicine in greater numbers. Higher MCAT score indicates urban origin and parents who are have greater levels of income, education, and professional occupation.

Proximity to a medical school also impacts admissions and career choice. When comparing birth county income quartiles to hold income and education factors constant, those born in a county with a medical school have better admissions probability, lower choice of family medicine, and other distributional choices are also less.

Foreign born US allopathic students are even less likely to choose FP, unless they are older. Age and FP Physicians Generally foreign born and Asian students tend to be younger. The foreign born group is the fastest rising group of students admitted.

Choice of Family Medicine: Birth Origins

Robert C. Bowman, MD

rcbowman@atsu.edu      http://www.ruralmedicaleducation.org

Key Words: family medicine, rural background, rural origin, rural, underserved, medical school admissions, career choice, rural medical education, physician workforce, distribution

ABSTRACT Background: This study investigates the relationship between medical student birth origins and choice of specialty, particularly with regard to family medicine. Methods: This national study used American Medical Association (AMA) Masterfile data and family medicine databases provided by the Robert Graham Center. The primary cohort involved 17,518 self-designated family medicine and general practice physicians compared to all US allopathic graduates of 1994–2000 (n = 110,639). Results: Students born either outside of the 50 United States or in US counties of over one million were both admitted to medical schools in increasing percentages in the past 30 years, and are also the least likely to choose family medicine. Students born in less population-dense areas, older students, and instate born students were more likely to choose family medicine and distributed where most needed but have been admitted in lower numbers. Health policy changes in the 1990s greatly improved the distributional choices of allopathic medical students, with greater impacts upon those least likely to distribute. Discussion: The physicians most likely to distribute are the least likely to gain admission. Those more likely to choose family medicine are also more likely to choose rural practice locations regardless of specialty and to choose rural family medicine, primary care, office-based primary care in poverty locations, and psychiatry. The nation's policies in education, medical education (admissions), and health are important factors in physician distribution and will need major revisions to meet the ever-increasing needs of rural and underserved peoples in the country. (247 words)

Introduction

Fewer medical students in the United States are choosing family medicine. This is a major concern since family medicine is the physician specialty that distributes in the same pattern as the US population. Accompanying decreased choice of family medicine is decreased choice of primary care, decreased choice of rural practice location for all physicians, and increased student choice of subspecialties. Such changes are likely to greatly reduce health care access and increase the cost of medical care and may also result in lower quality health care (Starfield)

The choice of family medicine has most often been considered a result of medical school influences. Not surprisingly most of these studies were done by researchers affiliated with medical schools. This medical school perspective may limit a broader viewpoint involving student origins, education, access to college, standardized testing, and socioeconomic barriers that students face. Other studies have noted that schools emphasizing research generally do not do well with choice of family medicine or physician distribution (Rosenblatt, Senf). Although schools graduating more researchers are less likely to distribute physicians, the real issue may be a separate factor that correlates positively with research and negatively with choice of family medicine and distribution.

The choice of family medicine appears to be related to socioeconomic factors. Students with lower income origins are known to choose family medicine and primary care in greater numbers (Cooter, Madison). Rural origin students, older students, and underrepresented minority students have the most challenges gaining admission and tend to have the lowest Medical College Admission Test (MCAT) scores (Wheat, Basco, AAMC data). They also share the lowest income origins. There are significant gaps in income levels between students admitted and rejected (AAMC data). Education difficulties have multiplied for inner city and rural areas, the known origins of many family physicians (Xu, Funding Gap 2004). Increasing mean parent income levels for those admitted to medical school indicate that lower income students are being left behind (AAMC Minorities in Medicine, AAMC Data Warehouse). More tragically many may not even apply. This would explain increases in the national MCAT averages in recent years, especially the one point rise in bioscience MCAT (AAMC MCAT). Another explanation would be students "gaming the system." Students with higher income levels are more able to afford the top colleges and top preparation courses. The costs of applications, test preparation, and college continue to rise, often at double-digit rates. It is certainly possible that the students most likely to choose family medicine, the ones with the lowest income levels and facing the most education barriers, are being excluded from medical schools.

The goal of this study is to investigate the influence of birth origins on physician career choice related to family medicine.

Methods

The American Medical Association Masterfile (Masterfile) and American Academy of Family Physician databases were accessed with the assistance of the Robert Graham Center and the support of the Federal Office of Rural Health Policy. The databases were used to identify all family physicians (FP) and all general practice (GP) physicians who finished training from 1997 - 2003. Birth origins (city, state), class year, and age were available for over 98% of physicians graduating from US allopathic medical schools dating back over 40 years. Birth city and state were converted to county of origin. This was usually an easy task, but some of the towns were more challenging since there were duplicate names in some states, name changes, and towns such as internment camps and military towns that no longer exist. The story of physician birth origins is the story of America during some of its most challenging years. Use of multiple internet search engines allowed the categorization of towns by zip code or county locations over a six-month period of effort by the author. The county of origin was also translated to Federal Information Processing Standard (FIPS) codes and then to 1993 urban influence codes (Ghelfi and Parker), metropolitan or nonmetropolitan designations, and population density (1970 Census). Practice location zip codes were also converted into rural-urban commuting area (RUCA) codes (WWAMI). The RUCA coding was grouped into 4 categories using Categorization A suggested by Hart: urban/urban-focused, large rural, medium rural, and isolated rural categories (Hart). Medical student admissions ratios were calculated by dividing the medical students who were born in each type of county by the 1970 population in each urban influence code county type 1-9. This admission ratio for the seven years of graduates was divided by seven and multiplied by 100,000 to obtain a per year per 100,000 ratio. The year 1970 was the approximate birth year of this cohort of students. County income levels of that time period were also appended. Another comparison involved ethnicity comparisons using Association of American Medical Colleges data on admissions as a numerator and census data on 18 to 24 year olds as a denominator (AAMC MIM). Student origins also were coded as Instate Births for students born in the same state as their medical school. Ethnicity data was also available by entire class for over 95% of allopathic students (AAMC data warehouse) and specifically for over 90% of individual family medicine residency graduates from allopathic medical schools (Masterfile), allowing choice of family medicine determinations by ethnicity. Zip codes with a Community or Migrant Health Center (BHCDA) or those where 20 % of the population was at or below poverty levels were considered poverty zip codes. Zip codes that were unique were translated to the nearest zip code geographically that had a population.

Results

There were 110,639 graduates of U.S. allopathic medical schools from 1994-2000. Of these graduates there were 15,355 self-designated family physicians and 1581 self-designated general practice physicians in the Masterfile and 1546 (or less than 10%) that did not have specialty data listed. Another 585 family physicians were added to the database from family medicine sources for a total of 17,521 FPGP physicians. Over 13,560 FPGP doctors were listed in office-based practice, another 1390 were not classified (most likely office-based), an additional 1548 were still coded as residents, and 840 were in hospital based practice.

The physicians likely to choose family medicine were not limited to rural origins. Medical students who were born or raised in all but the most densely populated areas of the nation were more likely to choose family medicine.

Table I. Choice of Family Medicine By Allopathic Graduates

Characteristics of Age and Origin

% Family Practice General Practice

Number of FPGP

% of all FP/GP*

% of Medical School Graduates

Recent Trends in Admissions 1994-2000

1994 - 2000 Allopathic Graduates

16.1%

17518

100.0%

100.0%

Down

Urban Birth (RUCA)

15.0%

14730

84.0%

90.0%

Up

Rural Birth (RUCA)

25.8%

2801

16.0%

10.0%

Down

Urban Influence 1 Birth, metro, county pop of over 1 million, average density of 674 people per square mile

14.6%

7496

42.8%

46.9%

No Change

Urban Influence 2 Birth, metro density of 180 people per square mile

19.1%

4828

27.6%

23.2%

No Change

NonMetro Birth Influence Codes 3-9

25.7%

2697

15.4%

9.6%

Down

Foreign Birth

10.7%

1892

10.8%

16.2%

No Change

Military Birth

19.8%

165

0.9%

0.8%

Down

Younger than 30 yrs at graduation

14.8%

12747

72.8%

79.4%

No Change

Older than 30 at graduation

22.5%

4770

27.2%

20.6%

Down

Age 20 – 25

10.6%

882

5.0%

7.7%

Down

Age 26

13.9%

4971

28.4%

32.8%

Down

Age 27 – 28

16.2%

5680

32.4%

32.2%

No Change

Age 29 – 30

16.8%

2072

11.8%

11.3%

No Change

Age 31 – 32

18.5%

1205

6.9%

6.0%

No Change

Age 33 – 36

21.6%

1350

7.7%

5.7%

Down

Age 37 & Over

29.5%

1358

7.8%

4.2%

Down

Over 5000 Per Sq Mile (NYC, DC, Balt., Phil., Chicago, St. Louis)

7.8%

1977

11.9%

25.0%

Down

2500 – 5000 Pop Per Sq Mile

12.3%

3070

18.5%

24.6%

No Change

1000 – 2500 Pop Per Sq Mile

15.2%

3039

18.3%

19.6%

No Change

250 – 1000 Pop Per Sq Mile

20.2%

3744

22.5%

18.2%

Down

Less than 250 Pop Per Sq Mile

37.2%

4779

28.8%

12.6%

Down

Less than 50 Pop Per Sq Mile

75.6%

1400

8.4%

2.4%

Down

Instate Born

18.7%

7769

44.3%

38.2%

Down

Out of State Born

14.5%

9762

55.7%

61.8%

Up

*Final totals of physicians in each category range from 103000 to 110,600. Note that these values for choice of family medicine were 30 % greater than any time in the past 20 years because of increased FP choice in the 1995 – 1998 graduating classes. Family medicine choices are now 40 % below these levels listed.

Increasing Dominance of FP Unlikely Students

Students born in counties of over 1 million and those born outside of the 50 states are the least likely to choose family medicine and are designated for this study as FP Unlikely students. This FP Unlikely group involves 63% of students and shares the highest income origins. Another way of expressing this is that medical students born or raised in less than 10% of the geographic area of the nation provide over 70% of the nation's physicians. The schools with the highest percentages of FP Unlikely students are also in the most densely populated cities. This suggests a birth origin impact upon medical school choice as well. Studies of Asian students choosing family medicine reveal that the most densely populated cities in California were the final practice locations of 700 even though only 100 were born there. The others originated mostly from Chicago, Michigan, and New York City.

Increasingly, medical schools are recruiting and admitting FP Unlikely students. The FP Unlikely students are also the least likely to choose rural family medicine, office-based primary care in poverty locations, and rural practice for all types of physicians. Medical schools are also admitted more and more who were born in out of state locations and in counties with high income levels. Over 40 medical schools have over 80% of their class composed of FP Unlikely students, making it difficult for such schools to graduate family physicians.

The schools with the most FP Unlikely students also have the highest Medical College Admission Test scores and the fewest older students. The connections between scores, socioeconomics, student characteristics, and distribution are ripe avenues for exploration.

The general trend is that medical schools are not admitting the outliers. The youngest and oldest, the poorest, the lowest scoring, and those from the most and least densely populated areas are not being admitted to the same degree as in the past. The MCAT bioscience score is up 1 point in the last decade (MCAT). The age range in the schools with the highest MCAT scores is a narrow spike with a greatly restricted age range. This is certainly consistent with the narrowing process that has been a concern of leading medical educators for decades, especially those concerned with the current use of standardized testing in admissions (Herman, McGaghie, Cohen century).

Table II. Distribution, Admissions, Age, and Income Levels

Urban Influence Code (1993) or other Origins

County Income 1969 in 1989 $

Admit Ratio per year per 100000

Age < 30 Age > 29

FPGP % 1994-2000

Rural FPGP %

% of all Doc Types Rural Locations

Code 1 Metro Over 1 Million (47% of allopathic students)

$9653

7.31*

Younger

11.1%

1.9%

7.2%

Older

17.2%

3.7%

11.4%

Code 2 Metro Less Than 1 Million (23% of students)

$8439

6.28

Younger

15.6%

3.7%

11.9%

Older

21.2%

5.7%

16.0%

Code 3 Adjacent Metro Over 10000 Population

$8088

3.67

Younger

19.4%

7.7%

17.9%

Older

23.5%

7.4%

20.9%

Code 4 Adjacent Less Than 10000 Population

$7141

1.68

Younger

23.1%

9.5%

24.6%

Older

24.3%

9.5%

21.2%

Code 5 Adjacent Small Metro > 10000 Pop

$7829

4.19

Younger

19.8%

7.2%

19.7%

Older

23.1%

9.7%

23.1%

Code 6 Adjacent Small Metro < 10000 Pop

$6870

1.94

Younger

23.5%

9.9%

22.0%

Older

28.1%

11.7%

24.2%

Code 7 Not Adjacent > 10000 Population

$7825

5.86

Younger

19.9%

8.9%

23.2%

Older

26.2%

10.2%

25.1%

Code 8 Not Adjacent 2500 – 10000 Pop

$7215

3.18

Younger

25.4%

12.4%

27.5%

Older

29.7%

13.3%

28.6%

Code 9 Not Adjacent Less Than 2500 Population

$6826

1.91

Younger

29.1%

15.4%

29.8%

Older

33.8%

18.0%

35.9%

Birth State Data Only

 

 

Younger

14.3%

3.9%

9.6%

 

 

Older

14.0%

2.7%

10.7%

US Birth Outside 50 States (PR, GU, VI, CZ)

 

 

Younger

8.5%

0.7%

4.2%

 

 

Older

17.8%

2.2%

7.1%

Foreign Born – 14 % of medical students and increasing

 

 

Younger

8.8%

0.9%

4.7%

 

 

Older

14.0%

2.1%

7.8%

Military Base Birth

 

 

Younger

15.0%

3.4%

11.8%

 

 

Older

20.0%

4.9%

14.3%

Students With Missing Birth Data

 

 

Younger

10.3%

1.8%

5.8%

 

 

Older

13.3%

2.5%

10.8%

Total

 

 

Younger

12.8%

2.9%

9.4%

 

 

Older

18.8%

4.8%

13.6%

*Admission ratio for Urban Influence code 1 would be 9 if the foreign-born students who are raised mostly in the most urban counties were included. About 9.6% of allopathic medical students have origins in codes 3 - 9. County types 1,2,3,5,7 also have higher educational attainment levels, more colleges, more hospitals, more physicians, and a higher ratio of primary care physicians (Ghelfi and Parker)

 

Those born in nonmetropolitan areas and military bases are categorized as FP Likely students. This group continues to decline in number along with the instate born or those who were born in the same state as the medical school. The FP Likely group and those born instate are also more likely to choose rural locations (regardless of specialty choice), primary care, rural family medicine, and urban primary care poverty practice locations. The declines in instate and rural born have extended back for decades. It is not surprising that the nation continues to suffer from a shortage of physicians caring for rural areas and for underserved populations.

Student Characteristics, Age and Origins

Younger students at graduation from medical school also had greater probability of admissions (AAMC data warehouse) and lower levels of distribution to the careers, locations, and populations most in need. Younger students tend to be the more urban in origin, regions of the nation where the levels of income are the highest. Younger students are more likely to have skipped grades or may have been granted early admission and may also have the highest test scores. Only 6% of those graduating at age 25 were born in rural areas, 9% of those at age 26, and 13% of older students.

Student age appears to be a proxy for socioeconomic considerations involving income and education.

Medical students who were born in less urban areas, older medical students, those born in military bases, and instate born students, were more likely to choose family medicine. Population density figures yielded the most dramatic variations, ranging from a low of 7.6% choice of family medicine for those born in the most densely packed urban areas to 76% for those born in the most frontier regions.

Population density of birth origin may well be the best socioeconomic representation available from secondary data.

Older students have been admitted when applicant pools decrease and also when there have been expansions of class size. Admissions committees would rather admit younger students. The combination of older age and FP Likely characteristics enhances the choice of family medicine and distribution. Older students were also more likely to choose rural locations and psychiatry. The choice of psychiatry careers doubled from 3% to 6% for students age 25 compared to those age 31 at graduation.

Breakdowns regarding age reveal a pattern where older students trend toward direct contact patient care, primary care, family medicine, generalism, rural location, and behavioral aspects. Younger students tend to make career choices involving technology, procedures, and less direct contact with patients. The only exception to the primary care preference with advancing age was medicine pediatrics, but again this is not a surprise. Recent studies of this specialty revealed that the ability to preserve subspecialty choice is a major consideration of this group (med peds study).

Those born in the same states as public allopathic medical schools had greater choice of family medicine. Most allopathic private medical schools did not share this distributional tendency. Instate born students may represent those with limited income levels, families, or debt who may not have any viable medical school options in states without either a public medical school (lower tuition) or without a school with broad admissions policies. States with special rural admissions may give such students some hope. Schools with special admissions tracks and those with a rural mission did admit more rural born students. In states with poor investment in education, poor distribution of education funding, or lacking specific aid, there may be even less hope for lower income students born in such states. They may lose interest in medicine long before college.

Global Competition for US Medical School Admissions

The fastest growing component of FP Unlikely students involves students born in other nations. This group doubled from 1300 (out of about 15,500) students in 1987 to 2600 by 1992, but did not increase significantly for the classes of 1993 - 2000. Those born in the lowest income groups and areas of the nation now face international competition, just like US workers in other areas. Asian medical students are the largest component of this international group. The total Asian group has risen to 22% of all allopathic students (AAMC Data Warehouse) and this group, predominantly born or raised in the most urban areas of the nation, has the least family medicine choice for any ethnicity, at 7%. This is the same distribution into family medicine as those born in the most urban areas of the nation, the area known to be the primary residence of Asian citizens and residents in the US. For Asians born in other countries, three US cities contain 45% of the foreign-born Asian population (Census Asians). Asian choices appear to be no different than comparable choices of other students with similar characteristics of age, income, education, and origin. The Indian-Pakistani group which is the fastest growing group in US allopathic school admissions (likely due to English language spoken, parent income, parent education) is the least likely to choose family medicine of any group at 2.3%. The rural and poverty choices of Asian family physicians born in other countries are much higher than the same choices of Asians born in the US. Vietnamese students chose family medicine at the highest levels of any ethnicity at 24%. Vietnamese parents of medical students have the broadest income distribution of all ethnicities (AAMC Minorities in Medicine). Asians born in the Midwest had much higher choice of family medicine. Ethnicity studies add to the consideration of socioeconomics and choice of family medicine.

Table III

 

Allopathic US Medical Student Admissions, FP Choice, Income Levels

 

1994 - 2000 Allopathic Graduates

One out of ___ males are medical students

One out of ___ females are medical students

US Age 18-24 (1995 Census)

Medical Students 1994-2000 (AAMC)

Male/ Female

FP Choice

Rural Choice in FP Graduates

Approximate Money Income Levels 2003

Parent Income Level of Accepted Parent Income Level of Applicant MCAT all applicants 1996 (AAMC) MCAT Accepted 1996 (AAMC)

Asian Indian

18.8

20.4

159236

8136

0.53

2%

15%

$55,000

100000   9.70  

Chinese

41.2

44.6

208868

4882

0.53

6%

6%

 

80000   10.30  

All Asian

48.9

53.0

1034000

20340

0.53

7%

11%

 

90000 80000 9.70 10.6

Vietnamese

65.7

71.2

97196

1424

0.53

22%

5%

 

42500   9.10  

All Urban Born

183.9

176.7

19691600

109228

0.5

13%

21%

 

higher      

US All Student

206.9

198.8

25466000

125549

0.5

18%

24%

 

       

White

200.6

226.3

17413000

81973

0.54

14%

26%

$48,000

90000 80000 9.50 10.3

Native Am

270.2

240.6

222000

871

0.48

9%

47%

$33,000

60000 55000 8.10 8.9

All Rural Born

462.7

321.9

6218400

16321

0.42

22%

30%

 

lower      

Black

589.6

305.0

3593000

8880

0.35

13%

11%

$33,000

55385 50000 6.90 8.4

All Hispanic

488.4

597.2

3204000

5975

0.56

12%

12%

$33,000

       

Mexican Am

967.4

1222.1

3110600

2887

0.57

19%

13%

$33,000

50000 48000 8.00 9.1

Other Hispanic

931.7

1139.3

2400000

2346

0.56

7%

11%

$33,000

70000 60000 8.60 9.7

Income levels vary the most in the last 6 rows.

Admissions varies with income, population density, and parent education level. Population density, education, and income levels of the county of birth of medical students predict well over 50% of the variance in admissions. These socioeconomic measures also influence test scores such as SAT/ACT and MCAT. Higher socioeconomics means low choice of distributional careers and poor retention for practice in the state where students attended medical school. Family medicine is a more likely choice in lower socioeconomic students and in allopathic public schools, FPs are 44% more likely to be retained in their state for practice (1987 - 2000 medical school graduates compared to 2005 locations in the Masterfile)

In summary,

 

Only white, Mexican American, and Native groups have any appreciable percentage born in rural areas and this is reflected in their choice of rural practice locations.

Those with the highest income levels by urban, ethnicity, and population density considerations are the most likely to be admitted and the least likely to distribute to rural and poverty primary care locations. In blacks, Natives, and Mexican Americans there are more females that choose rural locations compared to males. This is a reflection of who gains access to college and medical school. This female dominance also includes some residency programs in states with high poverty levels. The effect of poverty seems to penalize male changes of gaining college and medical school admission. Black males and rural males are admitted in the lowest levels, share some of the best distribution when admitted, and share other important characteristics such as income and first time college attendance.

The current designations of underrepresented minorities do not make sense without income determinations.

White rural males and Vietnamese face great barriers and have little assistance and high choice of family medicine and distribution where needed. It is difficult to separate the individual contributions of income, education level, origins, population density, and ethnicity in the U.S. It may also be difficult to separate medical school admissions and physician distribution from such socioeconomic influences.

Challenges Regarding Admission of Rural-born Students The students most likely to choose family medicine are also more likely to choose rural family medicine and rural locations regardless of specialty choice. However, students born in the lowest income and most unorganized county types were the least likely to be admitted to medical schools. Rural variation is legendary with some of the best education and income and some of the worst. Top honors for individual county ratios of admission involve some of the most urban locations in the nation and a mix of rural counties in the Midwest. Overall, 9.6% of all allopathic medical students had rural origins and this group shares origins with 23% of the US population inhabiting 80% of the land area of the nation.

Figure 1

As county income levels and county education levels rise, the percentage choosing family medicine declines. The choice of family medicine is likely to involve a greater number of first time college attenders. High school graduation rates are likely to be more important than college graduation rates in graduating more family physicians. Graduation of a family physician is truly and accomplishment for and entire team, including the parents, the student, teachers, and advisors. It may well be that a higher income student needs only one of these influences to be admitted whereas a rural or underrepresented student needs all of these boosts for admissions.

First generation to college is the intersecting point. The populations first generation to college are rural, Vietnamese, and Medican American populations and all have 19 - 24% choice of family medicine, the highest levels.

Medical School Type, Orientation, and Mission

The traditional black medical schools, the newer allopathic schools, those with a mission for rural health, and medical schools in the Midwest were more likely to graduate family physicians.

Figure 2 at Origins Changes

 Medical School Expansion: Past, Present, and Future

The impacts of past medical school expansion can be seen in the dramatic increases in the admissions of the most urban origin and white students, the highest-income groups of the time period from1970 - 1982. There was no such magnitude of increase in admissions of those born in rural areas or underrepresented minority students (URM).

The largest increase in URM student admissions was an abrupt increase from 3% to 8% of total medical students at the start of expansion, not related to increased class size. A smaller increase slowly from 9% to 12% did occur after expansion coincident with major efforts in medical education related to admissions (NEJM 3000 by 2000).

The numbers of students admitted from rural areas did increase slightly during expansion, but nowhere near the massive increase of urban-born students. Any current expansion is more likely to involve the students who have been increasing the most in recent years, those born in urban areas or students born in other nations.

Expansion that does not specifically target underrepresented minority, rural, and lower income students is unlikely to improve physician distribution and patient access to care. This is made more complicated by recent accreditation where a medical school that did target rural, minority, and geriatric needs faced some of the greatest obstacles to accreditation despite extensive documentation and preparation (FSU). The rural, older, instate born, and lower income underrepresented minority students are capable of choosing nearly all careers and locations. Comparatively, workforce versatility is not a characteristic of higher income, urban born, younger, and foreign-born allopathic medical students in US medical schools.

Since the time of expansion there have been major declines in the number of white medical students (AAMC data warehouse) and those born in towns of less than 10,000 (AAMC GQ). This AAMC category seems to be a mix of rural and urban students, however.

There have also been slow, steady and less dramatic declines in rural-born admissions that have predominantly involved younger, rural-born students.

Long Term Trends in Medical Education and Admissions

Rural areas, low income areas, disadvantaged populations, and poorer states and nations face the same challenges. It is important to retain education and health resources as much as possible. These "human capital" investments result in education, jobs, economics, property taxes, and leadership. The most common term used by states is "brain drain" or the loss of students to the east and west coasts. Sadly many have invested in the best and brightest only to watch as these students left for the coasts with additional college investment. Meanwhile the more average exceptional students with slightly lower scores receive less attention for college funding and medical school, yet these are the students more likely to be retained by a state.

It is entirely possible that admission committees (by themselves or under pressures from deans) are pushing the envelope to admit more students from out of state or from other countries to boost MCAT scores, US News and World Report rankings, prestige ratings, student research potential, or to reduce the potential complications of upcoming accreditation visits. This seems a high price to pay. Those medical students born in a state are far more likely to be retained in a state to practice. The figures are even more dramatic for those choosing family medicine (likely lower income in origin) where 35.3% of those choosing family medicine are retained in a state to practice compared to 26.6% of non-family physicians.

Admitting more students to medical school who are less likely to choose family medicine (younger, big city, born out of state, higher income) or who are less likely to stay in a state to practice means a tremendous loss of state investment in education, college, and medical education.

The medical education policies and procedures that make sense for the elite 20 - 30 schools that graduate half of the physician researchers for the nation do not make sense for the 100 others. Such policies make even less sense for the country as a whole.

People seem less and less willing to trust the government to address the barriers of education and income that later drive significant societal costs in education, health, prison, social programs, disability, and more.

1990s Health Policy and Family Medicine Choice and Distribution

The FP Unlikely students did have a 50% increase in choice of family medicine involving the classes of 1995-1998. The FP Likely students maintained their higher FP choice but had only a 25% increase. The combination of increased family medicine and primary care choice from the largest group of FPUnlikely students together with the smaller FP Likely group that distributes much better was a "perfect storm." This was a temporary effect of health policy that resulted in the best distribution of physicians in the nation's history. This distribution included a record number of physicians where they were needed including 700 - 750 rural family physicians and an additional 750 office-based primary care physicians in poverty locations each year for 1995 - 1997 from the nation's allopathic medical schools alone.

The stellar physician distribution choices of the classes of 1995, 1996, and 1997 forever ended doubt that physicians could distribute where most needed in rural and urban underserved areas. This was more than enough to make progress regarding underserved populations. This effort involved the most-physician career restrictive health policy in the nation's history. It also involved some of the most supportive efforts for primary care since the creation of Medicare with improvements in reimbursement for primary care, loan repayment increases, Rural Health Clinics, and increases in reimbursement for those who hire and support rural physicians including rural hospitals and Community Health Centers.

The urban-born students who chose family medicine during this time period truly believed that there were going to be great limitations in jobs associated with subspecialty and hospital locations. This effect was expected to be most dramatic in urban subspecialty locations.

When reviewing birth origins it is increasingly clear that urban students prefer urban practice locations. The urban students quickly perceived that the way to preserve future urban location was to choose primary care and family medicine. This did not appear to be a bad choice financially since subspecialties received cuts and primary care was receiving progressive increases in pay. When this brief period was over, the policies resumed their previous alignment, and students resumed previous career choices.

Therefore, the lifestyle choices of medical students may not involve career lifestyle, but preference of urban living which is really a matter of a return to birth origins.

Given the massive changes in career choice in this huge group of students, it is likely that studies involving primary care and family medicine choice during this time period are severely flawed (Title VII and "lifestyle" choice) since they did not include considerations of atypical health policy, student career choice, and student origins.

The rural and office-based primary care poverty numbers have since declined to half of peak levels and at the current rate of decline, will soon be back to pre-Medicare year 1965 levels. This is an even greater concern given 40 years of population increases in rural and underserved areas. The same increasing pattern of primary care choice involved the 1965 - 1978 graduating classes.

When the nation was willing to pay for primary care, the nation's physicians were more than willing to make primary care choices. Over this period office-based primary care choice rose from 28% to 41% with declines since 1978. A recent study noted that internal medicine choices in the match of 2004 were 1000 less than 1978. The class of 1978 also graduated 4000 fewer medical students.

Health policy is a most necessary requirement for physician distribution and together with education and admissions, can distribute physicians in a way that addresses significant areas of need in this nation.

Discussion

Those most likely to meet the needs of the nation in the physician workforce are the least likely to be admitted to US allopathic medical schools. The decline in choice of family medicine has paralleled the decline in the admissions of instate, rural, and lower income students and the rise in urban and foreign-born admissions. Clearly, physician distribution is influenced by birth origins. Health policy is also a most important consideration.

When the nation coordinated health policy and primary care well, the nation was able to distribute physicians. However, the nation does not appear to be willing to sustain this type of effort that involved significant career restrictions regarding physicians. In the current scenario, the only method of distributing physicians involves the pipeline to admissions.

Admissions efforts have been successful, but remain largely unreplicated. Those schools that admit more older, rural, and lower income students graduate more physicians who distribute. These successful distributional efforts have a common lower socioeconomic connection. Such efforts are made not only by medical schools (special mission schools like Duluth, osteopathic schools, Caribbean schools, newer allopathic schools, traditional black schools), but also by medical school programs (rural admissions tracks, inner city magnet schools).

Fixing some of the major problems in the health care system must involve addressing problems in the education system. There are significant problems all along this pathway that must be explored, including the distribution of education resources and funding, career preparation, funding for college, socioeconomic bias related to standardized testing, admissions committee decisions, distortions in admissions due to health policy (research/subspecialty dominance), and the expectations and influences of students, parents, and teachers. Without a solid foundation of quality state education and without continual increases in first time college attenders, admissions committees soon run out of instate, rural, lower income, and older students who have “acceptable” risks. Sadly, these committees set their sights too high, as 90-94% of "at risk" students graduate when schools are willing to take those risks (Crump, Wheat, Cooter). T

he challenge of admissions for distribution is enormous. The sensitivity for at risk student determination is high but the specificity for failure is low. No physician would accept such testing regarding patient care yet we use these tests everyday in admissions. For 70% of medical students the current admissions procedures make sense, but not for the 30% of students who are "different." The differences of these students invalidate the results of standardized testing in college or medical school and these are the students most likely to distribute. There are also major errors in the definitions of disadvantaged students that must be addressed.

The nation continues to turn to international physicians and international students in the attempt to graduate enough physicians. Increasing dependence upon those born in other nations is a policy inconsistent with the crippling health and education issues in Africa, Asia, and South America and extremely inconsistent with the policies of a nation attempting to fight a global war on terrorism. Long before the costly and difficult battles of police and the military is a preventive war fought by addressing health and education needs. Draining other nations of important health and education resources is not likely to help other nations to maintain education, health, economics, or the respect of their peoples.

The only real question worth debating is what sacrifices this nation or any nation is willing to make to consistently provide education and health access to the broadest range of inhabitants.

Solutions likely to improve physician distribution and the graduation of family physicians are also likely to improve a wide range of health, economic, legal, education, and social components in the nation. All such solutions involve long term investments in human potential. In the current post-recession status of the nation, the careers most involving long-term human potential (school teachers, public servants, counselors, family physicians) are suffering the most. It is also these careers that are most dependent upon education.

When significant numbers "move up" in socioeconomic status via education, the nation is replenishing important sources of service-oriented professionals. Every serving profession wants to dip from this well, but few are working to replenish it. Teamwork between educators and professionals is a most important consideration. Beyond education is understanding. A nation that does not understand public health, public education, and primary care is not likely to have effective systems of any kind. The condition of education, transportation, power transmission, social support, and health systems is a testament to poor understanding and lack of effort by those that we have promoted via higher education, as much or more than those we have elected.

Study Limitations

The limitations of this study involve the reliability of birth data provided by the medical schools to medical associations. Some have expressed concern regarding actual birth origins reporting. However, numerous groupings of data by dozens of coding schemes and comparisons with education and census data reveal a consistent pattern across the nation. The current study method using national data also tends to negate errors in some schools. The data for the primary variables is complete for over 98% of physicians and there is no sampling error since all national data is used. The methods used also avoid the kind of discipline, association, medical school type, or individual medical school bias that could influence results.

There are also limitations in interpretation. For example, foreign-born students in Midwest medical schools have higher choice of family medicine and an ethnicity (Vietnamese) that suggests lower income levels. Older students in the research-oriented medical schools tend to choose research careers and also are less likely to distribute. Such students may have been internally recruited after establishing a research career. Schools admitting more Hispanic students may or may not distribute physicians. Mexican American students, as compared to Other Hispanic or Puerto Rican students, are more likely to choose family medicine and poverty locations. Again the income levels of Vietnamese and Mexican American students are lower. Admissions committees can best use the results of this study to pursue their own studies of the potential students available to them and the distributional outcomes of the student types who have graduated from their institutions.

Why have birth origins not figured more prominently in career studies?

The emphasis at the highest levels in medical school rather than a broader and earlier perspective is a primary consideration. The overall impact seems to be limited to primary care, family medicine, and rural location which frankly are not major emphasis areas of allopathic medical education. The changes in AAMC GQ data and birth origin data have never involved more than 1 percentage point of change year to year. This has allowed the major changes in admissions to go unrecognized for decades. The recent transient increase in choice of family medicine due to health policy changes also helped hide these relationships and primary care leaders appear seem to deceive themselves with efforts at the medical school level, basically attempts to convert the converted or to convince those beyond convincing. Interest in admissions remains poor and efforts to involve earlier levels are in infancy.

Socioeconomic Obstacles

The obstacles faced by different and diverse students are enormous, but those posed by income levels have been largely overlooked., and are probably more important than issues of ethnicity. Special pre-professional diversity efforts involve over 80% of underrepresented minority students (AAMC MIM 2001); however, the same is not true for the rural, older, and lower income students. Older students may have the least help of all. Many appear to be able to afford only one attempt at admission and perhaps many more never get that far. Special efforts that are coordinated over multiple years can improve medical school graduation rates for "at risk" students from 76% to 90% and can increase admissions of disadvantaged students (Crump). Such efforts require a great deal of state and federal funding. Even with special programming and a nationwide effort (NEJM 3000 by 2000), the growth of underrepresented minority physicians failed to keep pace with population increases in underserved populations (NEJM). The 10% increase in rural population in the past decade is also leaving admissions of rural born students far behind. Black students and rural students are admitted in the lowest ratios in the nation, with black males and rural white males at even lower levels of admission (AAMC Minorities in Medicine calculations).

It may be better to improve education in general. States with better high school graduation rates graduate more family physicians, but interestingly, not those with a higher percentage of bachelor's degrees. The relationship between education and graduation of family physicians also indicates that broader education efforts targeting earlier and earlier levels may be more valuable in the distribution of young professionals than efforts at college and higher levels.

Call to Action

Admissions of diverse and nontraditional students will require far more tolerance on the part of medical education and far more teamwork with primary, secondary, and college education. Schools choosing to increase admissions of out-of-state and foreign-born students are not helping the nation to improve state education or physician distribution. Schools heeding the call of medical education leaders such as Butler and Cohen to team with rural and inner city schools and admit nontraditional students are making a difference in education and physician distribution (Butler, Cohen century). Medical education leaders that continue to promise progress without significant effort are taking a terrible risk regarding the leadership role that physicians still enjoy, at least for now.

Don Madison has given sage advice in his article regarding generalist outcomes of the class of 1985 at the University of North Carolina (Madison): “If an admission committee informs itself of "what finally happens" to those it admits, its decisions can contribute to achieving whatever policy its medical school adopts with respect to the mix of physicians it wishes to produce.” The nation would do well to decide the education, health, and financial outcomes that it desires so that it may better prepare and select medical students and other young professionals accordingly.

Physician Workforce Studies

www.ruralmedicaleducation.org

 

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