Distribution: Index Concentrations of Physician Distribution

The indexes were generated by comparing the percentage of each group found in each location to the percentage composition of the group in the US workforce. For example, rural born US born FPGP physicians have 9.1% rural underserved location and are only 2% of total physicians in the United States workforce. 9.1 / 2 is 4.56. The following are ranked from the top total underserved contribution to the bottom. Improving the distribution of physicians in the nation involves admissions or training that concentrates physicians in underserved areas and disperses physicians away from major medical centers.

WARNING  WARNING  WARNING   Unlike other sites and the top workforce reports in the US, this site warns you that the following data is bivariate. The actual distributions are the results of multiple factors - origins, training, career choice, and other factors. Bivariate is instructive, but can be distracting or deceptive if not understood.  see www.basichealthaccess.org for logistic regression with multiple variables and controls.

Total Under-served

Group 

Urban Under-served

Rural Under served

All Rural

Rural Not MMC

Major Med Center

Isolated Rural

Isolated Under served

Military

18.4%

Black,Hisp, PR, Native FP

3.78

2.33

1.26

1.48

0.69

1.33

1.51

1.06

15.5%

Rural Born US Born FPGP

1.07

4.56

4.26

4.89

0.55

6.09

6.08

3.78

12.6%

Foreign Born IMG Off IM

1.97

2.48

1.47

1.71

0.82

2.00

3.63

0.28

11.8%

Fam Practice Gen Practice

1.70

2.48

2.28

2.64

0.67

3.36

3.43

1.06

11.3%

Urban US Born FPGP

1.83

2.15

1.89

2.19

0.70

2.91

2.93

2.00

11.1%

White Family Physicians

1.15

2.28

2.15

2.48

0.57

2.90

2.40

1.92

10.3%

Historically Black School

2.46

1.08

0.81

0.85

0.89

0.67

0.82

1.44

9.3%

Bottom Quartile County Birth

1.17

2.15

1.97

1.97

0.91

1.86

2.17

1.39

9.2%

Osteopathic Low MCAT

1.39

1.85

1.66

1.75

0.81

1.75

1.77

1.34

9.0%

Office Primary Care

1.47

1.70

1.53

1.69

0.84

2.00

2.13

0.72

8.4%

Asian Family Physician

1.67

1.27

1.08

1.24

0.80

1.79

1.53

1.19

8.4%

Inclusive Primary Care

1.40

1.56

1.39

1.53

0.87

1.82

2.00

0.94

8.2%

Rural Born in US

0.83

2.11

2.30

2.31

0.89

2.18

2.28

1.39

8.0%

Foreign Born IMG

1.40

1.41

0.98

1.04

0.99

1.18

1.63

0.22

7.8%

School MCAT < 9.5

1.15

1.61

1.56

1.52

0.94

2.18

2.34

2.09

8.0%

Foreign Born IMG Off FP

1.33

1.37

0.94

0.99

1.00

1.18

1.60

0.22

7.7%

Osteopathic High MCAT

1.32

1.38

1.59

1.65

0.81

1.65

1.72

1.21

7.3%

Office Internal Medicine

1.27

1.30

1.09

1.13

0.96

1.18

1.55

0.50

6.8%

Office Pediatrics

1.43

0.93

0.90

0.90

0.95

0.73

0.63

0.72

6.7%

Not Born MS City/County

1.07

1.30

1.24

1.26

0.96

1.36

1.37

1.00

6.6%

All Foreign Born

1.30

1.00

0.78

0.81

1.01

0.82

1.03

0.50

5.7% National Underserved Average of 3.0% Urban Underserved and 2.7% Rural Underserved                
5.3%

Off IM US Born

0.93

0.93

1.05

1.01

1.01

0.82

0.80

0.61

5.2%

US Born

0.87

0.96

1.09

1.08

1.00

1.00

0.95

1.28

6.6%

Foreign Born USMD Grad

1.17

0.52

0.54

0.53

1.05

0.36

0.33

0.78

4.8%

General Surgery

0.65

1.07

1.22

1.21

1.04

0.86

0.54

1.59

4.8%

Born in MS City/County

0.93

0.74

0.80

0.78

1.03

0.73

0.70

1.00

4.0%

Top Inc Quartile County

0.82

0.56

0.70

0.67

1.05

0.68

0.56

1.12

3.9%

Orthopedic Surgery

0.53

0.85

1.07

1.00

1.05

0.43

0.49

1.51

3.1%

School MCAT 10.5 - 12

0.74

0.31

0.36

0.33

1.13

0.21

0.18

0.63

Improving distribution is about concentrations. Increasing the numbers of physicians with higher concentrations of a desired underserved or rural location will be more likely to increase the workforce in this location. This can involve admissions, training, or health policy support. It takes additional work and expense to locate physicians against their desired career and location choices. Retention is also likely to be lower and services may be more compromised. Cost, quality, and access are more likely to improve with physicians that share common origins, background, and experiences.

 Points
1. Those least likely to gain admission are most likely to distribute to the most needed careers and locations
2. Physicians tend to return to birth origin locations, especially when choosing a career with broad scope such as family medicine which allows the full expression of birth origin tendencies
3. Accelerated graduates contribute at the highest levels of distribution
4. Understanding physician distribution requires understanding origins, admissions, training choices, and health policy
5. Physicians most closely connected to major medical centers for the first 30 years of life are the least likely to leave these careers and locations
6. Obligations and health policy supports are important for distribution. J-1 Visa effects in international medical graduates in internal medicine, in military careers, and in family physicians (NHSC, CHC, etc.) make important contributions to career and location choice


By categorizing physician locations across the nation, the total contributions to rural underserved and to urban underserved locations can be determined. Rural underserved locations have about 2.7% of US physicians and urban underserved locations occupy 3.0%. This is a total of about 5.7% for the 1987 - 1999 Graduates of all medical schools in the world in US locations as listed in the AMA Masterfile for 2005, This is about 50% of the active physicians of the nation and the most recent to graduate and distribute to equilibrium careers and locations

The Total Underserved percentage in the table below represents the urban underserved plus rural underserved contributions of the particular group. All with greater than 5.7% are contributing to the distribution of physicians in the nation above the national mean. Underserved locations are zip codes with 20% or more in poverty or have a CHC, NHSC, or whole county shortage area designation.

Total Underserved %
Group of physicians

18.4% Black, Mexican American, Other Hispanic, Puerto Rican, or Native FP
15.5% Rural US Born FPGP
14.7% Accelerated family medicine residency grads (n=136 from 12 schools)
12.6% Foreign Born IMG in Office Based Internal Medicine
11.8% All Family Practice Gen Practice
11.3% Urban US Born FPGP
11.1% White Family Physicians
10.3% Historically Black Medical School Grad
9.3% Bottom Quartile County US Birth
9.2% Grad of Osteopathic Lower Half MCAT School
9.0% Office Primary Care - IM, FM, PD, MPD, GP and the office based primary practice activity, a measure closest to actual primary care
8.4% Asian Family Physician
8.4% Inclusive Primary Care - any primary care type adding geriatrics to the above and any primary practice activity (poor measure of PC)
8.2% Rural Born in US
8.0% Foreign Born IMG
7.8% Grad of School MCAT < 9.5
7.7% Foreign Born IMG Office FP
7.7% Grad of Osteopathic Highest MCAT half
7.3% Office Internal Medicine
6.8% Office Pediatrics
6.7% Not Born in a City or County with a Medical School
6.6% All Foreign Born
National mean of 5.7% here for the 294,000 in the 1987 - 1999 cohort from all sources
5.3% Office IM US Born
5.2% US Born
4.9% Foreign Born US MD Grad - about 16% of US MD Grads now
4.8% Born in MS City/County - a likely proxy for children of professional parents
4.0% Top Inc Quartile County
3.1% Grad of School with MCAT 10.5 - 12 - obviously other areas are emphasized as these schools lead in MCAT, board scores, wealthy parents, foreign born, youngest graduates, researchers, and fellowship positions, but distribution, primary care, family medicine, and diversity are found at the lowest levels in the nation for this 20% of US MD Grads. Much of the medical leadership of the nation also arises out of this group with the least exposure to physicians choosing distributional careers, primary care, or family medicine.

I don't have parent income, but I can use birth county income origins as a proxy.
I don't have MCAT scores on individuals, but I can use school MCAT as a proxy for national distributions. Higher MCAT is associated with lower distribution and lower choice of FM and lower levels of income in a number of studies. Higher MCAT is a measure of parent influences.

One other proxy that I have developed involves birth in a city or county with a medical school. This appears to be a proxy for parents who are physicians or professionals or at least professional and physician parents are concentrated at the highest levels in counties or cities with medical schools in the United States. Concentrations are also seen in certain populations. For example the top quartile counties that have a medical school are just 51 counties, 1% of the land area of the United States, 20% of the population, 47% of the Asian population, 32% of the Hispanic population, 22% of the black population, and 17% of the white population. These counties are also declining in percentage of the US population as many are stagnant or losing population.

Admissions ratios are lowest for the medical students socially and geographically distant and physician distribution levels are the highest.

MCATs, board scores, origins, and parents line up for major medical center physician locations. Schools admitting under policies based more on the student than their scores/parent influences admit older students, diverse students, lower income origin students, and graduate more family physicians, who distribute at the highest levels.

Family medicine is the only specialty with more than 50% of the specialty located outside of major medical centers. This allows family physicians to be the largest proportion of physicians in all other locations, including urban underserved, urban served, rural, rural underserved, rural served, and all of the various shortage designation types. Family medicine choice also doubles teaching probability, a level not found in internal medicine or other career choices.

Family physicians benefit from broad scope, enhanced privileges, increased procedures, lower costs, and better income levels in states with fewer physicians concentrated in major medical centers. These are also states with lower health care costs and better quality of care, for a number of reasons that may or may not related to family physicians. These are also states that do better in a wide range of education, income, economic, social cost, prison, and other outcomes.

Percentage of Physicians Compared to % found in underserved areas, both urban and rural underserved types

% of Physicians   Urban Under-served Rural Under served
US Population 2000    
100.0% National Averages 3.0% 2.7%
29.7% Office Primary Care 43.5% 50.5%
15.3% Fam Practice Gen Practice 26.1% 38.1%
11.2% Office Internal Medicine 14.2% 14.5%
11.2% White Family Physicians 12.9% 25.6%
3.4% Black,Hispanic,Native FP 12.8% 7.9%
6.4% Urban US Born FPGP 11.8% 13.8%
5.8% Office Pediatrics 8.4% 5.4%
6.3% Off IM US Born 5.9% 5.8%
2.0% Foreign Born IMG Off IM 3.9% 4.9%
1.4% Asian Family Physician 2.3% 1.7%
2.0% Rural US Born FPGP 2.1% 9.1%
0.7% Foreign Born IMG Off FP 0.9% 0.9%

FPGP physicians are only 15.3% of the total physicians but are 26% of the urban underserved physicians of the nation and 38.1% of the rural underserved physicians. Family medicine choice more than doubles distribution levels. Multiplier effects are seen for a variety of origins and for family medicine choice. Again this is possible for specialties that give up major medical center location. No other medical specialty does so and nurse practitioners and physician assistants also concentrate in major medical centers. Family physicians stay in family medicine at 98%, office primary care at 90%, and outside of major medical centers above 50%. All other forms of primary care collapse into major medical center careers and locations over time. Family medicine remains at double rural and underserved national averages (>22% rural and > 11% underserved) for all class years dating back to the creation of family medicine.

International medical graduate physicians in office based internal medicine also double urban underserved and rural underserved distribution. These levels require J-1 Visa waivers for distribution. Bypass of waivers would result in loss of rural underserved distribution although the urban underserved distribution would remain. The lack of distribution for IMG family physicians is worthy of study and may require examination of qualification procedures and preferences.

Similar high levels distributions are found in obligated US born family physicians.

Family medicine accomplishes distribution despite higher levels of military obligations that take the family physicians most likely to be found in rural underserved and urban underserved locations.

Asian and foreign born IMG family medicine contributions are limited by concentrations in practice in California, a state with only 4% rural population and lower levels of urban underserved location. Asian FP rural levels of 8% do not seem like much, but this is double the California rural concentration. Asian and foreign born family physicians are the fastest growing component. White, rural, males are declining at the most rapid rates.

Different types of family physicians make different contributions to various locations, usually according to birth origins.

Qualifiers - Family physicians who are youngest in age at graduation, those from elite and highest scoring schools, those from highest income counties, and those from international medical schools do not have the same 2 - 6 times multpliers for distributional locations as found in typical family physicians.

Family physicians also have the highest levels of retention within the state location of their medical school for practice. Admissions of medical students born in a state (Instate birth) and choice of family medicine are the two major factors in brain drain prevention in physicians. Osteopathic, older, and lower income origin factors also increase instate retention.

Robert C. Bowman, M.D.   rcbowman@atsu.edu    www.basichealthaccess.org

VISA Programs: Do They Help In Primary Care and Rural Areas?

Ranking Medical Schools and FP Residency Programs - listings of actual medical school contributions to rural workforce
 

Sources of the Current US Physician Workforce - who provides rural, essential, and other types of physicians

Frontier Family Medicine Choices by medical school name and type

Rural Coding RUCA 2.0 and the US pop and poverty by state

Accelerated Family Medicine Training Programs

Rural Recruitment and Retention Factoids

Physician Workforce Studies

www.ruralmedicaleducation.org

 

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