Instate Office Primary Care Contributions

 

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

 

Most states are in big trouble regarding basic health access primary care workforce. The United States does not even understand what true primary care workforce is. Not only that, but all states are producing insufficient primary care that remains primary care. Finally the physician and non-physician workforce produced by many if not most states, will be leaving for other states. In each case the gradient is provided by US health policy that moves primary care away from primary care (destructive policy); by US health policy that moves physicians and non-physicians to other states that have greater concentrations of physicians, health funding, economics, and people; and by US health policy that fails to support health care for the populations that most depend upon primary care.

This study includes tables for the individual medical schools divided into four medical school quartiles regarding instate primary care contributions. It is even more tragic to deliver the really bad news. This is older data based on 2005 practice locations that reflect 2003 and 2004 locations. In the past 5 years, serious changes have resulted in far less primary care. All of the medical schools listed make lower contributions to primary care as health policy changes have decreased primary care capacity greatly. The last medical school to fall prey to policy was the school that focused most on permanent primary care and rural workforce contributions. Up until 2008, Duluth managed to maintain 46% family practice choice. Family practice is the most important instate primary care component. Duluth has not changed admission and training, but Duluth appears to have succumbed to US health policy with a decline to 36% family medicine for 2009 graduates.

 

The greatest declines have involved schools declining the most in family medicine graduates. The values were calculated using 30 years of primary care for family practice residency graduates and for residency graduates expected to remain in office based general internal medicine and office based general pediatrics. Since these figures were compiled, internal medicine retention in primary care has declined even further. Only 10% of recent graduates are expected to remain in primary care. Pediatric primary care retention is heading for 50%. Levels would be even lower without 15% of white females consistently choosing pediatric primary care.

 

Instate primary care is about graduating physicians that remain in primary care that also remain instate for practice. A number of factors determine instate primary care such as medical school admission and training, state health policy regarding primary care, graduate medical education training, economic considerations, and geographic considerations (large state, island, peninsula, coastal, few competitive neighbor states and the fewest tough competitors such as high growth or high recruitment states).

 

Top Quartile Above 6.28 Instate Primary Care Years Per Graduate

 

 

Total

Instate Office Primary Care %

Instate Primary Care Years Per Grad

Office Primary Care %

Office Primary Care Years

Ratio Instate to Total

Duluth

MN

235

39.6%

11.87

60.4%

18.13

65.5%

Mercer

GA

427

37.7%

11.31

51.8%

15.53

72.9%

UC Irvine

CA

1061

32.4%

9.73

38.5%

11.54

84.3%

UC Davis

CA

1055

31.4%

9.41

42.7%

12.82

73.4%

Western Osteopathic

CA

1422

30.0%

9.01

54.8%

16.43

54.8%

Wright State

OH

1028

27.5%

8.26

47.9%

14.36

57.5%

U North Texas Osteopathic

TX

1103

26.8%

8.05

41.2%

12.35

65.2%

Michigan St Osteopathic

MI

1398

26.5%

7.94

38.0%

11.39

69.7%

Ohio U Osteopathic

OH

1088

25.9%

7.78

38.6%

11.58

67.1%

U of Minnesota

MN

2568

25.9%

7.76

38.9%

11.68

66.4%

U of Massachusetts

MA

1165

25.8%

7.75

41.7%

12.52

61.9%

UC San Diego

CA

1401

25.5%

7.64

35.6%

10.69

71.5%

Brody East Carolina

NC

807

25.4%

7.62

37.5%

11.26

67.7%

Arkansas

AR

1519

25.3%

7.60

39.6%

11.87

64.1%

UCLA

CA

2077

25.3%

7.58

33.1%

9.94

76.3%

Morehouse

GA

352

25.0%

7.50

47.4%

14.23

52.7%

Hawaii

HI

656

25.0%

7.50

38.9%

11.66

64.3%

East Tennessee State

TN

662

24.2%

7.25

36.4%

10.92

66.4%

NY Osteopathic

NY

1804

23.8%

7.15

40.6%

12.19

58.7%

U of Southern Cal

CA

1753

23.8%

7.14

30.5%

9.16

77.9%

Nova SE Osteopathic

FL

1254

23.8%

7.13

41.7%

12.51

57.0%

U of Texas Houston

TX

2207

23.7%

7.10

34.9%

10.47

67.8%

Michigan St Allopathic

MI

1224

23.0%

6.91

42.5%

12.75

54.2%

UT San Antonio

TX

2309

23.0%

6.90

33.7%

10.12

68.2%

U of Tennessee

TN

1803

23.0%

6.89

36.2%

10.85

63.5%

U of Arizona

AZ

1047

22.9%

6.88

38.4%

11.52

59.7%

Southern Illinois

IL

806

22.8%

6.85

43.2%

12.95

52.9%

U of Washington

WA

1899

22.8%

6.84

40.6%

12.18

56.2%

UC San Francisco

CA

1745

22.1%

6.62

34.3%

10.30

64.3%

Texas Tech

TX

1156

22.0%

6.59

32.2%

9.65

68.3%

South Alabama

AL

733

21.4%

6.43

38.9%

11.66

55.1%

Texas A & M

TX

547

21.2%

6.36

30.9%

9.27

68.6%

Oregon

OR

1050

21.0%

6.31

35.9%

10.77

58.6%

U of Louisville

KY

1471

21.0%

6.30

34.0%

10.20

61.8%

U of South Dakota

SD

572

21.0%

6.29

43.4%

13.01

48.4%

Oklahoma St Osteopathic

OK

836

20.9%

6.28

38.9%

11.66

53.8%

 

Consistent levels of family practice choice above 35% was the defining characteristic of medical schools contributing the most to instate primary care and all location primary care. In these top distributional medical schools the internal medicine and pediatric residency graduates arising from these medical schools also had top levels of office primary care retention.

 

It is impossible to separate admission and training of the types of medical students associated with primary care capacity from family medicine, from retention of office based primary care, from more average MCAT scores, from a wider range of medical student parents, from older medical students, from a wider range of origins in a number of dimensions such as geographic, socioeconomic, culture, language. In each case the changes are generally in the direction of lower and middle income origins and matching to the United States population best instead of shifted 3 or 4 standard deviations to highest concentrations in origins, training, career choice, and health policy concentrations.

 

Osteopathic schools and the newer allopathic medical schools contributed the most.  Without the 1970s health policies that created new public medical schools that lead in all primary care categories and all six of the osteopathic public schools, the nation would have a much more serious primary care problem. The losses of 1970s family physicians and primary care physicians (primary care numbers quadrupled in the 1970s expansion) to inactivity and retirement are now a part of the current problems in primary care capacity and distribution.

 

The lack of state and federal support to shape medical education is one of the primary difficulties of the current era. Poor primary care reimbursement deflects medical students from the remaining permanent primary care choice of family practice, incents residents to leave generalist primary care careers to do fellowships, and destroys primary care capacity in nurse practitioners and physician assistants.

 

 

Background

 

Across the United States there is great uncertainty in primary care. Most have a sense that primary care capacity is decreasing, but the nation has no actual measure of primary care capacity. The nurse practitioner, physician assistant, and internal medicine forms that are thought to represent primary care are 70 – 90% specialty care. The so-called collapse of primary care is only a part of the larger collapse of all of health care into fewer locations. Super Center and Major Center locations have 75 or more physicians at a zip code and contain 50% of family physicians, 70% of internal medicine or pediatric generalists, 75% of physicians and 80 – 92% of most specialists, GME positions, and research positions. They continue to grow while urban and rural locations outside of super centers and major centers continue to shrink. Movements to major medical center careers and locations involve higher levels of transition out of state. Generalist physicians have the best opportunity to stay instate but again this depends upon state conditions relative to nearby states, powerful states, and the policies of the United States involving primary care support. Weaker states, powerful states who fail to invest their fair share in children, education, opportunity, higher education, and medical school positions, and policies that fail to support primary care all favor concentrations in major medical centers in fewer states and locations. Better investments in birth to admission, broader opportunity, and supportive national health policies involving primary care enhance primary care capacity in all states.

 

The author created a standard primary care workforce year using the results of the physicians most likely to remain in primary care and distribute to the most needed rural and underserved locations. Family physicians with rural origins that attended medical schools with the most focus on family practice, primary care, rural, and underserved locations were used to set the standard. In these schools the family physicians remained 96% in family medicine, 96% active, had the top primary care volume delivered 100%, and had an estimated career length of 35 years. This results in 32 years of primary care. More typical family physicians have 90% retention in primary care, 90% activity, and slightly lower volume of primary care for 29 years of primary care. When measured at the training program level, pediatric residents deliver about 16 years of primary care while flexible primary care training forms (IM, NP, PA) deliver 2 – 4 Standard Primary Care Years per graduate.

 

The rapid collapse of internal medicine has been unanticipated, but fits with internal medicine graduates receiving by far the greatest benefit from specialization. Using 1987 – 2000 graduates, the internal medicine graduates remaining in generalist office based internal medicine as well as the office based pediatricians were counted as 30 years of primary care. This is a known overestimate as the US has lost 30,000 internal medicine generalists to hospitalist careers in the past 6 years alone.

 

The primary care workforce year estimates are a way to attribute all of the future primary care years to a single class year. This can include all graduates in a school or a program or a physician origin. Class year contributions also reveal much about health policy with 1990s class years maximal in primary care capacity. Medicaid doubled from 1990 to 1995, managed care pushed graduates into family medicine choice and internal medicine residents into primary care careers, and the nation sequentially shifted more reimbursement to primary care and away from specialty and hospital care. Since this period of time complete reversals of policy combined with rapidly rising costs of delivering care have destroyed primary care numbers, choices, retention, and durations. Good primary care policy years greatly expand the potential for primary care capacity through a number of mechanisms. Poor policy years distract, divide, and fragment primary care capacity and kill off primary care practitioners directly and indirectly.

 

Different types of medical schools make different contributions to the nation’s primary care capacity. The schools that exclude the students most likely to choose primary care by selecting those with the highest scores, by training environments involving the lowest exposures to primary care, and by training students away from primary care in mission and curriculum graduate the fewest family physicians. Their graduates are also least likely to remain in generalist internal medicine and pediatric careers. Distributional medical schools admit the broadest range of medical students in scores, origins, ages, and socioeconomic levels; focus more specifically on family practice in mission, admission, training, and training environment, graduate more family physicians, retain more in office based generalist primary care, deliver more primary care volume per graduate, deliver more primary care in underserved locations, deliver more primary care outside of major medical center concentrations where primary care levels are most often adequate, deliver more geriatric care, deliver more economics of health care to areas in need of economics, and deliver more care to less educated populations, populations with less health care coverage, populations with lower income and lower social organization, populations with higher need, and populations with the lowest physician concentrations.

 

This article is written from the perspective of instate contributions. In the first table different types of medical schools are listed by their office primary care graduates for the class years of 1987 – 1998, the percentage of Office Primary Care Physicians in Instate Practice, and the Instate Office Primary Care Years or the number of office primary care physicians multiplied by 30 years per graduate divided by the total medical school graduates.  The West Coast Distributional schools include UCLA, the University of California Irvine, the University of California Davis, and the University of Washington. These are schools that have admitted a broader range of students, focused on primary care, and graduated higher levels of family physicians, at least for this time period. About 1633 of the 6092 graduates of the 1987 – 1998 class years remained in office primary care and instate for practice resulting in 8.04 instate office primary care years. States such as California that are large and have fewer neighbors and fewer competitive border areas retain larger shares of graduates. States with stronger economics, more physicians, and different geography (island, peninsula, and coastal geography) have fewer physician losses. Other states have multiple neighbors who are often economically stronger presenting difficulties with instate retention. Some states manage to retain more even with multiple competing neighbors. This takes a very coordinated statewide effort involving birth to admissions, training, and policy. Some states have no true medical school or few instate medical school positions. This creates a number of problems such as poor selections of the students who will return to serve a state (choice of those who specialize and leave rather than those who return and serve primary care needs), less training experiences instate, fewer graduate medical education positions instate (hurts all access to all 3 physician sources allopathic, osteopathic, and international), and neglected instate health policy development.

 

 

Types of Medical Schools, Primary Care, and Instate Primary Care

 

FPGP

Off PC

Total PC Years Per Grad

Instate PC Years Per Grad

% PC Remaining Instate

Allopathic Private

 

 

 

 

 

Historically Black

19.0%

38.3%

11.48

2.37

20.6%

MCAT 10.5-12

5.0%

21.5%

6.45

2.13

33.0%

MCAT 10-10.5

8.6%

26.3%

7.90

2.43

30.8%

MCAT 9.5-10

11.0%

29.0%

8.69

2.91

33.5%

MCAT 9.25-9.5

13.2%

29.8%

8.93

2.49

27.8%

MCAT 8.5-9.25

29.1%

48.8%

14.65

8.56

58.5%

Allopathic Public

 

 

 

 

 

UMKC NEOUCOM

13.3%

28.9%

8.66

4.52

52.2%

West Coast Distributional

20.2%

38.0%

11.41

8.04

70.4%

MCAT 10.5-12

10.5%

27.9%

8.36

4.48

53.7%

MCAT 10-10.5

17.0%

33.6%

10.07

5.30

52.7%

MCAT 9.5-10

14.2%

31.5%

9.46

4.84

51.1%

MCAT 9.25-9.5

17.5%

33.9%

10.17

6.03

59.3%

MCAT 8.5-9.25

19.7%

36.3%

10.90

6.13

56.2%

Osteopathic Private

35.2%

43.8%

13.14

4.91

37.4%

Osteopathic Public

36.2%

39.7%

11.90

7.10

59.7%

US Graduates Not Military or Puerto Rico

15.6%

31.6%

9.49

4.47

47.1%

Primary care physicians associated with military medical school or family practice residency are most commonly listed as hospital based. Graduates past the 1998 class year or before 1987 have higher levels of primary practice activity listed as residency, not classified, inactive, researchers, or administrators.

 

 

 

 

Office Primary Care in Instate Practice

Total Graduates 1987 – 1998

% Office Primary Care in Instate Practice

Instate Office Primary Care Years

West Coast Distributional

1633

6092

26.8%

8.04

Osteopathic Public

1369

5781

23.7%

7.10

MCAT 8.5 – 9.25

3740

18079

20.7%

6.21

Allopathic Public

21040

118287

17.8%

5.34

MCAT 9.25 - 9.5

4365

24878

17.5%

5.26

Osteopathic Private

2391

14597

16.4%

4.91

U MO KC, NEOUCOM Early Admit

331

2197

15.1%

4.52

MCAT 9.5 – 10

7817

54626

14.3%

4.29

MCAT 10 - 10.5

5057

39045

13.0%

3.89

Puerto Rican

358

3126

11.5%

3.44

MCAT 10.5 – 12

3375

35558

9.5%

2.85

Allopathic Private

5837

69420

8.4%

2.52

 

 

 

One point must be clarified. In the past decade primary care contributions from each of these medical schools have decreased substantially with family practice choice cut in half and with declines from 50% to 25% for internal medicine residents remaining in office based primary care.

 

Top Quartile Above 6.28 Instate Primary Care Years Per Graduate

 

 

Total

Instate Office Primary Care %

Instate Primary Care Years Per Graduate

Office Primary Care %

Office Primary Care Years

Ratio Instate to Total

Duluth

MN

235

39.6%

11.87

60.4%

18.13

65.5%

Mercer

GA

427

37.7%

11.31

51.8%

15.53

72.9%

UC Irvine

CA

1061

32.4%

9.73

38.5%

11.54

84.3%

UC Davis

CA

1055

31.4%

9.41

42.7%

12.82

73.4%

Western Osteopathic

CA

1422

30.0%

9.01

54.8%

16.43

54.8%

Wright State

OH

1028

27.5%

8.26

47.9%

14.36

57.5%

North Texas Osteopathic

TX

1103

26.8%

8.05

41.2%

12.35

65.2%

Michigan St Osteopathic

MI

1398

26.5%

7.94

38.0%

11.39

69.7%

Ohio U Osteopathic

OH

1088

25.9%

7.78

38.6%

11.58

67.1%

U of Minnesota

MN

2568

25.9%

7.76

38.9%

11.68

66.4%

U of Massachusetts

MA

1165

25.8%

7.75

41.7%

12.52

61.9%

UC San Diego

CA

1401

25.5%

7.64

35.6%

10.69

71.5%

Brody East Carolina

NC

807

25.4%

7.62

37.5%

11.26

67.7%

Arkansas

AR

1519

25.3%

7.60

39.6%

11.87

64.1%

UCLA

CA

2077

25.3%

7.58

33.1%

9.94

76.3%

Morehouse

GA

352

25.0%

7.50

47.4%

14.23

52.7%

Hawaii

HI

656

25.0%

7.50

38.9%

11.66

64.3%

East Tennessee State

TN

662

24.2%

7.25

36.4%

10.92

66.4%

NY Osteopathic

NY

1804

23.8%

7.15

40.6%

12.19

58.7%

U of Southern Cal

CA

1753

23.8%

7.14

30.5%

9.16

77.9%

Nova SE Osteopathic

FL

1254

23.8%

7.13

41.7%

12.51

57.0%

U of Texas Houston

TX

2207

23.7%

7.10

34.9%

10.47

67.8%

Michigan St Allopathic

MI

1224

23.0%

6.91

42.5%

12.75

54.2%

UT San Antonio

TX

2309

23.0%

6.90

33.7%

10.12

68.2%

U of Tennessee

TN

1803

23.0%

6.89

36.2%

10.85

63.5%

U of Arizona

AZ

1047

22.9%

6.88

38.4%

11.52

59.7%

Southern Illinois

IL

806

22.8%

6.85

43.2%

12.95

52.9%

U of Washington

WA

1899

22.8%

6.84

40.6%

12.18

56.2%

UC San Francisco

CA

1745

22.1%

6.62

34.3%

10.30

64.3%

Texas Tech

TX

1156

22.0%

6.59

32.2%

9.65

68.3%

South Alabama

AL

733

21.4%

6.43

38.9%

11.66

55.1%

Texas A & M

TX

547

21.2%

6.36

30.9%

9.27

68.6%

Oregon

OR

1050

21.0%

6.31

35.9%

10.77

58.6%

U of Louisville

KY

1471

21.0%

6.30

34.0%

10.20

61.8%

U of South Dakota

SD

572

21.0%

6.29

43.4%

13.01

48.4%

Oklahoma St Osteopathic

OK

836

20.9%

6.28

38.9%

11.66

53.8%

 

Consistent levels of family practice choice above 35% are the primary characteristic of all of the medical schools contributing the most to instate primary care and all location primary care. In these top distributional medical schools the internal medicine and pediatric residency graduates from these medical schools also have top levels of office primary care retention. It is impossible to separate admissions of the types of medical students associated with primary care capacity from primary care emphasis in training from family medicine and from office based primary care retention.

 

Osteopathic schools and the newer allopathic medical schools make top contributions. The osteopathic public schools as a group have consistently excellent contributions across family practice, primary care, rural, and underserved careers. Without the 1970s health policies that created new medical schools, the nation would have a much more serious primary care problem. The lack of state and federal support to shape medical education is one of the primary difficulties of the current era. Poor primary care reimbursement deflects medical students from the remaining permanent primary care choice of family practice, incents residents to leave generalist primary care careers to do fellowships, and destroys primary care capacity in nurse practitioners and physician assistants.

 

 

Second Quartile of Instate Primary Care Contributions at 4.58 to 6.27 Years

 

 

Total

Instate Office Primary Care %

Instate Primary Care Years Per Graduate

Office Primary Care %

Office Primary Care Years

Ratio Instate to Total

U of Colorado

CO

1498

20.9%

6.27

35.4%

10.61

59.1%

UMDNJ Osteopathic

NJ

661

20.9%

6.26

41.0%

12.30

50.9%

U of Indiana

IN

3054

20.8%

6.24

32.5%

9.76

63.9%

U of South Carolina

SC

733

20.7%

6.22

35.9%

10.76

57.8%

U of Mississippi

MS

1159

20.5%

6.16

33.5%

10.04

61.3%

Philadelphia Osteopathic

PA

2473

20.5%

6.14

38.5%

11.56

53.1%

U of Missouri Columbia

MO

1226

20.4%

6.12

36.9%

11.08

55.2%

U of Kentucky

KY

1034

20.0%

6.01

36.2%

10.85

55.3%

LSU Shreveport

LA

1117

19.9%

5.96

31.7%

9.51

62.7%

Med Col Georgia

GA

2066

19.5%

5.84

33.5%

10.05

58.1%

LSU New Orleans

LA

1991

19.2%

5.77

29.8%

8.94

64.6%

U of Nebraska

NE

1431

19.1%

5.74

35.2%

10.55

54.5%

U of South Florida

FL

1101

19.1%

5.72

30.5%

9.16

62.5%

Wayne State

MI

2986

18.9%

5.67

30.4%

9.13

62.0%

Marshall

WV

531

18.8%

5.65

42.0%

12.60

44.8%

U of Wisconsin

WI

1689

18.5%

5.54

33.4%

10.02

55.3%

U of New Mexico

NM

830

18.4%

5.53

39.2%

11.75

47.1%

UTMB Galveston

TX

2210

18.4%

5.51

29.2%

8.77

62.8%

Medical College of Ohio

OH

1541

18.2%

5.45

34.9%

10.47

52.0%

U of Kansas

KS

2066

17.6%

5.29

37.4%

11.21

47.2%

Loma Linda

CA

1705

17.6%

5.28

36.2%

10.86

48.6%

U of Oklahoma

OK

1678

17.4%

5.22

31.1%

9.33

55.9%

U of Alabama

AL

1827

17.4%

5.21

30.5%

9.16

56.8%

The Ohio State

OH

2507

17.3%

5.19

32.5%

9.74

53.3%

Northeast Ohio

OH

1139

17.3%

5.19

29.1%

8.74

59.3%

U of Nevada

NV

562

17.1%

5.12

37.4%

11.21

45.7%

Medical U of SC

SC

1611

17.0%

5.10

31.1%

9.33

54.7%

U of Florida

FL

1337

16.5%

4.94

28.1%

8.44

58.5%

U of Illinois

IL

3427

16.4%

4.91

32.4%

9.71

50.6%

Rush

IL

1394

16.3%

4.89

32.6%

9.79

49.9%

UT Southwestern

TX

2350

16.2%

4.85

25.4%

7.63

63.5%

U of North Dakota

ND

631

15.8%

4.75

39.5%

11.84

40.2%

Midwestern Osteopathic

IL

1392

15.6%

4.68

41.0%

12.31

38.0%

West Virginia Osteopathic

WV

695

15.5%

4.66

42.0%

12.60

37.0%

U of Cincinnati

OH

1879

15.3%

4.58

34.5%

10.36

44.2%

U of Utah

UT

1172

15.3%

4.58

30.3%

9.09

50.4%

 

There are two ways that schools find their way to a lower instate primary care ranking. Some have lower primary care percentages of graduates. Others lose more graduates to out of state locations.

 

Many of these medical schools make outstanding primary care contributions, but only about half of this primary care contribution remains instate. A number of factors are involved. Many of these schools are private schools that have more students admitted from out of state locations. Some states have multiple competing neighbor states. Some states have lower levels of instate primary care residency positions.  Some public schools admit more from out of state and this can be a temptation for medical school admission committees when instate students tend to have lower scores, especially when deans and alumni are pushing for higher scores and rankings.

 

Schools that graduate higher levels of primary care are likely to have some “leakage” outside of a state. If the United States hopes to address primary care shortages, more will need “leakage.” Unfortunately with primary care levels in all forms declining, there will be less leakage. This is likely to be most difficult for those who do not have their own medical schools. In the Western states other than California, Washington, and Arizona, the lack of a public medical school can be a particular problem as international graduates are found in lowest percentage and these states have access to fewer osteopathic graduates, the graduates most likely to be found in the primary care, rural, and rural underserved careers that are most needed by these states.

 

 

Third Quartile of Instate Primary Care Contributions from 2.66 to 4.51 Years

 

 

Total

Instate Office Primary Care %

Instate Primary Care Years Per Graduate

Office Primary Care %

Office Primary Care Years

Ratio Instate to Total

U of North Carolina

NC

1856

15.0%

4.51

33.5%

10.04

44.9%

SUNY Buffalo

NY

1716

14.3%

4.30

30.0%

8.99

47.9%

MCV VCU

VA

1935

14.3%

4.28

33.2%

9.97

42.9%

U of Miami

FL

1816

14.0%

4.21

25.3%

7.58

55.6%

Eastern Virginia

VA

1069

13.9%

4.18

35.6%

10.69

39.1%

U of Iowa

IA

1954

13.8%

4.15

35.5%

10.66

38.9%

SUNY Syracuse

NY

1782

13.8%

4.14

31.0%

9.29

44.6%

Penn State

PA

1126

13.5%

4.05

28.2%

8.47

47.8%

Medical College WI

WI

2250

13.2%

3.97

33.2%

9.95

39.9%

Loyola Stritch

IL

1500

12.9%

3.88

31.5%

9.44

41.1%

Bowman Wake Forest

NC

1219

12.9%

3.86

30.4%

9.13

42.3%

U of Maryland

MD

1745

12.8%

3.85

31.7%

9.51

40.5%

U Missouri Kansas City

MO

1058

12.7%

3.80

28.5%

8.56

44.4%

SUNY Stony Brook

NY

1258

12.4%

3.72

27.3%

8.18

45.5%

Baylor

TX

1903

12.1%

3.63

25.3%

7.60

47.7%

Stanford

CA

995

12.1%

3.62

23.0%

6.90

52.4%

West Virginia U

WV

940

11.9%

3.57

31.4%

9.41

38.0%

Temple

PA

2035

11.8%

3.54

29.8%

8.95

39.5%

SUNY Brooklyn

NY

2501

11.7%

3.50

22.2%

6.65

52.7%

U of Connecticut

CT

961

11.3%

3.40

31.0%

9.30

36.6%

Mayo

MN

468

11.3%

3.40

27.4%

8.21

41.4%

Case Western

OH

1689

11.2%

3.36

30.9%

9.27

36.2%

New Jersey

NJ

1949

11.2%

3.36

27.6%

8.28

40.5%

Emory

GA

1305

10.7%

3.22

24.1%

7.24

44.4%

U of Virginia

VA

1598

10.7%

3.21

28.0%

8.39

38.3%

UMDNJ RWJ

NJ

1715

10.7%

3.20

29.6%

8.89

36.0%

Mt. Sinai

NY

1547

10.3%

3.10

23.7%

7.12

43.6%

U New Eng Osteopathic

ME

874

10.3%

3.09

49.9%

14.97

20.6%

Albany

NY

1542

9.9%

2.98

29.4%

8.81

33.8%

U of Pittsburg

PA

1522

9.7%

2.90

24.3%

7.29

39.7%

U of Rochester

NY

1153

9.6%

2.89

30.1%

9.03

32.0%

U of Puerto Rico

PR

1369

9.5%

2.85

17.5%

5.24

54.4%

Boston U

MA

1754

9.4%

2.81

26.4%

7.92

35.4%

Jefferson

PA

2575

9.2%

2.75

26.5%

7.95

34.6%

Des Moines Osteopathic

IA

2118

9.0%

2.69

46.9%

14.07

19.1%

 

The osteopathic schools in this quartile admit more from out of state and distribute more graduates outside of their state locations

 

 

Bottom Quartile in Instate Primary Care Contribution or Less than 2.66

 

 

Total

Instate Office Primary Care %

Instate Primary Care Years Per Graduate

Office Primary Care %

Office Primary Care Years

Ratio Instate to Total

Albert Einstein

NY

2015

8.8%

2.65

24.8%

7.43

35.7%

U Central del Caribe

PR

794

8.6%

2.57

22.2%

6.65

38.6%

Hahneman

PA

1425

8.2%

2.46

30.5%

9.14

27.0%

U Michigan

MI

2241

8.2%

2.45

22.8%

6.84

35.8%

Tufts

MA

1800

7.9%

2.38

27.6%

8.28

28.8%

UHS Osteopathic MO

MO

1630

7.7%

2.32

44.2%

13.27

17.5%

Northwestern

IL

2003

7.7%

2.31

23.4%

7.01

32.9%

New York Medical

NY

2341

7.0%

2.09

24.2%

7.25

28.8%

New York U

NY

1791

6.9%

2.08

18.8%

5.64

36.8%

St. Louis U

MO

1694

6.8%

2.04

30.5%

9.14

22.3%

Ponce

PR

615

6.7%

2.00

22.8%

6.83

29.3%

Medical College PA

PA

1968

6.7%

2.00

26.5%

7.96

25.1%

Meharry

TN

808

6.3%

1.89

35.0%

10.51

18.0%

Cornell

NY

1174

6.3%

1.89

21.0%

6.29

30.1%

Kirksville Osteopathic

MO

1530

6.3%

1.88

43.1%

12.92

14.6%

Chicago Finch

IL

1879

6.2%

1.87

25.8%

7.74

24.1%

Harvard

MA

1952

6.2%

1.86

20.0%

6.01

30.9%

U of Pennsylvania

PA

1758

6.0%

1.81

21.0%

6.30

28.7%

Chicago Pritzker

IL

1219

5.8%

1.75

21.7%

6.50

26.9%

U of Vermont

VT

1080

5.6%

1.69

30.3%

9.08

18.7%

Brown

RI

859

5.5%

1.64

28.4%

8.52

19.3%

Vanderbilt

TN

1162

5.1%

1.52

18.6%

5.58

27.3%

Oral Roberts

OK

165

4.8%

1.45

41.2%

12.36

11.8%

Duke

NC

1225

4.8%

1.44

17.6%

5.27

27.4%

Creighton

NE

1347

4.5%

1.34

28.5%

8.55

15.6%

Washington

MO

1420

3.6%

1.08

20.9%

6.27

17.2%

Columbia

NY

1760

3.5%

1.06

14.8%

4.43

23.8%

Howard

DC

1071

3.5%

1.04

37.7%

11.32

9.2%

Tulane

LA

1729

2.5%

0.75

21.1%

6.32

11.8%

Dartmouth

NH

867

2.3%

0.69

31.4%

9.41

7.4%

Johns Hopkins

MD

1385

2.0%

0.61

19.9%

5.96

10.2%

Yale

CT

1164

1.9%

0.57

16.8%

5.05

11.2%

George Washington

DC

1776

1.5%

0.46

27.8%

8.33

5.5%

Uniformed Services

MD

1875

1.3%

0.40

11.2%

3.36

11.9%

Georgetown

DC

2370

0.9%

0.28

20.3%

6.09

4.6%

 

 

 

208085

14.7%

4.42

31.3%

9.39

 

Schools can produce more primary care for instate locations by producing more primary care physicians or by retaining more instate. This can mean schools that admit more students with greater instate connections (often public schools), schools that train graduates with emphasis on locations important to the state, schools and states that work to connect residency to medical school instate location, and schools in states with superior primary care health policy instate (reimbursement, support, recruitment, retention, coordination). Public schools tended to admit and train with an instate focus, but there has been great variation in the implementation of this emphasis.

 

Instate retention can be a matter of geography. Larger, more populous, coastal, peninsula, and island states can retain more graduates instate. Smaller states, less populous states, and those sharing many borders had lower instate retention.

 

With the exception of a few states, medical schools with family medicine graduates had top instate office primary care retention. The states that failed to retain family practice instate generally have had poor primary care salaries and have had the top concentrations of physicians in a few major medical center zip codes, locations not supportive of broad scope family practice. Mismatches in admission, training, and practice location are seen.

 

For example if Alaska, Montana, Idaho, and Wyoming admit and send the University of Washington the types of students least likely to be found in family medicine and primary care (higher scoring, children of professionals, youngest, least interested in primary care) and the nation forces training predominantly in major medical center locations with the fewest family physicians and the nation continues to reward primary care choices poorly, it can be most difficult to get graduates to return to or to stay in states that have the fewest physicians found in major medical center locations and specialties. Rural states have a need for family physicians, a specialty in short supply under current admissions, training, and health policy influences. States with poor primary care support have also lost family physicians to states with better support in the past, but with fewer family physicians there are less migrating in this pool than in past years. International graduates do not deliver that same primary care years with more years in delay in arriving in the United States, generally poor orientation to primary care and family practice from birth to the completion of medical school, and less distribution beyond the most concentrated locations that best represent their life experiences.

 

Medical schools with high subspecialization rates had lower primary care production from internal medicine, pediatrics, and family medicine. Special mission schools such as the Historically Black schools, Loma Linda, and Oral Roberts graduated more in office primary care but admitted broadly and scattered graduates over a number of states. Morehouse has been an exception with high rates of primary care, high rates of instate primary care production, and high rates of underserved primary care. The Universidad Autonoma De Guadalajara or UAG sends about 85 graduates a year to the mainland United States workforce as well as some each year to Puerto Rico. The family practice component also remained above average and contributed most to UAG’s urban underserved contributions. UAG led all medical schools with about 1 in 4 graduates found in urban underserved locations with the residency programs capturing UAG grads also capturing urban underserved primary care for their state.

 

Schools such as the University of Michigan admitted more born in other states and nations, graduated more subspecialists, and sent more graduates to out of state locations. Public osteopathic schools such as Ohio University admitted more from instate locations, graduated more family physicians and primary care physicians, and retained more instate to practice.

 

Graphic MCAT and Family Medicine in the 2007 Match    The steady declines in the family medicine match indicate even worse instate primary care to come.

 

Graphic Higher MCAT Score Medical Schools Contribute the Least Standard Primary Care Years per graduate - the effect of exclusive admission and training and lowest family medicine graduates.  

The instate primary care is lowest for the most exclusive schools who have the fewest with instate origins, admit medical students least likely to remain in primary care, and send graduates outside of the state. Often the state workforce environment is so poorly supportive of primary care in states with top concentrations of physicians and specialsits, that primary care is driven out of the state or is converted to specialty care.  

 

www.basichealthaccess.org

 

www.physicianworkforcestudies.org

 

www.ruralmedicaleducation.org