Robert C. Bowman, M.D.
Physician distribution is often presented as difficult, unlikely, possible in only a small group of medical students, or a function of poor economics and education in rural or underserved areas.1, 2 However distribution is unlikely only in a minority of the medical student origins. Only the medical students with origins in the top 30% of the nation are unlikely to distribute. This is the group most connected to major medical centers and medical schools by income, urban origins, or parents who are physicians or professionals. Because 70% of admitted medical students come from this minority 30% of the population that rarely leave major medical center locations, distribution is difficult.
Distribution to rural and underserved locations beyond physician national averages of 9 - 10% rural and 7% found in underserved locations is possible only under specific conditions. One condition is selection of trainees with origins outside of the top concentrations of income, people, professionals, physicians, and resources. The second condition is specific choice of family medicine, a choice that doubles or triples distribution levels beyond birth origin impacts to rural and to underserved areas. Distribution levels are increased another 30% with older graduates.
Dilemmas are involves as the lower and middle income origins associated with higher distribution are associated with lower probability of admission. Combinations of factors greatly enhance distribution such as older age, distributional origins, and choice of family medicine. Distribution by age, by maturity or other factors related to age, or by selection of those most committed to family medicine is the likely explanation for enhanced accelerated graduate distributions.
Accelerated grads are the oldest group at medical school graduation with over 50% graduating at age 30 and beyond. Only the best health access osteopathic schools admit such a high percentage of older graduates and both share similar top levels of distribution. Those understanding Older Age Graduates understand most needed health access. The dimensions include admission, lower and middle income, service orientation, family practice, MCAT, admission probability, people orientation, and much more.
In exclusive non-distributional schools (top ranking research or MCAT schools) about 18% were older than 29 at graduation. About 22% older graduates was the norm for all US MD Grads. Family physicians overcome barriers reflecting 28% older for all choosing family medicine, osteopathic schools most successful in health access average 40% and above and 54% of accelerated grads were older, twice the level of family medicine and three times the level of elite students.
Second and third careers and expanded life experiences are the rule rather than the exception. Older graduates are less likely to be the children of professionals.3 A related factor is that they are less likely to be born in counties with medical schools, counties with the highest levels of professionals. These both mean that older graduates are less connected to major medical centers by geographic proximity and by parents. Older graduates clearly have double the choice of people careers such as family medicine and psychiatry. They also have had prior careers involving areas such as teaching or ministry as described in those most service oriented by Madison.4 Older graduates are also known to be more service oriented, along with females, married students, and those with a business-like approach as described by O’Connor.5 Rural interested seniors were about 4 years older, were more likely to be married, attended rural high schools at high levels, chose family medicine at 68% levels, and volunteered to serve the underserved at twice the levels of other students throughout medical school. They were twice as likely to know their final career before medical school (early commitment); twice as likely to be dissatisfied with their medical school experience; twice as likely to leave major medical centers for volunteer, elective, rural, international, and military experiences; and 5 times more likely to be interested in a socioeconomically deprived area.6 Those forced to decide a year earlier may have greater commitment to family medicine and to distributional careers.
Younger graduates are more likely to be found in elite schools, subspecialties, and major medical center locations. Older graduates are more likely to be found in schools graduating family medicine, primary care, rural, and underserved physicians. Osteopathic medical schools have 30 – 40% older graduates, greater rural and underserved distributions, and the highest levels of family medicine choice. The enhanced distribution of accelerated graduates appears to be related to older graduates and graduates who are more committed to family medicine.
The factors that result in older graduates also result in family physicians and result in medical schools attended with greater health access focus and broader admissions. All of these interact for the highest levels of distribution where physicians are most needed - underserved locations, rural locations, and zip codes with 65% of the US population yet only 20 - 25% of physicians - those outside of concentrations.
Basic Table: Taxonomy, Themes, Theories Related to Experiential Place and the Principles of Health Access Probability of basic health access career and location choices can be demonstrated using logistic regression. Factors such as physician origins, career choices, older age at graduation, and training can be compared to most needed health access locations. Exclusive origin, training, and career choice can be separated out and all are linked to exclusive practice locations. More normal in origin, in training, and in career choice is associated with inceasing health access contributions.
1. Cohen JJ. Why doctors don't always go where they're needed. Acad Med. Dec 1998;73(12):1277.
2. Kassebaum DG, Szenas PL. Rural sources of medical students, and graduates' choice of rural practice. Acad Med. Mar 1993;68(3):232-236.
3. Harth SC, Biggs JS, Thong YH. Mature-age entrants to medical school: a controlled study of sociodemographic characteristics, career choice and job satisfaction. Med Educ. Nov 1990;24(6):488-498.
4. Madison DL. Medical school admission and generalist physicians: a study of the class of 1985. Acad Med. Oct 1994;69(10):825-831.
5. O'Connor SJ, Trinh HQ, Shewchuk RM. Determinants of Service Orientation Among Medical Students. Available at www.sba.muohio.edu/management/mwAcademy/2000/38c.pdf . Oxford, OH: Miami University Farmer School of Business; 2000.
6. Bowman RC, Schuchert M. Rural Interested Senior Medical Students. AAMC Graduation Questionnaire. 1995.
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