Robert C. Bowman, M.D.
Rural origin students continue to decline with impacts on rural location, primary care, and family medicine since rural origin students have distributions to all of these careers at the highest levels.
Lower income and middle income origin students continue to decline in admission with impacts on rural location, underserved location (top level), family medicine, primary care, and women's health.
US Born students continue to decline with impacts on rural location and family medicine.
Students born instate relative to their medical schools continue to decline. Instate born students have the highest levels of Instate Retention for practice. Instate Born have higher levels of rural practice
Declines in all of the student types most likely to choose family medicine will compromise this permanent form of primary care and the enhanced and persistent distribution of this specialty to rural and to underserved areas.
US MD Grads have been changing in a way that will compromise physician distribution. Those most likely to distribute are being replaced by those least likely to distribute. The additions include students with the highest income levels, the most urban origins, the highest test scores, the youngest ages, and out of state or foreign birth. Each of these groups were born, raised, educated, and trained in or near major medical centers and return to such locations at the highest levels. These elite students are significantly different than the 70% of middle and lower income peoples in most need of health care in the United States, a group that births only 30% of US MD Grads. Increasing inequities in income and education and health access are magnified by the nation’s choices in education, college, and medical education.
Higher Income Students Admitted from 1997 to 2004
· The medical students born to parents with over $100,000 in annual income have grown from 23.5% of medical students to 51.5%. Admissions of the lowest income quartile of students in the less than $40,000 category has declined from 24% to less than 15%. Each year about 3000 fewer lower and middle income students are admitted compared to 1997. Lower and middle income students have 2 – 4 times the choice of rural careers, underserved locations, family medicine, and primary care. The impact has been greatest on white students with a 77% increase in highest income white students and a 50% decline in lowest income quartile students.
· Based on the 7 different income levels from $10,000 to over $100,000 and the percentage of graduates by income level each year the nation graduates 256 fewer office family physicians, 165 fewer rural physicians, 212 fewer office primary care physicians, 192 fewer office based primary care physicians in underserved areas, and 345 more physicians for major medical centers.
· Family physicians accumulate outside of major medical centers in rural and underserved areas over time, fill in the gaps in health care in wider scope and the most needed areas, and because family medicine is a stable dependable end point career involving primary care, not a transition to another career. Family Medicine Contributes Much More Health policy changes often obscure the admissions changes, masking the impact of the managed care era and reversing course to reduce student choice by 50% in the past 8 years; however the admissions changes compound the problem of maldistribution with an additive effect.
Fewer Rural Born Medical Students and Less Physician Distribution
· Rural born medical students once were admitted at 80% or more of rural population levels. Rural born students have declined to less than 10% even though rural population remains over 22%. There is a 0.92 correlation between rural born student percentages and rural physician percentages at the allopathic medical school level.
· Rural distribution for specialties outside of family medicine does not extend beyond the contribution of rural birth origins. Family medicine choice extends rural choice beyond birth origins. Urban born family physicians have 20% urban choice and the rural born have 46% rural choice or 2 – 4 times the rural workforce at 11%. Facilitating Physician Distribution
· Family medicine is the major contributor supplying 30% of the total allopathic physician rural workforce. Family medicine fills in the gaps with 40% of the primary care supply and 50 - 70% of rural physicians in the areas with the lowest income, the fewest physicians, and the lowest population density. In the most urban counties with the highest physician concentrations less than 8% of physicians are office based family physicians. In the most rural counties, 59% are office based family physicians. Losses of rural born and declines in family medicine are a disaster for rural areas and also underserved areas, both rural and urban. Family Medicine Contributes Much More
Fewer White Medical Students and Less Rural Workforce
· White medical student admissions have declined significantly over the years. Whites are only 71% of the population in areas of over 1 million and 80% in other metro areas. There is no question that the 6 million in Reservations, border counties, and predominantly black rural counties have the most difficult health problems facing poverty, inequity, and multisystem failures. Whites are 90% in the remaining rural areas and increasingly share similar problems in education, economics, health, mental health, and dental health.
· Efforts to match up physicians with their patients can improve distribution, retention, and the quality of medical care. All suffer from temporary physicians who have not been trained in and for rural or underserved areas, who share few characteristics with rural peoples, who are costly to replace, and who often do not become a part of rural communities and economics.
· The family physician residency graduates of 1997 – 2003 found in the most rural areas in 2005 were white at 90%, were some of the oldest at medical school graduation (39% vs 22% older students) , and were the most likely to be born in rural areas or lower income areas of the nation.
· Increases in the admission of students from counties with a higher level of college education means fewer family physicians. States and counties with higher high school graduation rates graduate more family physicians. A nation that ignores child development and early education and emphasizes standardized testing instead of improving families, preschools, and elementary schools will not be graduating the lower and middle class origin professionals that will return and serve.
· Gender plays a role. The white males that have been the heart of rural physician distribution have declined from over 85% to less than 35% of medical students. Female contributions in rural family medicine have improved with 15 medical schools graduating more into rural practice as compared to a 25 school advantage for males, but females still trail in admissions in some states. Meanwhile every type of male except Asian is disappearing from college, medical school, and family medicine, especially those born in rural and low income populations. Failure to address the combinations of poverty, poor education, poor health, and poor environment seems to impact males much more and results in some of the most costly state budget items. This neglect generates tremendous inefficiencies in the function of cities, states, and the nation. We are now “Paying Later” for not “Paying Now” years ago.
Instate Born: Students Born in the Same State As Their Medical School
· Students born in the same state as their medical school have also been declining steadily. After the last expansion about 58% were instate born. Currently only 38% are born in the same state as their medical school.
· Instate born students have greater choice of family medicine (13.4% vs 10.4% for out of state), office based primary care (31.7% vs 28.9%), and rural careers (12.6% vs 9.9%) compared to those born outside of the state or outside of the US.
· Instate born students also have the greatest retention instate to practice and therefore return state investments at the highest level, particularly when choosing family medicine. Instate Medical Students and FP Choice
The nation has currently made a series of decisions that will continue to concentrate health, education, and income. More physicians from the most elite origins will only increase costs and supply more physicians in major medical centers. Only improvements in the professionals who are of the people, by the people, and for the people will improve the nation’s education, public safety, health care, and other infrastructure.
Admissions Changes Table 1967 to 2005