Have done some more thinking and examining the information on rural programs. There is obviously some regional variation (refer to RFD newsletter on regional tables and see PHS table below). This points to some as yet undiscovered factors that could be relevant. I think there are some economic, program creation/leadership, and procedural indicators that are worth examining.
The economic data are interesting. Programs in sites with lower median family income produce more rural docs. Are FP programs a response to physician need?
The case for procedural factors is circumstantial. Although we do see a relationship between the months of OB and % of program's residents choosing rural, the months of OB are not as important as possibly the actual OB volume and intensity. Note the west to east variation. Note also that the western programs produced a higher rate of rural than their state rurality would dictate.
Did some recent comparisons of 1994 and 1996 ob months required. Programs with a decline in Ob in the curriculum during that time (n=28) had a lower rate of production of rural physicians in 1992-1994. Perhaps there is a dynamic between programs and graduates. We'll see if this decline results in a decline in the rural production of the program in subsequent years.
The case for program leadership has to do with current data and the lack of rural infrastructure. Only program directors and predoc folks have the ability to impact much on programs. Rural faculty certainly don't. The highest individual correlation with rural doc production was the per cent of faculty that had been rural docs (.42), but this factor was not significant. Male program director gender is related to production of rural docs, but this is likely a timing thing that will disappear with more female fps over the years. A further question regarding the program director having rural experience will clear this up. This may increase the variance explained quite a bit. This has implications for where we 'want' to have new fp programs located. There are several new programs in smaller areas (used metro populations, not city pops):
Program site population for the newest FP Programs
less than 100k 28 generally smaller programs and rural training tracks
100-250k 8
250-500k 9
over 500k 15 generally larger numbers of residents per program
This may even be a trend. I doubt if it is guided by any state or federal policy or encouragement. Perhaps it is in response to problems training in academic dominated areas? As far as PHS regions go, the program creation is fairly balanced across the regions for the 1992-1995 group. So much for my bias that there were more western programs created. Haven't looked at increases in individual program size yet though. Even so, a movement of residents to more western states has the potential for more rural doctor production.
Factors with a Relevance to Rural Graduation Rate For Family Practice Residency Programs By Public Health Service Regions
|
PHS |
Rural Grad % |
Rural Months |
Ob Months |
# Other residencies |
City Pop Avg |
% of State that is rural |
Rural Mission |
Match |
|
Region |
|
|
1996 |
|
|
1 - 5 range |
1996 |
|
|
1 NE |
30.4 |
1.67 |
3.4 |
2.64 |
125k |
31.2 |
3.6 |
0.97 |
|
2 Mid At |
19.6 |
3.05 |
2.7 |
2.57 |
2969k |
6.1 |
4.6 |
0.84 |
|
3 CenSE |
29.2 |
5.78 |
2.7 |
2.50 |
321k |
21.8 |
4.2 |
0.86 |
|
4 SE |
36.2 |
3.13 |
2.8 |
2.42 |
173k |
34.6 |
3.3 |
0.86 |
|
5 SCen |
29.9 |
1.39 |
3.1 |
2.30 |
540k |
24.0 |
4.3 |
0.88 |
|
6 Cent |
29.6 |
0.59 |
3.0 |
2.74 |
421k |
30.8 |
3.1 |
0.85 |
|
7 N Cent |
36.7 |
1.20 |
3.0 |
1.71 |
222k |
46.8 |
3.5 |
0.90 |
|
8 NWCen |
42.8 |
1.12 |
3.6 |
1.4 |
126k |
39.9 |
3.0 |
0.94 |
|
9 NW |
19.8 |
0.70 |
3.0 |
2.56 |
856k |
7.3 |
4.3 |
1.00 |
|
10 W |
39.1 |
4.25 |
4.4 |
1.57 |
248k |
28.5 |
2.7 |
1.00 |
|
Avg |
30.4 |
2.35 |
3.0 |
2.35 |
636k |
25.3 |
3.9 |
0.89 |
|
required |
required |
|
|
1 is rural |
Rural mission, rural state, rural rotations, smaller towns for training, fewer other residencies, more OB months all are factors, more or less in various regions.