Choice of Family Medicine: Past, Present, and Future

Robert C. Bowman, M.D.

The new education must be less concerned with sophistication than compassion…it must teach man the most difficult lesson of all - to look at someone anywhere in the world and be able to see the image of himself.  Norman Cousins, Anatomy of an Illness   via John West MD Nebraska Academy of Family Physicians president

Being able to share that image is a critical area for teachers, doctors, and all who interface with people. The situation for physicians has become much more complicated. For all physicians other than family medicine, seeing the image is a difficult process. No other specialty has the wide variety of differences covered so that patients can find a physician most like them. That is because family physicians have origins most similar to patients, in geography, diversity, income level, and other key areas that improve patient interactions and can enhance health care or the perception of health care.

To understand how family medicine choice varies over birth origins, age, medical school type, and other factors, try

Multidimensional Choice of Family Medicine

Choice of Family Medicine Regression

Birth Origins and Distribution Tables

Birth Origins and FP Choice

Driving Difficulty or Distinction

MCAT and FP 2005

Summary see Short and Sweet on FP Choice or   Choice of FP Update, Progress beyond the Arizona Study

Introduction

Physicians need to be intellectual and practical, sophisticated and personal, but what happens if there are not enough with all of the qualities needed? Can physicians retain humanistic qualities in a medical world increasingly dominated by intellectual testing to get admitted, to survive basic sciences, to graduate, and to get the specialty of choice. If someone is intellectual, can they be practical?

If we have a system that selects for the intellectual and sophisticated, is this assisting us with the problems that we have in medicine, or bringing additional complications? Regardless, it is a system that we all have created, and can change. In this nation there is far too much blame and not enough understanding. Setting priorities is important rather than allowing "the world" to make the changes. Important areas such as education and health care are far too critical to allow them to move in directions not helpful for our nation, or the world. Understanding Higher Education and Income

We need strong leaders for a challenging time. There are no more important weapons in the fight against hopelessness and terrorism than education and health care, particularly for those in most need of it today.

Family and General Practice in the Past Century

Family medicine makes important health care contributions in the United States. No other type of physician contributes as much to improve access to care 1 and to serve rural and underserved areas. 2 3 New studies confirm the long standing association between family physicians and reductions in health care costs and increases in the quality of health care. 5, 6  Decreases in family physicians would compromise areas of national interest. 7

Family medicine, as measured by the choices of US medical students, has had a consistent 30 year decline. Only a brief period of popularity stimulated by managed care efforts interrupted this decline from 1994 – 1998, with continued decline since. The consistent nature of this decline does not suggest a recent problem. Nor does it indicate the swing of a pendulum. Without significant numbers of physicians imported from international medical schools, the situation would be even worse. The managed care panic years and the contributions of foreign medical schools have hidden the magnitude of the changes in US medical schools.

A precipitous drop in the number of US medical students choosing general practice in the 1950s and 1960s resulted in a series of reports and the creation of "family medicine" as a specialty in 1969. Initially family medicine gained state support and medical schools grudgingly accepted the new specialty. However in more recent years the new specialty has been eclipsed by massive increases in total numbers of US physicians and the more growth of the US population. Medical school priorities have also shifted away from teaching and primary care in favor of research and specialty care. Looking back a few more decades, family and general practice physicians have been in a steady decline for the past century in the US. 8

See changes in US physicians, FP

http://www.unmc.edu/Community/ruralmeded/admissions_and_origin.htm

Adapted from COGME and Colwill using total physicians and population instead of ratios

There have been repeated efforts to increase the choice of family medicine by US medical students. The most recent effort is the Future of Family Medicine project.9  The one area that is indeed critical to the future of family medicine is the selections process. Selections has yet to become a significant focus of family medicine or national efforts. This is puzzling since selections has been the cornerstone of every successful effort to graduate more family physicians at the medical school, state, or program level. 

Selections: Do US Medical Schools Admit Students Who Will Choose Family Medicine?

Birth Origin

A consistent element in the choice of family medicine has been admissions of students from small towns, particularly those who have interest in family medicine at matriculation. Medical schools, special admission tracks, and statewide efforts concentrating on students from rural background have all graduated more family physicians with success rates as high as 50 %. 10, 11, 12, 13. These programs remain models that are largely unreplicated. Medical schools have not adopted changes that would increase the numbers of family physicians.

There is a general impression that medical schools are indeed attempting to admit students who  "want to become family physicians and go to a small town to practice." The importance of rural selections has been highlighted. Without special admissions significant numbers of rural background students would not have even reached the interview stage  (Basco) Some 47 medical schools profess a policy of rural emphasis in rural selections. These have been documented in annual reports regarding medical education (JAMA Barzansky).

These rural admissions preferences are not confirmed by reality. Data from the Association of American Medical Colleges (AAMC) data reveals major decreases in rural background students admitted to US allopathic medical schools, from 27 % in 1983 to 16% in 1999.14 Yearly reporting has hidden longer term trends. The magnitude of the change using AAMC data was a 55% decrease in white rural background students in all medical schools from 1983 - 1999.

Such an important finding needs a confirmation by a different method, if possible. AMA Masterfile data includes birth city and state on over 600000 US physicians. Studies using the birth origin of physicians confirm this decline, revealing a consistent and steady decline in those admitted to medical school who were born in rural areas. Using the birth origin data, the average decrease in each medical school regarding admissions of students born in rural areas was 43.4 % from 1976 - 1980 as compared to 1996 - 2000 (Bowman birth origin).

Did any group of medical schools demonstrate rural admissions preference. Review of the data for individual medical schools notes that the decline was apparent even in schools with a rural mission, osteopathic schools, and even schools in states with a higher percentage of rural population. Only 2 medical schools managed to show even a small gain in rural birth admissions from 1976 – 1980 as compared to 1996 - 2000. The average decline for all US medical schools was 43.4%. (Bowman Birth Origin) This is comparable to the rural background declines calculated from AAMC data. The consistency in birth origin and the choice of family medicine is even more remarkable.

Family Physicians Are Born, Not Made

Studies demonstrate that family physicians are different, even from other primary care physicians. "Family physicians were more likely to have made their career decision before medical school, and were more likely to have come from inner-city or rural areas. Personal values and early role models play a very important role in influencing their career choice." (Comparisons Among Three Types of Generalist Physicians: Personal Characteristics, Medical School Experiences, Financial Aid, and Other Factors Influencing Career Choice  XU G.[1]; VELOSKI J.J.[1]; BARZANSKY B.[1]; HOJAT M.[1]; DIAMOND J.[1]; SILENZIO V.M.B.[1]  ).

The choice of family medicine by students born in various urban and rural locations has been remarkably steady from 1976 – 2000, with the exception of the 1994 - 1998 managed care impact years. This is data using RUCA coding applied to the birth city and state of physicians.

The consistency is also demonstrated in various urban categories as well. Students from the most urban locations in the nation choose family medicine at lower rates as compared to students from slightly less urban locations. 15 (Bowman Birth Origin One pager).

Birth Location of US Physicians Graduating After 1975

Updated Data

AMA Masterfile and Robert Graham Center, Birth Coding by RCB

Birth origins can divide students into those likely to distribute or not.

The choice of family medicine seems to be more related to student origins and experiences before medical school than what happens after admissions. The greater numbers of urban students results in more family physicians from urban origins. The rural contribution has diminished greatly over time, but rural born students contribute a higher percentage.

Changes in Matriculants

The rural origin group has been replaced by urban students who are much less likely to choose family medicine.

See graphic on matriculant changes at web site

http://www.unmc.edu/Community/ruralmeded/admissions_and_origin.htm

Allopathic US Medical Student Admissions, FP Choice, Income Levels

*Income level of Mexican American parents used. Other Hispanic incomes are higher and FP choices lower.

Black, rural (mostly white), and Native males admitted at even lower ratios.

Only white, Mexican American, and Native groups have any appreciable percentage born in rural areas and this is reflected in their choice of rural practice locations.

Those with the highest income levels by urban, ethnicity, and population density considerations are the most likely to be admitted and the least likely to distribute to rural and poverty primary care locations. In blacks, Natives, and Mexican Americans there are more females that choose rural locations compared to males. This is a reflection of who gains access to college and medical school. This female dominance also includes some residency programs in states with high poverty levels. The effect of poverty seems to penalize male changes of gaining college and medical school admission. Black males and rural males are admitted in the lowest levels, share some of the best distribution when admitted, and share other important characteristics such as income and first time college attendance.

New studies define the differences further in the Asian subgroups (Medicine, Education, and Social Status)

Asian US medical school graduates choose FP at 7.0 %. Other US Medical student choices (most recent US graduates and last 3 years of FP graduate data from 2001 - 2003.)

Birth Origin and Ethnicity

Includes only those with birth city and ethnicity in AMA Masterfile, basically US citizens graduating from US and International Medical Schools and choosing FP

When reviewing the following it is important to remember that urban origins are far more common in non-white as compared to white. Also there is great variation in socioeconomic status that seems to have more to do with FP choice   Medicine, Education, and Social Status, although rural locations are a concern as well.