Recent Black Family Physicians: Origins, Age, and Locations

Robert C. Bowman, M.D.

Question from Stephen Wilson on Family L list serve:

When comparing Black US Born and Foreign Born US MD Grad medical students

1.      Do Foreign Origin US MD Grads have lower choice of family medicine?

2.      Do Foreign Origin US MD Grad family physicians distribute at the same levels as US Born graduates?

Answer:

1. There is no difference across US or international birth origins in choice of family medicine for the 1997 – 2003 graduates of family medicine residencies from US allopathic medical schools.
2. When considering all of the various urban underserved contributions, rural contributions, military, and teaching contributions, there is very little difference for Black family physicians by US or foreign birth, by rural or urban birth, or by type of medical school. Each of the various types of Black family physicians contribute in important areas of physician workforce. When considering the sum total of rural, urban underserved, teaching, and military careers as all important workforce outcomes, there is little difference in overall contribution. This may reduce down to the final consideration, which is that those who decide for family medicine are deciding for distribution.
3. US MD Grads younger than 26 at graduation from medical school and those graduating from highest MCAT medical schools have lower levels of distribution but have greater contributions in academic areas.
4. The few rural origin graduates have superior rural distribution. The most urban born are rarely found in rural locations but make greater contributions in urban underserved locations.
5. Actual comparisons by parent income level, by parents who are professionals, or by individual MCAT scores may demonstrate differences but this primary data is not released for study.
6. Older graduates do have advantages in rural and urban underserved distributions and are more likely to be found in the military. The military package is likely to be the best fit for an older graduate who is married with family, however direct studies are needed to confirm this. Military and academic careers in family medicine are more likely to involve rural, lower income, and older graduates who otherwise have consistently the highest distribution levels.

Introduction

Medical student career choices are shaped by factors as early as parent occupation to birth origins to education and college to medical school admissions and training. Medical students from higher income origins, elite schools, urban origins, and professional families are less likely to choose family medicine and are less likely to distribute to rural, underserved, and primary care careers. They also tend to be the youngest at medical school admission.

Foreign born medical students have the lowest choice of family medicine, primary care, and rural locations. Foreign born US MD Grads appear to be combinations of these origins and ages which may explain low levels of family medicine and distributional choice.

Which factors are strongest in career choice and distribution?

Family Medicine Choice, Physician Distribution, and Black Family Physicians: Health Policy

Career choices and locations are shaped by other factors. Health policy is one shaping factor. Career choice in family medicine is particularly sensitive to health policy involving primary care reimbursement and priority on support of practice locations outside of major medical centers. During the period of 1965 to 1978 and during 1992 to 1997, family medicine and primary care choice maximized as did physician distribution to rural and to underserved areas. The primary impact upon family medicine choice is within medical school years. For internal medicine the primary impact is during residency training. When medical student increases in family medicine choice are common, retention of internal medicine graduates within generalist office-based careers is also more common. When categorizing by medical school class year, internal medicine retention peaks are in class years 3 or 4 years earlier compared to family medicine.  Five Periods of Health Policy and Physician Career Choice

The differences are obvious to medical students, but not to workforce researchers. Family medicine is different as it is a permanent choice of primary care. All other physician and non-physician forms must continue to make a choice to remain in primary care with each passing month of practice. Those who desire to hedge their bets will choose a transitional form of primary care. In distribution neutral or supportive health policy, family medicine will do well. In the absence of primary care support or support for those outside of major medical centers, family medicine choice will decline. There is also evidence that declines in choice in family medicine are more likely to involve Black and Hispanic medical students. These are students that have made some of the earliest decisions for a medical career and are admitted to medical school later. After spending additional years to gain admission, it may be that these students are looking for health policies that will support their permanent primary care career choice. Historically black medical school students and students in the medical schools with the most Black and Hispanic students have had the greatest decline from 1997 graduates to 2005 graduates. One hypothesis worth testing for all lower and middle income students: after fighting against barriers of income and education for decades, it may well be that some reassurance on the part of government is needed such that more decades of systemic battles are not likely with choice of career. At the current time period and especially for urban family medicine, the reimbursements are low and the costs of practice and living are great and growing. Declines of family medicine choice below the level of distributional type students may indicate that the nation has entered another collapse of health policy eras similar to the time period before 1965. Five Periods of Health Policy and Physician Career Choice

Family Medicine Choice, Physician Distribution, and Black Family Physicians: Matching Ethnicity, Race, Gender and Pratice Location

Another factor involves considerations of the locations where particular graduates will practice. The best matches of patients and physicians clearly improve quality or at least the perception of quality. Better communication may well prevent unnecessary costs as well. Access issues also are important in a complex career such as primary care. Rookie family physicians in rural or in urban underserved areas can make contributions, but the contribution is far less than an experienced family physician who has had a few years to learn the patients, the system, the support personnel, and the referral sources. Estimates of $200,000 in losses for primary care turnover (Buchbinder) may be vast underestimates in underserved locations where losses involve teamwork, institutional memory, experiential learning, and other areas more than just recruitment, lost productivity, and orientation.

Matching race, gender, and ethnicity is a challenge for Black and Hispanic populations since population growth is much greater than the growth of Black and Hispanic physicians. Increases in Black and Hispanic foreign born physicians may help to address certain needs, but do foreign born physicians choose family medicine, choose primary care, and stay in primary care?

Rural populations are growing also but rural born admissions are declining, especially for the males that are found at 15 – 25% greater rural location. Foreign born physicians are rarely rural born, with the exception of nations such as Canada or others that distribute income and education at higher levels and speak English. Even in America declining health and education policies disadvantage rural populations to the same degree as urban underserved populations. Rural born students had the same 40 – 50% probability of medical school admissions compared to Black medical students and the same greater admission rate for females compared to males. Admissions for lower income rural areas was similar to Hispanic students.

Matching up rural and urban backgrounds with patients may also be important, but quality studies have failed to progress beyond gender and race to class and geographic origin. There is little doubt regarding the findings however. Matchups have already played a key role in workforce distributions. Female primary care physicians have been a recent development and still receive a top priority in major medical centers and urban settings. There may well be greater demand than current supply. Major medical centers train 100% of physicians and get the first chance to recruit graduates. Urban served areas share training duties and offer attractive suburban locations. Females who marry physicians or professionals may also prefer the urban locations.Lack of training in rural areas makes it difficult to find rural spouses. Black females may face some of the greatest challenges in attempting to match up with Black males who are less likely to be physicians or professionals, especially outside of the most urban areas. Academic careers may be a nice match for those attempting to balance family, personal, and professional life.

The most difficult matchups involve the needs of the 6 million rural peoples in predominantly Black, predominantly Hispanic, and Native reservations. This is the 10% of rural America with the greatest challenges regarding income, economics, education, and health care access. Outside of these areas rural America is 85 – 90% white. Over 60 years of declines of whites, males, and rural born US MD Grads are a problem for most of rural America regarding all types of rural physicians. Asian, foreign born, Black, Hispanic, and other groups are less likely long term matches for such populations. Those choosing internal medicine are even less likely to be found in rural America. Internal medicine physicians and all other primary care types other than family medicine have been returning to major medical centers and urban locations and subspecialty training for over 50 years. Generalist pediatricians do not tend to subspecialize over time, but 75% are consistently found in major medical center locations. Rural born pediatricians and other specialists may maintain a different equilibrium since about 14 – 20% are found in rural areas consistently over time. The only consistent sources of rural physicians are rural born physicians and family physicians.

Family physicians do not have the same major medical center location or focus as other specialties. This is a likely result of the advantages and disadvantages of family medicine. In some ways family physicians are excluded from major medical centers. In other ways family physicians prefer locations outside of major medical centers. When tracking family physicians over the period from birth to medical school to residency to practice, family physicians leave states with high concentrations of major medical center physicians and move toward states with the fewest major medical center physicians. FP docs are found in the lowest concentrations at 7 – 9% in urban major medical center locations nationwide. In urban served and underserved locations FPs are 16% of physicians, in rural areas FPs are 30%, and in the rural low income and CHC settings (Rosenblatt, Jama) FPs are 50 – 70% or more.

Exclusion may also apply regarding other settings. Black and Hispanic family physicians may be more comfortable in urban underserved locations with predominant Black or Hispanic populations. Retention levels within 60 miles of FP residency training are highest for Mexican American family physicians. Whites may not be retained for prolonged years in Native reservation locations or inner city locations without significant white populations. Rural locations, isolated rural locations, and rural underserved locations are dominated by whites and Natives, populations with the most rural born physicians.

Underserved urban zip codes have a CHC, an NHSC physician, a whole county primary care designation, or serve a population of 20% or more in poverty. Urban underserved location is 3.2% for all physicians, begins at 3.8% for white family physicians, increases to 6% for Asian FPs, then 10% for Other Hispanic and Native FPs, then 14% for Black FPs, 17% for Mexican American FPs, and over 20% for Puerto Rican FPs. Some needs of urban underserved populations are met by major medical center and urban served physicians, but these are locations that decide the types of physicians and the types of patients accepted. Urban underserved locations have higher concentrations of poverty, are more dependent upon federal and state efforts, have decided upon increased concentrations of primary care. Urban underserved locations are the best indication of specific underserved care in urban areas.

Foreign Born Considerations

Foreign born US MD Grads are increasing. Asian US MD Grads share the characteristics of Asians in census reports and are 90% foreign born or have a parent who is. Asian and foreign born components of US MD Grads are over 30% of current graduates. In general Asian and foreign born US MD Grads have the lowest choice of family medicine, primary care, rural locations, and underserved areas. They tend to have parents who were most urban, most educated, highest status, and professionals.

The Historically Black medical schools have increased admissions of foreign born medical students of recent decades, but overall at rates less than other private medical schools. Howard has increased from 20 to 40 in each class or from 15% to 30% from 1987 to recent graduating classes. Meharry has remained about 15% foreign born. Morehouse has admitted 3 or less in 12 of 17 class years since 1987. Since 1970 the Black medical students and foreign born Black medical students have a much wider range of medical school locations. In recent years the Black medical students have had fewer opportunities outside of a select group of "distributional" medical schools that focus more on admissions of individuals rather than their scores. Admissions changes in the United States have been most apparent by income level with 3000 more highest income admissions replacing 1500 lowest income and 1500 middle income medical students now compared to 1997 matriculants.

Admissions Ratios, Changing Admissions, and Physician Distribution

Age is a key factor in elite or humble origins. Those less than 26 at graduation tend to be higher income, most urban, and foreign born medical students. Age 26 is the most common graduation age with 30% and a normal distribution of various types and origins of students. Age 30 and above represents students delayed in admission by obstacles of income and education related to parents and origins and those with second careers in medicine. Historically black medical schools have some of the older allopathic graduates and in recent years the average age has been increasing. This may represent a shift of Black students away from schools that once admitted more Black students back to the historically black schools and the few schools that clearly admit the widest range of students of all origins, ages, and income levels.

One other factor does seem to impact choice of family medicine. Different types of medical schools and different regions of the nation have greater choice of family medicine. The Midwest has greater FP choice followed closely by the west. The south and the Northeast have lower choice of family medicine. Higher MCAT schools have lower choice of family medicine. Populations with eastern, northeastern, southeastern, or east central distributions tend to have lower choice of family medicine. Because black, Puerto Rican, and Other Hispanic populations are eastern in location, FP choice would be expected to be 11 or 12% rather than an average of 14%. Vietnamese and Mexican American populations are located in areas and medical schools with greater family medicine choice. Asian populations are more likely in the most metro areas and Asian populations concentrate on the east coast and west coast in these locations.

An unknown factor is local and state economics. Declines in inner cities are present in most major metropolitan Midwestern and Northeastern states. These are counties that have been losing 5 - 15% per decade. The impacts on education, education policies, reversals of affirmative action, and local economics are significant. Opportunities for Black students may be impacted by these changes.

Finally although family medicine choice is stable across class years dating back for decades, the earliest years after the graduation of any physicians are subject to obligations for military or underserved location. In family medicine this tends to balance out, but this is also a group with the most atypical career and location choices in the history of US workforce. The 1997 – 2003 family medicine residency graduates are generally the same population as the 1994 – 2000 US MD Grads. This group had maximal family medicine choice for the 1995 – 1997 class years and rapidly declining choice until the 2000 US MD Grads. The impacts on workforce are more difficult to predict in this situation. After 2000 the declines in health policy make predictions even more difficult. Below an unknown baseline of health policy support, declines in family medicine choice may make predictions chaotic. This was seen prior to Medicare and Medicaid.

Given the background on choice of family medicine, Black physicians, and family physicians, it is time to return to the questions:

Do foreign born Black Medical Students choose family medicine?

Do foreign born Black family physicians choose underserved locations?

Methods

The following fields were accessed in the AMA Masterfile 2005 Office Max version: birth city, state, and nation of birth; self-designated career choice; ethnicity, gender, and race for family physician graduates of 1997 - 2003 only; age at graduation; and type of medical school. The Masterfile birth origins version involves cleaning and coding of origins by geography and birth county income levels and coding of zip code practice locations. The nation is divided into military, major medical center, served, and underserved locations and rural and urban coding using RUCA 2.0. In addition Historically Black medical schools and the top 20 MCAT medical schools were coded for comparison.

Results

Foreign born Black family physicians are a balance of male and female. US born Black family physicians are 60 - 70% female.

Ethnicity and race data was not provided to the author except for family physicians. By assuming that nations with the highest Black populations contribute Black physicians and checking this assumption with ethnicity and race in known family physicians, birth country estimates can be made.  

The average for FPGP choice for this time period is 14% for US MD Grads. The 15.5% choice is similar to the average and similar to FPGP choice in US born Black Physicians. The average FPGP choice for foreign born US MD Grads increases to 17.3% without Ethiopia and the 3 lower choice African nations. This is similar to FPGP choice in older and lower income US MD Grads. Only rural origin grads have greater FPGP choice and are more of a combination of rural, lower income, and older US MD Grads.

In studies of family physicians, the most exclusive populations have lower family medicine choice. This includes higher income or more elite types of students by US origins, medical school type, or birth in other nations. With increases in the percentages of physicians born in cities or counties with medical schools in the United States or in other nations, there is a decreased choice of family medicine and physician distribution. The most likely explanation is that children of physicians or professionals are a primary factor in career and location choice. The Masterfile with secondary data does not capture scores, parent income, or parent occupation. However comparisons by ethnicity and race also are consistent. Asian US MD Grads do have the highest levels of professional parents followed by White and by other groups. Within Whites the % choice of family medicine goes down as levels of professionals in counties go up.

Actually the total FP admission rate is a constant 1 per 100,000 per year in normally distributed populations, but the total medical school admissions for all specialties increases from 3 to 20 with higher levels of people, income, education, and professionals. This means a lower percentage choosing family medicine in areas with a higher rate of admission as in 1 in 4 or 25% for 100,000 rural or lowest income people compared to 1 in 20 or 5% for 100,000 people in top income or most urban areas. One consideration is that in lower income groups, individual student characteristics make more impact. In the higher income groups, the admission and the chance for admission is about parents and how they structure environments for their children and others in the area. Shaping a Nation: Physicians Who Serve

So far there is no difference regarding foreign born and US Born Black physicians.

Income Origins

Comparisons by birth income level do not reveal differences in distribution for underserved or urban underserved locations. Rural location for US born top income birth origin black family physicians is 7% compared to 11 or 12% for other origins and foreign origins. Those raised in the highest income and most urban environments have few rural experiences and their training tends to be in locations surrounded by the least rural workforce.

Age at Graduation

Comparisons of younger US MD Grads can indicate those of more exclusive origins, regardless of US or foreign birth. Younger US born family physicians have only 7% rural location and concentrate in major medical centers at 70%. These are low levels of distribution common in general internal medicine graduates. Underserved urban location remained at 6 – 7% which is twice the average of all physicians, but half of the usual urban underserved distribution of Black family physicians. Younger graduates and elite medical schools both have about 20% of the younger graduates found in teaching positions.

Perhaps the best measure of physician distribution overall is a measure of the total physicians minus those found in major medical centers. A group concentrated in major medical centers is not distributed to rural, urban underserved, or military careers. Historically Black US MD Grad family physicians are found outside of major medical centers at greater levels. Foreign born Black US MD Grad FPs from the three Historically Black medical schools give up some rural distribution but maximize underserved distribution at 26.8% while US Born Grads have greater rural and rural underserved distribution and maintain superior overall underserved distribution at 21.5%. Overall the small numbers of younger Black US MD Grads limits much analysis.

Lower underserved and rural numbers in elite schools have compensation in greater teaching positions and some military FP. In a few more years the study population can be repeated to see if academic, military, and other locations change from 2005 locations and careers.