Robert C. Bowman, M.D.
Rural origin students continue to decline with impacts on rural location, primary care, and family medicine since rural origin students have distributions to all of these careers at the highest levels.
Lower income and middle income origin students continue to decline in admission with impacts on rural location, underserved location (top level), family medicine, primary care, and women's health.
US Born students continue to decline with impacts on rural location and family medicine.
Students born instate relative to their medical schools continue to decline. Instate born students have the highest levels of Instate Retention for practice. Instate Born have higher levels of rural practice
Declines in all of the student types most likely to choose family medicine will compromise this permanent form of primary care and the enhanced and persistent distribution of this specialty to rural and to underserved areas.
US MD Grads have been changing in a way that will compromise physician distribution. Those most likely to distribute are being replaced by those least likely to distribute. The additions include students with the highest income levels, the most urban origins, the highest test scores, the youngest ages, and out of state or foreign birth. Each of these groups were born, raised, educated, and trained in or near major medical centers and return to such locations at the highest levels. These elite students are significantly different than the 70% of middle and lower income peoples in most need of health care in the United States, a group that births only 30% of US MD Grads. Increasing inequities in income and education and health access are magnified by the nation’s choices in education, college, and medical education.
Admission to medical school is a matter of inside. More important the dividing point does not involve extremes of income or geography. The dividing point involves the top status most concentrated types compared to all others of lower or middle levels of income, education, professionals, and resources.
The percentage of total medical students was compared to the percentage of the US population for each 5 year period using the AMA Masterfile, AAMC data, and census data. About 95% of US MD Grads have birth origins and about 70% of osteopathic graduates, a much smaller or tiny group compared to US MD Grads across this time span from 1941 to the present.
Asian admissions are about 22 - 23% (17% now for osteopathic) compared to 4% of the US population. White admissions are about the same as white population at 100% although different segments have higher and lower admission.
Large rural or micropolitan born admissions have decline slowly to 80% but again large rural areas with major universities, medical schools, and federal facilities have top levels of admission in the nation.
Rural admissions have declined faster than rural population decline resulting in 50% admission levels and down to 25% for lower income rural born children. Black admissions have increased with social organization efforts abruptly to levels of rural born admissions and have remained similar in recent years. African American and rural born males have half the admission rates compared to females. Mexican American and Hispanic admissions improved with Civil Rights and the opportunity to gain admission to any medical school. Slight improvements in African American, rural born, and Hispanic admissions were seen in the 1990s, possibly due to admissions training involving 3000 by 2000 with a focus on personal characteristics and not just scores.
Admission for all of the types of physicians that have greater choice of health access primary care careers has stagnated in recent years. A number of factors are involved. Children from combinations of concentration do have advantages with higher scores that reflect parent influences.
The test scores are not always a function of performance. Standardized test scores also reflect the populations that are closest to the standard student being tested. Highest income, most urban, children of highly educated parents and professionals are going to have higher standardized test scores for tests such as the MCAT. Those with the most differences and the greatest degree of differences from the standard will have lower scores that will be difficult to interpret since much of the lower score is about differences in parents and environments and not differences relevant to medical school or physician performance.
The past decade has involved more changes within race and ethnicity and geographic origin.
A continued focus predominantly on race, ethnicity, or rural origin is not likely to help with physician distribution.
A better marker for most needed health access career choice is "inside or outside" and this is a good fit with future location inside or outside of current concentrations.
Children born, raised, educated, and trained for 30 years in top concentrations in multiple dimensions are not going to depart the 4% of the land area with 75% of physicians and 90% of the health resource funding related to physicians.
Only children "outside" in origin, family physicians, older graduates, and those trained "outside" have the experiential place or life experiences outside that help shape practice location "outside". Coding systems that capture inside and outside capture this relationship and important influences on family practice choice, the "outside" choice.
All races, ethnicities, and rural to urban origins involve higher and lower status children. Those of highest status within groups are taking more medical school positions. About 3000 more highest income medical students have replaced 1500 lowest income and 1500 middle income US MD students for the entering class of 2004 compared to a more balanced admission in 1997. 3000 of those least likely to choose family medicine, primary care, rural, and underserved careers have replaced 3000 most likely to choose such careers.
About 65% of US MD Grads now arise from the top 20% in parent income in the US, an increase from 60% in the past 10 years. 60% has been the level for decades prior to this time. Declines have been greatest in those of lower income and status in all races, ethnicities, and populations, including rural. Rural born admissions have decreased below 10% despite 20% of the population in rural areas. Rural physician levels are also 10% of total physician workforce.
Underserved areas are also about 20% of the population and about 8% of admissions and about 7 - 8% of the total physician workforce of the nation. This includes urban underserved and rural underserved.
The same forces that shape education, opportunity, admission to college, admission to medical school, training, and policies impacting all these areas also appear to shape physician distribution. There are consistent matches all across the income, population density, and social organization spectrum. Those least likely to gain admission are most likely to distribute to family medicine, primary care, rural, and underserved areas. Then there is a small percentage of neutral ground with average admission and average distribution. Then there is the great majority of top status origins, those most connected to major medical center locations for the first 30 years of life in the United States or in other nations. These are children that become the physicians least likely to be found in family medicine, primary care, rural, and underserved careers for the 1987 - 2000 graduates (n = 316,000)
The variables can involve children of professionals, MCAT scores, county birth origins, population density, social organization, county economics, geographic coding, race and ethnicity - with one major requirement. One must understand the factors involved. For example one must understand that Asian populations in the United States have higher levels of income, education, professional degree, urban origin, and closest proximity to major universities and medical schools in a number of dimensions. Greater numbers of whites share the same high status origins as Asian populations but also have a wide range of lower and middle income origins. Studies of the top 51 income counties that have a medical school in their city or county can be revealing. This 1% of the land area has 20% of the population of the US, 47% of total Asians, 32% of Hispanics, 22% of African Americans, 17% of White, and less than 0.5% of the total Native population.
In correlations with medical school admission at the county level, % of professionals in a county, birth in a county with a medical school, higher income, higher population density, and higher levels of college education % are all important. Geographic proximity remains a major variable in linear regression along with percentages of professionals and population density. Indicators of extremes of poverty (whole county shortage areas, predominantly minority) also contributed negatively to admission ratios.
Those geographically and socially isolated are admitted at the lowest levels, typically a bottom threshold of 4 admissions per 100,000 birth population per class year. They also have the top choice of rural, underserved, family medicine, and primary care careers at 2 - 4 times other physicians.
Average admissions are 7 - 9 per 100,000 (9 if including the 16% who are foreign born US MD Grads) using 1970s birth county population as a denominator. Those with average admission levels have average to slightly greater choice of family medicine, primary care, rural (if rural born), and underserved (rural or urban depending upon birth origin) careers.
Those most connected to concentrations of professionals, income, people, education, medical schools, and health facilities after 30 years from birth to admission are least likely to depart major medical center locations (75 or more physicians) and are least likely to be found in family medicine, primary care, rural, or underserved careers. Only family medicine choice in this group increases rural or underserved location rates above national averages. Temporary obligations can force these careers temporarily but do not appear to be required with medical students from ordinary populations and ordinary medical schools. Only exclusive origins, exclusive medical education training, and exclusive health policies limit physician distribution.
With 70% exclusive admissions, a focus on 100% major medical center training, and health policy that sends the most lines of reimbursement and the highest levels of reimbursement to major medical center locations, distribution of physicians and economics and health resources outside of major medical centers is difficult.
For specialists, about 50% are crowded into 1% of the land area with 200 physicians at a zip code and 80% are found in 3% of the land area in major medical centers with 75 or more physicians, usually competing head to head in the same blocks or adjacent zip codes. This makes access to specialists costly, difficult, time consuming, and even deadly for those who have to travel and those who cannot travel but need to do so.
Higher Income Students Admitted from 1997 to 2004
· The medical students born to parents with over $100,000 in annual income have grown from 23.5% of medical students to 51.5%. Admissions of the lowest income quartile of students in the less than $40,000 category has declined from 24% to less than 15%. Each year about 3000 fewer lower and middle income students are admitted compared to 1997. Lower and middle income students have 2 – 4 times the choice of rural careers, underserved locations, family medicine, and primary care. The impact has been greatest on white students with a 77% increase in highest income white students and a 50% decline in lowest income quartile students.
· Based on the 7 different income levels from $10,000 to over $100,000 and the percentage of graduates by income level each year the nation graduates 256 fewer office family physicians, 165 fewer rural physicians, 212 fewer office primary care physicians, 192 fewer office based primary care physicians in underserved areas, and 345 more physicians for major medical centers.
· Family physicians accumulate outside of major medical centers in rural and underserved areas over time, fill in the gaps in health care in wider scope and the most needed areas, and because family medicine is a stable dependable end point career involving primary care, not a transition to another career. Family Medicine Contributes Much More Health policy changes often obscure the admissions changes, masking the impact of the managed care era and reversing course to reduce student choice by 50% in the past 8 years; however the admissions changes compound the problem of maldistribution with an additive effect.
Fewer Rural Born Medical Students and Less Physician Distribution
· Rural born medical students once were admitted at 80% or more of rural population levels. Rural born students have declined to less than 10% even though rural population remains over 22%. There is a 0.92 correlation between rural born student percentages and rural physician percentages at the allopathic medical school level.
· Rural distribution for specialties outside of family medicine does not extend beyond the contribution of rural birth origins. Family medicine choice extends rural choice beyond birth origins. Urban born family physicians have 20% urban choice and the rural born have 46% rural choice or 2 – 4 times the rural workforce at 11%. Facilitating Physician Distribution
· Family medicine is the major contributor supplying 30% of the total allopathic physician rural workforce. Family medicine fills in the gaps with 40% of the primary care supply and 50 - 70% of rural physicians in the areas with the lowest income, the fewest physicians, and the lowest population density. In the most urban counties with the highest physician concentrations less than 8% of physicians are office based family physicians. In the most rural counties, 59% are office based family physicians. Losses of rural born and declines in family medicine are a disaster for rural areas and also underserved areas, both rural and urban. Family Medicine Contributes Much More
Fewer White Medical Students and Less Rural Workforce
· White medical student admissions have declined significantly over the years. Whites are only 71% of the population in areas of over 1 million and 80% in other metro areas. There is no question that the 6 million in Reservations, border counties, and predominantly black rural counties have the most difficult health problems facing poverty, inequity, and multisystem failures. Whites are 90% in the remaining rural areas and increasingly share similar problems in education, economics, health, mental health, and dental health.
· Efforts to match up physicians with their patients can improve distribution, retention, and the quality of medical care. All suffer from temporary physicians who have not been trained in and for rural or underserved areas, who share few characteristics with rural peoples, who are costly to replace, and who often do not become a part of rural communities and economics.
· The family physician residency graduates of 1997 – 2003 found in the most rural areas in 2005 were white at 90%, were some of the oldest at medical school graduation (39% vs 22% older students) , and were the most likely to be born in rural areas or lower income areas of the nation.
· Increases in the admission of students from counties with a higher level of college education means fewer family physicians. States and counties with higher high school graduation rates graduate more family physicians. A nation that ignores child development and early education and emphasizes standardized testing instead of improving families, preschools, and elementary schools will not be graduating the lower and middle class origin professionals that will return and serve.
· Gender plays a role. The white males that have been the heart of rural physician distribution have declined from over 85% to less than 35% of medical students. Female contributions in rural family medicine have improved with 15 medical schools graduating more into rural practice as compared to a 25 school advantage for males, but females still trail in admissions in some states. Meanwhile every type of male except Asian is disappearing from college, medical school, and family medicine, especially those born in rural and low income populations. Failure to address the combinations of poverty, poor education, poor health, and poor environment seems to impact males much more and results in some of the most costly state budget items. This neglect generates tremendous inefficiencies in the function of cities, states, and the nation. We are now “Paying Later” for not “Paying Now” years ago.
Instate Born: Students Born in the Same State As Their Medical School
· Students born in the same state as their medical school have also been declining steadily. After the last expansion about 58% were instate born. Currently only 38% are born in the same state as their medical school.
· Instate born students have greater choice of family medicine (13.4% vs 10.4% for out of state), office based primary care (31.7% vs 28.9%), and rural careers (12.6% vs 9.9%) compared to those born outside of the state or outside of the US.
· Instate born students also have the greatest retention instate to practice and therefore return state investments at the highest level, particularly when choosing family medicine. Instate Medical Students and FP Choice
The nation has currently made a series of decisions that will continue to concentrate health, education, and income. More physicians from the most elite origins will only increase costs and supply more physicians in major medical centers. Only improvements in the professionals who are of the people, by the people, and for the people will improve the nation’s education, public safety, health care, and other infrastructure.
Admissions Changes Table 1967 to 2005