Robert C. Bowman, M.D.
Distribution involves movement outside of Major Medical Centers where 70% were born, raised, and educated and were 100% were trained. Distribution includes urban underserved, urban served, rural underserved, and rural served areas.
Standards for distribution involve rural location as in rural major medical centers, rural underserved areas, and rural served areas and this is about 11% of physicians in the United States. Urban underserved areas are 3.5% and rural underserved areas are 2.9% for US MD Grads but increase for osteopathic and international graduates. The US Physician average is 7.0%.
Medical schools that distribute have admitted more medical students from outside of major medical centers, they benefit from policies of state education that prepare a broader range, they train with emphasis on practice outside of major medical centers, and they distribute graduates.
Family Medicine is a major factor in distribution. Family medicine choice basically doubles rural or underserved distribution levels in all types of students, from the most urban origin major medical center types to the most rural lowest income origin types.
For each type of medical school listed below, the following data was compiled for 1987 - 1999 graduates: birth county income quartile, % born in other countries, % older than 29 years at medical school graduation, % in family medicine for 1997 and for 2005 graduates, and the distributional indicators of outcomes in rural and in underserved locations. Table data on birth origins is included at Birth Origins and Distribution Tables
The West Coast Distributional schools were UCLA, UC Irvine, UC Davis, and the University of Washington.
Medical Schools and Distribution for tables comparing origins, income levels, and outcomes
Distributional types of students are those "outside," distant, or excluded. This 30% of US MD Grads is a group with lower and middle income origins, older age, and rural birth. They choose distributional careers at higher levels. Non-distributional types of students are highest income, foreign born, younger, and born in counties with medical schools. They are found in major medical centers and subspecialties at the highest levels. They also have greater probability of admission.
With increases in distributional types of students, medical schools distribute at higher levels and the students have increasing choice of family medicine and locate outside of major medical centers in rural and in underserved locations.
Health policy impacts are seen by comparing the 2005 FP choices with the 1997 class choices. During this period of time the nation increased primary care and Medicaid funding and decreased funding to those outside of primary care. Students had to reconsider jobs outside of primary care, given predictions of future workforce. This essentially limited GME positions in all except primary care and family medicine residency programs. FP positions offered and filled increased over 30% from 1992 to 1998 and hospitals support specialty positions plunged.
Who changed choice also is an interesting consideration. The highest MCAT schools did graduation more family physicians in the peak levels of 1995 - 1997, but the numbers involved were small. This appears to be a group largely committed to subspecialty choice and major medical centers and includes the most younger, higher income origin, foreign born, and highest scoring types. The schools that have the highest level of distributional types of students also had less change. The most distributional types such as Rural Interested Senior Medical Students have also had earlier decisions. Health policy does not appear to impact the extremes of socioeconomics at either end. However the great majority in the middle did react, particularly those with ties (instate or birth in the medical school county) The impact of health policy was great on the Historically black schools and the schools with greater percentages of Black and Hispanic students, as indicated by the West Coast Distributional schools.
Without the reassurance of support for primary care and funding outside of major medical centers, it is difficult to get students to commit to the lifetime of primary care known as family medicine, or to be retained in all other primary care careers. Primary Care Retention The precipitous decline in primary care is apparent in the US MD Grads mostly and in US MD Grad choices in family medicine which have cut in half, but the demise of family medicine is exaggerated since the sources of family physicians have changed. Filled first year positions have remained at the 3400 per year level since 1996.
Actually those choosing family medicine have been forced to take a different route as the lower income, rural, and middle income types most likely to choose family medicine had been replaced in allopathic schools. The osteopathic and Caribbean schools have greatly increased in number, students, and contributions to family medicine during the same period. Given the costs of applications, MCAT preparation, and interviews and the lower probability of admission for humble origin types, they may be making an efficient decision to bypass medical schools unlikely to admit them or to be able to meet their needs, as in the case of Rural Interested Students. Unfortunately humble origin students in states without a public medical school, a distributional medical school, or support of education and higher education for lower and middle income students, are unlikely to gain admission.
Distribution of professionals requires distribution of state and local education to lower and middle income populations, admissions with less focus on scores and greater focus on people skills, training emphasis on areas needed by distributional types of students (see evaluations by Rural Interested Students), and distributional health policy.
Five Periods of Health Policy and Physician Career Choice
Changes in Specialty Choice 1987 - 1999
Physician Workforce Studies
Medical Schools and Distribution
Physician Distribution in the United States