Rural Interested Senior Medical Students and Rural Workforce 

Robert C. Bowman, M.D.  rcbowman@atsu.edu

Studies of senior medical students who have indicated an interest in rural practice can be helpful in understanding the characteristics related to geographic distribution of physicians. The 350 senior medical students interested in practice in small towns of less than 2500 people and rural areas were compared to 14299 of their peers regarding their responses to the 1995 Association of American Medical Colleges (AAMC) Graduation Questionnaire.

Higher percentages of older, married, white, public medical school, and rural origin students were interested in rural practice. Rural interested seniors preferred family medicine at 68% and chose rural, international, military, government, public health, and extracurricular underserved experiences at 60 – 110% greater levels compared to other students at each year of medical school. The 60% level of interest in locating practices in a socioeconomically deprived area is over 5 times the 11.5% level of peers and the highest interest level noted in any student group.

Birth origins, maturity, service-orientation, spouse factors, an early decision for career, self-directed curricula, and dissatisfaction with current medical training are key characteristics of students interested in rural practice. The curricular choices and volunteer work of rural interested seniors may be a reflection of personal values or they may reflect specific preparation for a challenging career. This contrasts with more typical students who decide late, volunteer less, choose residency training that is still a transitional phase, and have less opportunity to use the full span of medical education to prepare for their final career choice.   

The literature regarding rural health was considered regarding the expected findings for rural interested seniors. This was also compared to the survey findings regarding the 350 rural interested seniors and the outcomes of 1995 graduates. The 301 family physicians in small and isolated rural locations in 2005 matched up best in age, in choice of family medicine, and in the AAMC selection criteria used in the GQ survey.

Literature Regarding Rural Physicians

Allopathic Rural Interested Seniors 1995

Actual 1995 Graduating Class Allopathic Workforce from Birth Origins and WWAMI CHC studies

Rural born students are the most interested in returning to rural locations

Rural born students are 7 times more likely than urban to indicate rural interest.

Rural born family physicians (FPs) have 46% choice of rural locations. Urban born non FPs have 6 – 8% rural choice and similar choice of family medicine. Urban born FPs have 20% rural choice.

Rural interested students should primarily be interested in family medicine.

68% indicated family medicine as their career choice after match choices were submitted.

FPs are 30% of rural physicians and 58% of physicians in isolated rural areas. Over 61% of rural Community Health Center physicians were FPs. (Rosenblatt)

New Findings from Birth Origins – Rural family physicians increase as population density, income, and physician levels decline. Family medicine choice fills in the gaps left by other physicians who concentrate in major medical centers and urban areas.

Rural interested students should be older than other students

32% of rural interested students were older compared to 22% of seniors. About 24% of those taking the MCAT were older. Characteristics of MCAT

Over 34% of small and isolated rural family physicians were older. Choice of rural FP increases by 80% for age 28-30 compared to those less than 26.

New Findings from Birth Origins – Graduates older than 29 years had 50 – 120% increased choice of rural careers, family medicine, primary care (PC), psychiatry, child psychiatry, underserved locations, and underserved PC.

Surveys of senior students preparing for rural practice may reveal frustrations with current medical training in the United States.

Rural interested seniors were twice as dissatisfied, designed their own curricula, and rated the curricula inadequate especially in PC and rural practice areas.

Retention within family medicine remains 98% for the graduates of 1994 – 2000 choosing family medicine. For family physicians office based primary care remains over 90%. Family physicians in medical school and in residency locations are trained in 100% in major medical centers which will be the practice locations of fewer FP graduates.

New Findings from Birth Origins - Over 57% of FPs locate outside major medical centers of 75 or more physicians. About 75% of pediatric and only 50% of internal medicine residency graduates (may be as low as 19% now – Garibaldi) remain in office based care and both remain in major medical centers at 70% levels. As the probability of family medicine choice increases in a medical school, the medical school graduates a higher percentage of FPs into office care and a higher percentage of FPs away from major medical centers and into rural and underserved locations. More family physicians are retained instate for practice and a higher proportion of the internal medicine residency graduates remain in office based general IM practice. (Office Based Proportions in IM, FP, Pediatrics)

Rural interested senior students should have background characteristics similar to the populations that they expect to serve.

Rural interested seniors were more likely to be white and born in rural locations with 50% from rural and 50% from urban high schools.

Rural family physicians are 85 – 90% white. About 65% were from urban counties and 35% were from rural counties. Rural family physicians were more likely to be born in rural counties and in counties in the lower or middle income quartiles. Only 10% of all 1995 graduates were born in rural areas.

New findings from multiple sources – Studies indicate that physicians who are more similar to their patients deliver higher quality care or the perception of higher quality. These studies have so far included gender, race, and ethnicity but income level and geographic origin may not be a difficult stretch. Whites are 90% of the 60 million in typical rural areas excluding the 3 million in Hispanic Border areas, another 3 million in predominantly Black counties, and Reservations. Changes in admissions indicate that Whites are declining the most, particularly rural born White males.

Rural interested students may well exhibit personal characteristics consistent with service-orientation, maturity, or altruism.

 

Curricular choices and volunteer activities at twice the level of other students, 5 times more   interested in socioeconomically deprived.

FPs supply the largest component of each distributional physician career including 31% of rural and rural underserved physicians. In isolated rural areas, Community Health Centers, lower income counties, or underserved locations; FPs are 50 – 70% of the physicians.

New findings from multiple sources not yet confirmed – Service orientation, empathy, and awareness of the needs of underserved peoples are related to humble origins. Students with the highest socioeconomic and urban origins and the highest MCAT scores are likely to have less service orientation, empathy, and awareness of the needs of underserved peoples. High scoring, foreign born, private schooled, and highest income types have been raised more exclusively. Those without characteristics such as service orientation are also less likely to respond to training in this area. (O’Connor, Jefferson Longitudinal, AAMC Minorities in Medicine, Birth Origins, Madison and Service Orientation, Rural Interested Seniors)

Those interested in rural practice should expect lower income levels and should plan practices much different than the typical major medical center expectation of most medical students.

Rural interested students were more comfortable with lower income, lower technology, lower prestige, unpredictable work hours, working under pressure, and primary care emphasis.

FPs are paid less than other physicians. Rural FPs may have higher salary and lower cost of living. Over the period from birth to practice, FPs leave states that have the highest percentages of physicians in major medical centers for states with better distribution of health and education resources and a lower percentage of  physicians in major medical centers.

Males should be more likely than females to be interested in rural practice.

More males were interested in rural practice at 187 to 166. Females were 47% of rural interested students but only 42% of total medical students.

Male FPs have 3 – 5 percentage points of greater rural choice but gender differences are diminished when controlling for greater levels of rural birth, lower income origins, and older age in males.

Findings from 1997 – 2003 FP Graduate studies (approximate 1994 – 2000 medical school grads) - female FP graduates of 16 allopathic medical schools had greater rural location compared to 28 with male advantage while most schools had no differences or few family medicine graduates.

 

Given the characteristics and contributions, there is only one problem with rural interested senior medical students. There are too few. The nation invests too little in child development, families, early elementary school, college access, medical school admissions, and the patients in most need of health care served by family physicians.

 

Older, lower income, rural born, and family medicine interested students are a great choice for distribution. Even urban born graduates have 20% rural choice when choosing family medicine. Declining admissions of distributional students, declines in choice of family medicine, and declining health policy support for middle and lower income peoples mean worsening health care access, increased threats to the survival of rural hospitals and rural health systems, decreasing rural economics, more difficulty recruiting rural jobs and businesses, and fewer professionals and leaders in rural areas.

 

Physician Workforce Studies

 

Physicians Who Serve

 

Service Orientation

 

Short and Sweet on Accelerated Family Medicine Training Programs - service orientation, older, FP focused

 

www.ruralmedicaleducation.org

 

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