Physician Workforce Studies

 

Articles and Letters Published By Dr. Robert C. Bowman July to September

Rural and Remote Health Original Research

Measuring Primary Care: The Standard Primary Care Year  http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=1009

Rural and Remote Health Editorials 

They Really Do Go  http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1035

The Illusion of Minority Status  to be published this week

Annals of Family Medicine Letters

Integrating Admission, Training, and Policy for Health Access Results  http://www.annfammed.org/cgi/eletters/6/5/397#10014

Health System Designs in the US and China  http://www.annfammed.org/cgi/eletters/6/5/421#10005

National Presentations

Rural Assistance Center Rural Spotlight    An Interview with Robert C. Bowman, M.D.   One of the country’s leading researchers in rural medical education discusses ways to recruit and retain rural physicians.   http://www.raconline.org/newsletter/web/fall07.php#spotlight

Logistic Regression and Rural Practice Location Association of American Medical Colleges Presentation 2007  http://www.aamc.org/workforce//pwrc07/2007annualmtgpdfs/panelg/bowmanaamcrural.pdf

Physician Distribution By Concentrations" Primary Care Methods and Statistical Research Meeting San Antonio, November 2007

Others submitted

Rural and Remote Health Letter - The geographic relationships between medical students’ birth location and high school location

Rural and Remote Health Editorial - Attempting to understand the primary care and health access crisis in the United States

Book Chapter on Rural Medical Education in Rural Education in the 21st Century    Primary Author of the Chapter is Rene J. McGovern Ph.D., Obl.S.B. Stephen Laird, D.O. and Tom McWilliams D.O. also as co-authors

Nations, States, Medical Schools and Programs Assisted in Health Access in the past six months with reports, communications, or presentations

AACOM Admission Staff, AACOM Student Leaders, North Dakota, Nebraska, Montana, Canada, Texas, New Mexico, Arizona, West Virginia School of Osteopathic Medicine (Tribute to retiring President Olen E. Jones, PhD), U of North Texas TCOM, Mexico Universidad Autonoma De Guadalajara

National Rural Health Association Annual Quality and Clinical Conference   Health Cost, Quality, and Access Have the Same Solutions    Robert C. Bowman, MD, A.T. Still University, School of Osteopathic Medicine Arizona    http://www.ruralhealthweb.org/index.cfm?objectid=6A183A9B-3048-651A-FE048E671102A334

National Rural Health Association National Rural Task Force Conference Call April 8, 2008     Recruiting the Right Students to the Health Professions - Dr. Robert C. Bowman, A.T. Still University

School of Social Medicine Genogram - A T Still School of Osteopathic Medicine Arizona   http://www.socialmedicine.org/2008/05/10/

"Policy Changes Needed to Address Physician Shortage" by Dave Gardner, Northeast Pennsylvania Business Journal  http://www.hcla.org/States/09.05.06_penn_business_journal.html

Last Year

Graham Center One-Pager   Medical School Expansion: An Immediate Opportunity to Meet Rural Health Care Needs  http://www.aafp.org/afp/20070715/graham2.html

Health Care Workforce Tools Developed

The Standard Primary Care Year

Physician Distribution by Concentration

The Framework of Experiential Place, Career Choice, and Practice Location

In Development

The National Primary Care and Health Access Recovery Plan

• United We Stand - Uniting primary care is less important than helping the United States understand Primary Care

• Primary Care Workforce Years, Short Review - The nation would need to graduate 2 to 5 times as many graduates of any form of primary care to deliver the equivalent workforce of one family physician over 30 years of physician services. Even the best category of international medical internal medicine graduate delivers is estimated to deliver less than 20% of a shortened medical career in primary care.

• Distribution: Index Concentrations of Physician Distribution - For the 1987 - 1999 class years, rural born family physicians and internal medicine IMG physicians are each about 2% of the US workforce. These rural born family physicians are 9% of the rural underserved workforce and IMG internal medicine physicians are 5%. Both are important contributors at greater than average levels. Compare and contrast the various types that distribute to rural underserved and urban underserved locations. How do international medical graduate internal medicine physicians compare to family physicians? What does birth origin and medical school type have to do with practice location?

• VISA Programs: Do They Help In Primary Care and Rural Areas? - international medical graduate office internal medicine, the best representative of underserved IMG distribution, is compared to various forms of family medicine. Data and links from GAO and other sources is also listed

• Family Medicine Choice: Initial Class Years of New Medical Schools - New osteopathic public schools start out with lower FP choice and build to top levels. Osteopathic private schools start out with high levels of FPGP choice. Comparisons of school type, school, and starting averages to national averages.

• Rural Recruitment and Retention Factoids - the latest changes in admissions, career choice, policies, and politics make it more difficult than ever to meet rural workforce needs.

• Changing Primary Care Contributions 1970 - 2015 - what has been, is now, and will be regarding primary care contributions for FM, IM, Peds, NP, and PA - Most will be steady or declining, while family medicine contributions increase

• What Could Have Been: Maximal Primary Care Training Capacity - why are we less than 80% when we should be near 100%, with a rosy future for lower and middle income patients?

• Primary Care Years: New Measures of Total Workforce Contribution - Adjusted Workforce Life Years in Primary Care - advantage goes to those who stay and go where they are needed. Family medicine contributions increase over time as others leave the primary care, rural, and underserved workforce.

• Five Periods of Health Policy and Physician Career Choice - the nation has distributed physicians and very effectively by health policy changes. The nation is now returning to an era not seen in 40 years.

• Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location - PA advantages a few years back included isolated rural areas but FPs led in large rural and small rural locations, state variations are seen, reviewing these variations and the deteriorations in PA rural levels should be important considerations to workforce planners.

• Who Fits the Pattern? Check out your medical school DNA income distribution on the rating scale. Does student birth income distributions match to rural careers, family medicine, or a subspecialist category. Birth county incomes compared to MCAT and careers.

• Community Medical Outreach Model Why wait, develop the physician servant leaders that we most need even before they reach medical school.

• Physician Distribution in the United States - Executive summary with linking documentation, this one is perhaps the best guide to the original works on this site and many other works.

• Failure To Launch - Counties with the lowest probability of admission, some reasons, and discussions of why Florida ranks among these counties.

• Divisions in Physician Career and Location Choice Related to Age at Graduation - Changes in the United States mean that physicians layer out by socioeconomics, age, and scores into three different career types: those that emphasis people, direct patient care, and generalist focus; those that those that distribute and those that do not.

• Distribution of Physicians: Medical Schools Listed with Distribution, MCAT scores, Instate Retention, and More

• Current Active Health Care Policy Decisions - Increasing GME positions generically is a very bad idea. Specific changes and their likely result, based on the decisions of the latest 40% of physicians.

• Health Care Workforce Estimates - National data is revealing regarding distributions of various professionals. The directions are also clear. Other than family medicine, there will not be much contribution for rural and for underserved areas at the higher percentage levels that make a difference, beyond the current 5.4% underserved and 11% rural.

• Family Medicine Standards and Constants - There are reasons for optimal distribution and primary care delivery. In fact it is very hard to keep a family physician from becoming a family physician. Research demonstrates a 25% maximum and a 6% minimum FP choice. Those graduating more than 25% or less than 6%, are working hard to do it.

• Physician Careers By MCAT Groups - certain schools graduate certain types of physicians

• Medical School Expansion 2004 - 2017 - updated version, now over 24,000 expected per year from US sources and 32000 total added each year from all sources in the world, this is over 7000 more than the previous stability for decades

• Flaws in the Concept of Controllable Lifestyle - updated, the very thought that a physician career can be less intense is a strange concept at best. There are many reasons for career choice changes over time such as health policy, different types of careers in careers, poor assumptions and poor design of the career surveys and more. Studies 6 years earlier would have had very different outcomes.

• Primary Care Retention - Updated primary care tables added in this piece now - family physicians remain in primary care while other physicians, nurse practitioners, and physician assistants fall away over time under the influences of current health policy and major medical centers

• Office Based Proportions in IM, FP, Pediatrics - some stay, some go, but those most committed to primary care remain as office based generalists.

• Top Workforce Outcomes Rankings - family medicine leads in Optimal Workforce Outcomes, not much competition

• Recent Black Family Physicians - US Born, Foreign Born, Higher income or lower, is there at difference in physician distribution to rural, underserved, academic, or military careers for US MD Grad Black Family Physicians? The early returns are in for 1997 - 2003 FP Grads. The real overall difference may well be choice of FP.

• Admissions: To Do No Harm - Access to medical school faces a new barrier. Just registering for the MCAT is a challenge. One more barrier in a whole series that shapes future physicians. Time for changes!

• Shaping a Nation: Physicians Who Serve - Handout for STFM Predoctoral Conference When the nation chooses physicians that are different than the 70% admitted from the top 30% in status, they have different distribution and career choice. But do they also have advantages in service orientation, empathy, awareness, physician satisfaction, and other areas that might impact costs and quality?

• Distribution: The 70-30 Distributions That Complicate Physician Distribution - Education, admissions, training, health policy  also see The One Per Cent Solutions that Resolve Distribution Problems

• Medical School Type and Distribution: Initial Database Description and Rural Application Graphics - new definitions of medical school type are needed based more on their admissions policies, also new database definitions are provided, with application to rural distribution

• Market Forces Admissions and Health Policy Versus Distribution of Physicians and Health Care - market forces shape who gets the best education, college, and medical school admission, just like health policy shapes distribution.

• Distribution as Related to Birth: Birth in a Medical School County or City - those most closely associated with medical schools and major medical centers for the first 30 years of life rarely distribute.

• Comparing Probability of Admission and Population Composition

• Changes in Specialty Choice 1987 - 1999 - review of each major specialty with changes during this time period and likely explanations. More flaws in controllable lifestyle exposed.

• Distributional Medical Schools - who serves America outside of major medical centers- those admitting students from outside, training outside, and graduating the specialty that distributes outside and remains

• Distributional Medical Schools: The Lost Lesson of Specific Forms of Government Support - osteopathic public medical schools lead in all categories of distribution to rural and to underserved populations and in primary care and family medicine choice and in most retained instate to practice. Why so few?

• Medical Schools and Distribution for tables comparing origins, income levels, and outcomes

• Major Medical Centers - understanding health policy, primary care, and distribution requires understanding major medical centers, concentrations of physicians, and why the nation cannot focus on major medical centers and still distribute health care to rural and underserved areas.

• Birth Origins and Distribution Tables - Different medical student types have different distribution. Medical schools with different students have different distribution.

• Medical School County Birth - those born in counties with medical schools are more likely to be admitted but are less likely to choose family medicine and to distribute to rural and underserved areas. Could it be that this is a proxy for children of physicians or professionals? Most medical students were born in a city or county with a medical school.

• Birth Country and Career Choice - where physicians come from can influence where they go and where they stay, also divided into foreign born US MD Grads and those born in other nations and attending medical schools in other nations.

• Medical School Type and Distribution - some schools distribute, others do not - comparisons by rural, underserved, office based, major medical center, and other factors

• Multiplier Impacts Involving Birth Origins, Age, Choice of Family Medicine - why admitting more urban, foreign born, Asian, and highest income medical students will not distribute physicians outside of major medical centers

• Family Medicine The Distributional Specialty - data on family medicine, the chief component of physician distribution

• Rural Interested Senior Medical Students - are compared to the literature, to survey findings on 1995 seniors, and to actual outcomes regarding medical student choices. The analysis integrates birth origin, Community Health Center, and primary care career choice studies.

• Choice of Family Medicine Regression - Schools admitting the most exclusive students and states that fail to present a broad range of students to medical school admissions committees will not be graduating family physicians. Newer medical schools and those in more western locations graduate more family physicians and distribute physicians more equitably.

• Distribution of Physicians - Table listing medical schools and their physician distribution levels, also MCAT, early research graduation rates, and graduate retention instate. Those that do well should expand. Those that are not doing well in distribution should consider special programs to admit more distributional types of students, or not expand.

• Family Medicine Contributes More - the significant contributions of family medicine are too often ignored, studies comparing physicians over longer time periods reveal the advantages of a specialty that goes and stays and stays in family medicine

• Matters of Perspective - why medical education leaders are missing the point about distribution

• Birth Origins and Distribution Tables - updated tables on the student characteristics involved in distribution

• Ethnicity Gender Admissions and Distribution - tables comparing admissions, choice of family medicine, distribution, rural, underserved, military, teaching, major medical center location

• Awareness and Future Physician Leaders - the students who are most likely to gain admission to medical school are the least likely to be aware of health access and other problems. The path for diverse and disadvantaged students is challenging but such physicians are more likely to distribute and to be aware of the serious health and education problems facing the nation.

• MCAT and Physician Distribution or lack of distribution - graphic and tables regarding physician distribution based on 1987 - 1999 graduate practice locations and career choices as of 2005.

• Admissions By Income Quartiles the students most likely to gain admission are not the ones that will distribute, includes admissions ratios and student numbers, based on AAMC income data and census data

• Medical School Admissions By Income - changes in the income origins of US physicians predict lower choice of family medicine and lower physician distribution. This pipeline table compares the highest, middle, and lowest income students from high school to college to medical school to choice of family medicine. Not good stats to view for a holiday.

• Multidimensional Choice of Rural Practice Compare by Birth Origins, Age, School Type, Region of the Nation

• Distribution of Physicians   includes info on rural choices, family medicine, MCAT scores, office poverty, by school, age of the class, and other factors important in distribution

• Medical School Type and Distribution - comparison of various medical school types and subtypes by distribution

• Geriatrics Distribution in the United States - sources and distribution levels for the 1987 - 1999 medical school grads

COGME Links at http://www.cogme.gov/pubs.htm Rural, Minorities in Medicine, International Medical Graduates, Physician Education, Improving Access to Health Care, Physician Workforce Reform, Women and Medicine, Physician Workforce Funding Recommendations, COGME Recommendations, Changing the Governance of Graduate Medical Education to Achieve Physician Workforce Objectives Physician Distribution and Health Care Challenges in Rural and Inner-City Areas, GME Payment Reform, Proceedings of the GME Financing Stakeholders Meeting, Collaborative Education to Ensure Patient Safety, Process by which International Medical Graduates are Licensed to Practice in the United States, Preparing Learners for Practice in a Managed Care Environment, The Effects of the Balanced Budget Act of 1997 on Graduate Medical Education

Those who wish to consider the impact of neglected infrastructure or how colleges gatekeep admissions by income levels may do well to review Winner Take All Economics by Robert H. Frank or others. The studies apply to higher education and make sense for medical education and medicine where 1 or 2 medical centers dominate a market or a few insurance companies dominate a state market or as the nation reduces down to 2 pharmacy chains. One size attempting to fit all is problematic for physicians, health policies, and other areas. New NY Times article in the Real World of Wages, Trickle Down 

The studies track the most recent graduates in their current locations. The studies involve equilibrium conditions, not just first practice outcomes. These studies involve the AMA Masterfile with locations using OfficeMax software. The major contribution involves extensive coding of the birth origins of the physicians with 97% of this data available for allopathic graduates from US schools. There are new frames of reference that assist with health policy evaluation such as Comparing Medical Students By Class Year and categorizations of major medical centers, rural, urban, and underserved locations.

For more on the interaction of education, admissions, and distribution see Growing Up America

The growth of the US population (63 % from 1970 - 2020) is outdistancing

• the growth of family physicians (56 % anticipated 1970 - 2020 or lower)
• the growth of black and Hispanic physicians (lower than population growth of each group)

The growth rate of rural areas at 10 % in the last decade is less than metro at 16 % but rural populations are still increasing. The rural born student admissions to medical school are decreasing, down from 27% to 11% even though 23% of the US population is in rural areas. The growth rate of physicians is 270 % from 1970 - 2020 without expansions. This is 4 times the rate of US population growth (63%), the growth of family physicians (56% and falling), or the growth of schoolteachers anticipated (64 % 1970 - 2020 NECS data). See Birth Origins and FP Choice regarding the loss of service oriented professionals (FP, schoolteachers, public servants)

Health care access is a function of numbers of physicians and physician distribution. The key components of physician distribution involve medical student choice of family medicine, the only specialty that distributes geographically and socioeconomically to those most in need of physicians. When attempting to graduate more family physicians, medical schools should pursue older medical students, those born in rural areas, those born in less dense or lower income urban areas, and those born in the same state as their medical school (allopathic public school).

Several national studies have raised questions regarding the quality of education and also medical education. Concerns have been raised about the capacity (enough patient volume available) to train physicians in areas where most medical schools reside. These are basically the most metro areas of the nation. 97% of medical education is in metro areas. 90% of medical students were born or raised in urban areas. 90% of physicians choose to practice in urban areas, unless they choose FP then 78% choose urban areas.

Increased numbers of primary care and family physicians are also important regarding health care quality and cost issues.  Baicker and Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries Quality of Care,  Health Affairs April 2004 http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf  

or Starfield's efforts with Phillips http://www.aafp.org/afp/20040801/editorials.html

or Starfield, Barbara. Primary Care: Concept, Evaluation, and Policy. New York, Oxford University Press, 1992.

Health Affairs has new articles by Starfield, Hsu, Xu and others. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97

or Phillips, Dodoo, and Green at http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.111/DC1

However the major flaw of most economic works is failure to consider distributions, child development, and early education. The nations that have more primary care, generalists, and family physicians also invest more in children, which make all facets of a nation more efficient including health care, education, economics, and more. Top health and education outcomes have only been reached by nations that invest the most in children.

There are also concerns as to whether the increasing numbers of urban and foreign born medical students can effectively serve a more and more diverse population involving a wider and wider range of income levels, cultures, and geographic areas.

Rural Medical Schools: A Different Kind of Education

Older graduates, those born in rural areas, and newer medical schools with older graduates have been the most resistant to changes in primary care health policy. Already at high levels of distributional choice, they are influenced, but not to the same degree. Managed Care Comparison Table

There is also the consideration of types of training

1. Osteopathic Medicine
2. Osteopathic Public Schools: The Lost Lesson of Specific Forms of Government Support
3. Newer Allopathic Medical Schools
4. Distributional Medical Schools
5. International schools with US citizens    Going Caribbean
6. Specific Rural Training, usually involving specialized admissions of the students described below Best Model or Rural Training in Family Medicine or Why a Rural Preceptorship Is Best   The growing problems and direction of US medical education is noted at Medical Education Retardation

Sources of the Current US Physician Workforce - who provides rural, essential, and other types of physicians

Frontier Family Medicine Choices by medical school name and type

Rural Coding RUCA 2.0 and the US pop and poverty by state

The 1990s represented a "perfect storm" of reimbursement and training and support and accountability and popularity for career choice with great improvements in distribution to rural and poverty areas.

Such a perfect storm allows RTT and accelerated and other programs with distributional students to shine.

This site considers the health needs of the people of the United States. The site attempts to avoid the bias of funded studies,  promotional needs of health profession associations, or the interests of major medical centers. The site attempts to integrate the relationships between education and the distribution of state education resources as they impact health care quality, cost, and access. This information is important for legislators, health care leaders, and those involved in education, medical education, and public health. Many workforce questions can be answered in hours. The longer term solutions usually involve rebuilding the infrastructures in health and education that have been neglected for decades. Collaborative work sharing writing and databases is encouraged.        Distributional Analysis Policy Center 
 

Comments Regarding the Future of Academic Medicine

Facilitating Distribution

Family Medicine Physician Distribution

Workforce References

www.ruralmedicaleducation.org