See also Flawed Physician Workforce Beliefs
There are more than a few ways of examining workforce. Two stand out from the crowd.
The nation continues to fail in physician distribution. Despite a number of elegant efforts and successful models, poor distribution remains. Models, programs, statewide efforts, and even nations such as Australia have managed to improve distribution and the health access, economics, health resource, and population support that health can provide. In the smaller rural areas, health and education provide the largest components of economics and are critical for maintaining jobs and recruiting new jobs.
The few distributional successes have few replications and the replications are often limited by accreditation. Publications have not been limited, but apparently are not read, not believed, or are conveniently ignored. The United States clearly could distribute physicians but has chosen not to.
The decisions that have influenced the United States include all of the areas related to distribution including education, admissions, training, specialty choice, and health policy.
In such situations it is useful to look at the reasons why a nation continues to make poor choices. Studies demonstrate that it is entirely possible that individuals or groups from two different viewpoints can observe the same types of data and come to two very different conclusions.
Percentages Versus Numbers
From birth origin studies involving all of the graduates of allopathic schools there is little doubt that the 30% of students who are most different have greater distribution. The 70% from the more typical urban and high income locations have the lowest percentage distribution. Because the urban origin students dominate admissions and have the largest share of total physicians, they also supply the most numbers of rural physicians, primary care, underserved physicians, and family physicians. For those training their kids for SAT tests: Core Metro birth origins is to admissions as family medicine is to distribution.
However increasing more and more students who are the least likely to choose rural practices will not help rural workforce. The nation must find ways to influence these physicians or find ways to balance out education so that more distributional student types are admitted. Rural workforce will not improve unless the physicians admitted and graduated have over 11% rural choice. A focus on percentages is a distributional perspective.
A focus on numbers is a major medical center perspective. Numbers, even small numbers, can be distorted. As long as there are students that get National Health Service Corps scholarships and as long as there are some alumni from rural areas, there is still some evidence of distribution, even temporary. These few can reassure faculty or leaders that the school is distributing physicians, even though it really is not distributing. Public relations can also shape this as in medical schools graduating only 4 black students but all 4 have major stories published at graduation.
Focus on the Year to Year Rather Than Long Term
Most medical schools focus on a few measures such as the matriculants in the current year, the graduates, “match” choices, and first practice locations. Matriculant and graduate characteristics change little year to year, but over recent decades there have been major changes in Asian students, foreign born students, and higher income students. Declines in whites, males, rural origin, instate born, and lower income types have also been prominent. Without the right perspective some important associations can be missed: nearly all distributional types have declined and all have similar problems with barriers of income and education. A perspective that considers the longer term view or one that approaches workforce from a more global perspective will ask and answer questions in a very different way.
A true recognition of the problems might also force medical education leaders to lobby for improved public education. It is also entirely possible that leaders may recognize that this might compete with higher education. This could cause problems in state budgets and might even conflict with the college hopes of their children.
Focus on “Outliers”
Good research always considers outliers as a most important group to consider. In Starfield’s research, there are high and low outliers in health care cost and quality curves. The outliers tend to be states that concentrate income, education and health resources that deviate most in one perpendicular while the breadth states such as Utah and the Midwest deviate the opposite direction. While the focus involves generalists in primary care, there is also the same scatterplot pattern generated with high school graduation rates and health care costs and quality, as well as prison costs, welfare costs, insurance costs, etc. It is possible that the real driving force for quality and costs and basic efficiency is breadth of education. Many still assume that we have this, but the variation state to state is remarkable and tragic. Since breadth of education also drives choice of family medicine and generalists the cost, quality, family medicine, primary, and high school graduation curves are all related. They may even be complementary. However a focus on family medicine and primary care has gone no where. Education problems are also obstacles for school teachers, public servants, counselors, nurses, and basically all of the other service oriented young professionals who stabilize all of the major systems in the United States in health, education, and public safety. A focus on education could have more allies from the 70% of the population being left behind and the 100% of the population that depends upon functional systems. Such a focus could help states turn around the massive costs of prisons, health care, social costs, and energy that continually choke back the remaining efforts in education.
The key to understanding the total picture often means developing theories that integrate current science with new developments. Such observations can be difficult when the focus is elsewhere. As an example, during managed care the focus was on health care costs, physician loss of autonomy, changes in career choice impacting certain disciplines, or loss of hospital revenues. Lost in the controversy was the best distribution of physicians in the nation’s history, including a 45% increase in rural family medicine and the first time period that rural workforce stopped a steadily downward year to year decline, for a short time.
The Case of Disappearing Distribution
Medical education leaders have been known to support the admission of a variety of different student types publicly. This is often a chosen venue near retirement. However during their early and middle careers this was lacking. Even in the late career reform efforts they may not fully express the same concepts in private or in discussions. While some may consider this hypocritical, another explanation is the perspective of medical school leaders.
When considering the choice of family medicine and distributional careers, those in lower income origins have greater choice. The distribution disappears at higher income levels.
It is important to control for rural or urban origins when doing such studies. Rural birth origin is known to have the greatest choice of family medicine and rural distribution, but is this always true?
Tables on Birth Income vs FP and rural choice by urban or rural birth
At lower and middle income birth county levels in both rural and in urban birth, there are differences in distribution. Much the same is true of student age and school MCAT. At older ages there are differences in distribution, but not in younger. In schools with the top MCAT score averages, the distributional differences also disappear.
This means that the wisdom of rural origin admissions for rural distribution has a corollary. Rural born students are more likely to choose rural locations, as long as they represent the 75% who are lower in income and the 75% who are older in age. It also means that the elite schools are not going to distribute physicians. They are also not going to graduate family physicians.
Perhaps more importantly is that the graduates of elite schools and the leaders who graduated from these top ranking schools are not likely to believe that birth origins or career choices impact distribution.
The Pennsylvania medical schools provide an illustration of the perspective of top MCAT schools. In the bottom line for the University of Pennsylvania there is low choice of family medicine across the income distribution. Next up is the University of Pittsburg in ranking and in poor choice of family medicine. The the MCP Hahneman graduates and finally Penn State and then Jefferson. Jefferson manages improved choice of family medicine in the middle and lower income origin segments. Temple has slight improvements from the lower income group and also in the $14000 income level group that tends to have medical school admissions from inner city origin students. The top ranked schools actually have very few lower income origin students and so the perspective is even more stacked in favor of those of typical high income, most urban, highest scoring students.
Viewed from the standpoint of most of the top 25 or 30 research schools with low levels of distributional students, low levels of family medicine, and low levels of middle and low income origin students, distribution does not vary. At the highest MCAT schools there is little difference across age or birth origins or birth county income levels.
Mercer has a wide range of lower income county origin types and has one of the lower MCAT average scores as a result and has one of the best physician distribution patterns of all medical schools. Duluth is interesting because it gains consistent choice of family medicine across income and also across rural and urban and other characteristics as well. Duluth has perhaps the most atypical admissions of all and by far the most focus on rural and family medicine and overcoming obstacles and true primary care interest and returning to rural locations. The only thing that holds Duluth back is that Greater Minnesota does fairly well for a rural portion of any state. The distribution of education and income and health resources are a part of the reason for the successful admissions of Duluth and a product of Duluth’s graduates as well.
Restrictions on Perspective
Common to the above scenarios is a major problem. Most of the evidence in the above has been developed at great extra cost because the individual student data is not readily available in important and sensitive areas such as income, ethnicity, and MCAT scores.
Most are blissfully aware of the importance of income levels and how closely linked income, family education, and student age at admission are to MCAT scores and choice of family medicine and all distributional careers.
Even reassurances regarding the quality of the MCAT have not satisfied the concerns. The MCAT is not the problem so much as medical school admissions committees need a greater understanding of the linkages between birth origins, education, college access, admissions, training, health policy, and distribution. Not stimulating each school to do their best to understand this at the local, state, and national level means that the nation will continue to divide.
In summary, perspective is very important to understanding. All physicians must understand weak areas or situations where they need help. Those with leadership positions that are responsible for health care in a nation, state, or medical school must broaden their perspectives in other leadership or advisory positions.
As the nation admits more and more students from narrow origins and a greater concentration in the elite medical schools, there is every potential that the mainstream of medicine will deviate significantly from the mainstream of the United States.
Newer studies will also be indicating differences in the socioeconomic levels regarding service orientation and empathy in addition to family medicine choice and distribution. Medical schools and medical educators can choose to join in early, or they can wait for the inevitable consequences that will result.
Those who would hope to heal divisions in health, income, policy, and leadership must first attempt to understand differences in persp
Physician Workforce Studies