Numerous studies document that fp residents diffuse out into even the smallest rural areas (burkett,Stefanu, geyman jfp 1980)

Madison DL, Combs CD (1981) Location Patterns of Recent Physician Settlers in Rural America" Journal of Community Health 6:4 267-274 Summer 1981  

951 docs who stayed at least a year in mid 70s in counties of less than 50000 in towns of less than 10000

Nebraska number 1 in location in small counties when adjusted for size of class, number 2 overall

Nebraska was number 2 in med school production of these physicians  (in 1981 study) with 28, NE was number 1 when adjusted for size of med school class.

NE state data 13 of 24 located in towns with fewer than 4 docs.

mainstream nhsc

<2500 358 38 197 70 17 81

<4999 244 26 52 19 4 19

<9999 349 36 26 11 0 0

951 275 21

Other findings from other studies

1. mid 1990’s data in FP - only a small number of young physicians going small rural

686 in three years 7743 per yr production or 3% per yr

2. fmgs 28% esp in certain states

3. most new docs moved where existing 4 doc or more

4. lower than 4 and not likely to get back above without external help as outside the mainstream choices above

grimes study from 20 yrs ago - delphi of "rural experts"

student factors practitioner factors

1. rural preference 7

2. rural preceptorship

3. potential for rapid practice growth 4

4. availability of group 8

5. spouses attitude 1

6. community orientation of practice 5

7. assistance with start up 10

8. activities for spouse 6

9. location of residency 12

10. close (one hour) to larger center 9

culture and shopping

11. availability of peer professionals 3

12. available facilities 2

13. available cultural 18

14. orien of prof ed to problem

15. location of internship 16

16. recreational activities 11

17. financial incentives

18. curriculum to pc and underserved

19. family attitude 17

20. available specialists 15

21. per capita income 13

22. rural location of pri sec educ 14

23. advice, location of friends 19

24. commun prestige, opp for comm leadership 20

policy effects

cannot change 1,5,8,19

4,11,12,20 better facilities and manpower

3,10,13,16 geography and economy happenstance

2,9,14,15,18 selection, education, decentralize

7,17 financial assistance

6 inherent in rural practice

only a few variables can be changed by govt and only moderate effect

Confounders

Previous studies predicted the diffusion of residents into smaller rural areas (langwell Jrh july 85 ODAM report jun 83)

Conclusions

FP residents are the most likely to go rural

FP residents choose areas with more health resources

Certain programs produce residents which go to small rural

Diffusion theory has limits

specialist practice ratios

fp ratios shared call, resources, patient numbers

Smallest rural very different

no hospital, comprehensive office, pharmacy, etc, call variable

It is not possible currently to show that smaller community based or rural programs contribute to more rural locations because

selection bias

trends are toward more diffusion

Major benefits of a more rural location for training may be in better preparation which may pay off in better quality and better retention

Some areas will not be able to successfully attract and keep rural physicians