A Framework of Experiential Place
Taxonomies, Themes, and Theories in Physician Distribution
Robert C. Bowman, M.D. [email protected]
Introduction
A Framework for Experiential Place
I. Theme: Geographic and Related Demographic Dimensions
II. Theme: Super Centers and Major Centers: Inside or Outside
III. Theme: Retention within State, Province, or Nation
IV. Theme: Spouse and Family Experiential Place
V. Theme: Socio-Cultural Experiential Place
VI. Theme: Experiential Place Impacts on Career Choice
VII. Modifications and Limitations of Experiential Place Involving Career Choice
VIII. Modifications and Limitations Involving Health Policy
IX. Practitioner Interactions: Facilitations and Limitations of Experiential Place
Experiential place can provide a framework for understanding physician practice location and distributions of health care resources in the United States.
Physicians with extremes of origins such as the most rural origin physicians have consistently been found to return to rural practice locations at the highest levels. Physicians with origins most closely associated with lower income levels or underserved origins have the greatest rates of return to such practice locations. Other life experiences clearly have impact, but often have less study.
Experiential place has often been limited to studies involving practice locations in need of physicians. The studies have often been done by researchers attempting to improve physician distribution. Often the prize for such research is government funding. This of course tends to bias the research in ways that favor those doing the research.
A biased perspective has made it difficult to understand basic health access. A focus on extremes of lower population density, lower income, or lower densities of physicians can also cloud the important relationships regarding health access.
Common sense can aid the researcher with regard to health access. A most basic division can illustrate the origins, types of training, policies, career choices, and practice locations that are associated with health access.
Inside or Outside of Concentrations
The most common experiential place factor appears to involve life experiences closely associated with concentrations. Over 70% of physicians were born, raised, and trained for 30 years in concentrations of income, professionals, people, physicians, and health care resources. Experiential place connections are strong and physicians have consistently remained in top concentrations.
The development of the concept of inside of concentration with most desiring to remain in side of concentrations in location or career choice results in at least 3 reasons for physicians to locate in zip codes beyond concentrations. One reason is a desire to be away from concentrations due to personal or family requirements. This is also likely to be an experiential place concept. The second is that physicians are not as competitive for a variety of reasons. A third reason is that some physicians are likely to do better by leaving top concentrations (or may be treated poorly in concentrations).
A broad scope generalist such as a family physician may not have the ability to utilize broad scope in a physician concentration location. Privileges may be restricted and the procedures that are reimbursed at higher rates may not be available to generalists as compared to locations outside of concentrations that are dominated by generalists. There are still unfortunately situations where physicians of various origins or career choices are not as accepted. Nurse practitioners, physician assistants, osteopathic physicians, international medical graduates, and minority physicians may still have some difficulties with acceptance although most have made great strides in recent years.
From the perspective of health access, exclusion is often a good thing. Those excluded from physician concentrations provide substantial most needed health access. In the past 15 years, nurse practitioners and physician assistants have made the most headway in acceptance but the cost has been the family practice mode in NP and PA. With departure from the family practice mode, departures from rural and underserved most needed health access have followed.
Another way to categorize tendencies to concentrate or distribute is to compare exclusive higher income and most urban origins (those associated with concentrations) to more normal origins. Exclusive origins also tend to have exclusive scores. Those more normal (lower and middle income for example) tend to have more normal and less than the most exclusive scores.
Associations with Exclusive Concentrations Versus Normal Origins
The physicians most closely associated with combinations of concentration have the most exclusive origins. They are least like normal Americans, especially lower and middle income Americans. They are commonly
Each of the above factors is more likely to result in higher probability of medical school admission for those of concentrations, those more exclusive in origin, those attending exclusive colleges, those living in exclusive property value schools, and those that can afford exclusive college prep or prep for standardized tests. Even a magnet school or a gifted program can identify a student as exclusive and result in differences from those more normal.
Each factor makes physicians different than normal Americans and much more different compared to lower and middle income and rural and minority Americans in most need of health care.
Selection for college and medical school that favors that above also favors a narrow, science oriented group of physicians. Exclusive selections also moves physicians away from the service orientation, people orientation, empathy, and awareness of the needs of those most in need of health care that are more commonly found in lower and middle income medical students.
It is interesting that medicine is more and more a business, but is less and less likely to be governed by the practicality found in business approaches. Businesses must be businesslike to survive. Medicine and medical schools appear to be best served by serving their own needs regardless of the needs of others, especially those left behind in health care.
A true business model that applies can be found in the works of Geert Hofstede. Culture is considered the software of the mind. One of most important areas to address before new learning can begin is to unprogram the software of the mind to allow new learning. Learning in areas such as culture, awareness, and application is lacking in the current medical education design. The programming involves areas of thinking, feeling, and acting, often without awareness.
Also the ways of thinking, acting, and feeling are the result of collective experiences unique to populations. The principles of Hofstede are important to consider in medicine and include power distance or how subordinants respond to power and distance, individualistic versus collectivism, feminity versus masculinity, uncertainty avoidance, and long term versus short term orientation. These applications are now being applied to areas of medical communication with interesting results that apply to access, cost, and quality.3
http://radio.weblogs.com/0107127/stories/2003/01/16/cultureGeertHofstedesModel.html
http://en.wikipedia.org/wiki/Geert_Hofstede
It is not hard to figure out that people within nations vary in ways important to the design and implementation of health care and particularly with regard to health access. An individualistic nation and those at the top who have pursued the most individualistic careers may be least likely to understand the need to work together in areas such as health access and other basic infrastructures in a nation. Poor attitudes toward taxation, policies such as No Child Left Behind in a nation that leaves 65% of children behind, and abysmal child development are a fit with deteriorations of health access, declining education for lower and middle income children with lower admission rates to medical school, public health as a lower priority, top concentrations of health resources, and condemnations of the less individual and more collective nations that are branded �socialistic� or worse. Long term orientation is necessary for the most basic priorities that build, revise, and rebuild nations although the United States is consistently short term in focus, especially in areas such as health care budgets. Uncertainty avoidance is supposed to be low in Americans although American medical students certainly exhibit this behavior even when asked to only spend a few hours of their medical education with underserved populations.
The physicians found in family practice, rural, and underserved careers are consistently more likely to be associated with birth origins in counties with lower levels of income and lower population density. The same data is used to calculate admission ratios and the family medicine, rural, and underserved careers are most likely from populations associated with lower concentrations of income, people, and physicians. As birth county origins get more exclusive, the resulting physicians are more likely to have exclusive careers (general to specialty to subspecialty), are more likely to have exclusive medical schools (lower ranking MCAT allopathic, osteopathic, higher ranking MCAT, allopathic private, international, most exclusive allopathic), and are more likely to be trained in the most exclusive locations (highest income, most urban, most subspecialists, most elite training, fewest normal physicians). They are also more likely to have higher scores and higher probability of medical school admission.
To understand experiential place the various life experiences of the physicians need to be captured from birth to admission to training to practice. Birth origins are available for over 95% of United States allopathic medical school graduates, 70% of osteopathic graduates, and 50% of international graduates in the Masterfile. Because foreign born United States medical school graduates and international origin physicians are consistent in career and location choices, over 90% of physicians can be coded by origins. Physician age, medical school type, career choice, residency training variables, and practice locations are also available.
One more important element is required. A coding database must capture locations across all of the experiential place locations. While geographic coding can capture rural experiences or even a wide range of rural experiences, urban locations are by far the largest proportion and urban sociodemographic variations are poorly represented. Coding based on income distributions fails to capture geographic variations. Geography and income both fail to capture the most important factor in physician location � concentrations of physicians. The Physician Distribution by Concentration coding system integrates three major influences on physician practice location. The priority is physician concentrations with zip codes having more physicians more likely to be organized in concentrations. The other two divisions involve poverty considerations and geographic segments. This is an ideal coding system for health access. Physicians, particularly those least likely to be found in health access, avoid locations that do not have concentrations of physicians, avoid locations with higher poverty, and avoid populations with fewer people. Health access physicians and non-physicians are best described by the family practice MD, DO, NP, and PA forms and are the ones remaining in lower concentrations of physicians, income, and people when other specialties (in physicians and non-physicians) have melted away.
Experiential place provides a framework or taxonomy of physician career and location choice. Themes and theories involve origins, training, health policy, and practice location.
At the individual physician level, experiential place relationships can be described by geographic locations; life experiences related to parents, spouse, or family: environmental influences; lifestyle; socioeconomic; or socio-cultural influences. For purposes such as medical school admission, those who are more socially organized are more likely to gain admission at the family, social group, community, or state level. Professional parents are another social group that can greatly aid their children or others of the professional parent social group.
Life experience connections are also important determinants of health. Status, poverty, child well being, and other measures of distribution are the most important factors related to health care. Health care quality in a state has 0.7 to 0.9 correlations with these factors. Health care access in a state is about admission to medical school for lower and middle income children who are 2 to 3 times more likely to be found serving the underserved and twice as likely to be found in family medicine which is also 2 � 3 times more likely to be found serving the underserved. Health care costs are related to birth to the patient ability to access care appropriately, health care access factors, and state efficiency and effectiveness. Cost, quality, access, child well being, distributions of income and education, employment, dependency rates, voting rates, higher rates of the more normal middle class Americans (fewer extremes of rich and poor), efficiency, and effectiveness are all closely associated with one another.
Theories can help predict future physician career and practice location decisions.
Experiential place factors have been used in the design and implementation of needed health access. The Principles of Health Access are the result of study of experiential place.
Schools, states, and nations can modify admission to prioritize those with experiential connections to a state (instate) or a desired practice location (rural or underserved).
Experiential place can impact career choice. Those raised in generalist environments where the dominant occupations are service oriented professionals such as nurses, teachers, or family physicians are more likely to choose generalist careers. Children raised in concentrations of professionals tend to choose specialized careers that compliment their super center and major center location tendencies.
Experiential place can be facilitated or suppressed. Generalist careers have allowed the greatest expression of experiential place in the past due to greater flexibility in training and in location choice. Highly specialized careers force very specialized training location and practice location.
Family physicians have the maximal range of physician origins with maximal ability to match up to the widest range of populations. Family physicians have the widest range of training locations and venues. Family physicians have the widest range of available practice locations, not uncommonly locations that are not available to most physicians or even most primary care trained physicians. This is seen in maximal rural or in underserved distributions in family medicine and facilitated by family medicine origins and training. Family physicians born outside of concentrations and trained outside of concentrations have top location outside of concentrations. Native American family physicians have the greatest numbers of connections to outside (rural, lower income, different culture), have different medical education experiences, and often have policy support that encourages family medicine, primary care, and outside location.
Any specialty choice beyond family medicine restricts location to zip codes with 75 or more physicians where 75% of United States physicians are found whereas family physicians remain 50% inside and 50% outside of such zip codes with concentrations. Physicians with specialized careers in the absence of competing experiential place (birth origin outside, rural, lower or middle income, underserved) are going to be found in locations with previous physician concentrations.
Asian Indian origin physicians have the most combinations of concentrated origins, have medical education with the least primary care and generalist exposures, have the lowest choice of family practice, are the least likely to have encountered family physicians from birth to admission and throughout training, and are found in the top concentrations of physicians, population, education, and income in the nation similar to their origins.
A Consistent Theme of Health Access - The most urban, highest income, most socially organized, closest to medical schools, most children of professionals in any race, ethnicity, or geographic origin will have top levels of admission and lowest levels of distribution.
Health Policy Is Essential for Health Access � the Multiple Dimensions
The relationship to of experiential place to health policy must be understood. Sufficient health policy is required for the expression of experiential place. Insufficient support of primary care or of practice locations outside of super center and major centers can impair primary care practice in locations outside of concentrations.
Poor support in the final years of training and first years of practice can even negate decades of coordinated preparation, admission, and training efforts integrating all the important experiential place influences. The impacts of culture can be seen in terms of obstacles to admission, career choice, and most needed health access distribution. While the voice of medical education experts says physicians cannot go where most needed, the evidence demonstrates otherwise.
Career pathways may be resumed after completion of obligations, but once again the most recent life experiences shape the future. The losses of rural and underserved primary care are substantial under the current design.
States such as Oklahoma have adapted support packages to bring completion to previous state investments. Oklahoma pays higher salaries to family practice residents to encourage this career choice. The state pays additional salary to family practice residents who select an underserved practice location. By keeping life experiences connected to the state, the state ends up shaping future life experiences in Oklahoma.
For about 20 � 30 states, life experiences within a state are of utmost importance in physician location patterns. Often in these states, the lowest levels of medical school and graduate medical education experiences are found. This makes it very difficult to recruit physicians as they have had few or no medical school or residency experiences in a state. States without their own 4 year medical school, the most rural states, and states that get a very poor share of graduate medical education distributions are greatly disadvantaged at the current time and this all has to do with physician experiential place. The experiential place that shapes practice location the most is the most recent life experience. The location of the final year of residency training is crucial, but all previous life experiences have impact.
Admission and training efforts made little sense before 1970 as the support for primary care, rural, underserved, and elderly populations was so poor. The United States required several years from 1965 to 1978 to rebuild health care infrastructure so that it was even possible to distribute physicians outside of the existing urban highest income locations. With new policy support available new markets in lower and middle income urban and rural areas were opened up. The usual 20% rural choice was 30% for the initial few years of family practice residency graduates, another indicator of a new market opening up with an ideally suited candidate trained to fill that niche.
Versatility, organization, and leadership in individual physicians or in communities can also modify experiential place impacts in areas such as recruitment, retention, and building a better capacity to deliver health care.
Statewide coordination attempts to match up health care needs to physicians at every stage in the physician life cycle. This involves improvements in birth to admission process of preparation to become a physician, admission focus to admit more who match up to the locations and careers in most need in the state, training that also matches up to state needs, and policy support so that those prepared, admitted, and trained can actually fulfill state needs.
Minimal efficiency and effectiveness is the result of divisions of state education outcomes into rich and poor, admission of children born and raised in concentrations, training entirely in top concentrations, and policy support grossly insufficient to support primary care, health access, family practice, and distribution.
The states with the greatest divisions into rich and poor are states with the lowest percentages of family physicians. Those highest status that gain admission have the lowest choice. The middle income levels are missing that have a balance with ability to gain entry and higher family practice choice. The lower status children are not making it to admission. With lower and middle income status important to physician return to such locations and also important in greater probability of family practice choice, these are states that constantly suffer from health access woes. Also since fewer physicians distribute, fewer health care dollars also distribute, making divisions of rich to poor in the state even worse. Also the education and child well being conditions make it difficult for physicians to practice in underserved areas as more complex patients take more time and effort. This results in less efficient and effective practices. Physicians also find it difficult to remain in such locations as the education and opportunity for their children is limited.
In urban underserved areas there are similar problems. Family practice and primary care salaries are the lowest in these locations and the patient care populations are the most complex. The cost of delivering care is higher and physician employers often marginalize appropriate pay and support for primary care physicians. The worst case examples were the initial National Health Service Corps physicians that were grossly underpaid in multiple instances. The tendency to underpay, marginalize the physician role, and focus on processing underserved patients remains. Primary care physicians in urban underserved and medical school locations that stay tend to have higher paid leadership positions (medical director, chair), have some other way to make outside income (that often distracts from primary care), or have a spouse who makes the same or greater salary. Another survival mode is inheritance of land or housing such that the high cost of living in such an area is minimized. Why stay in Hawaii or Brooklyn where even a very good primary care salary of $150,000 is really only $56,000 compared to any location from Houston to Wisconsin where $150,000 is below average and is actually worth $150,000. Then there are locations that pay higher rates with low cost of living and less complicated patients to see.
College students, medical students, and residents are aware of these dysfunctional primary care settings and are not likely to be encouraged in a primary care path.6 Since the medical school and urban underserved locations are the least likely to have family physicians and primary care physicians are the least likely to have normal health access experiences, it is not a surprise that health access career choices are low. At a school like Duluth where all students have some contact with successful primary care practices and half spend 9 months in rural practice locations where they are treated very well as people, where family physicians have optimal pay and support, where patient complexity is normal, and where they have the time to gain some understanding of the complexities of primary care, family practice is the career choice for 40 � 50% even in the worst health policy in decades as evidenced by less than 10% family practice choice for other University of Minnesota graduates.
Experiential place can become an important framework for understanding determinants of physician career and practice locations.
Relationships and experiences in life have long been associated with eventual practice location choices. A wide variety of relationships are involved. How can life experiences best be translated in a way that allows workforce studies to interpret physician practice location? Is the relationship flat across a single dimension of geography, is the relationship multi-factorial, or is the relationship rich in life experiences involving community, social organization level, family, status, parent occupation, and spouse?
Experiential place remains most obvious for rural geographic origin as observed with higher probability of physician return to rural location. The great contrasts between rural and urban settings facilitate this observation. However there is no reason to limit experiential place to simple geographic terms.
Although rural origins and locations are distinct, rural life experience impacts may be the most limited in the years from physician birth to medical school admission. Rural experiential place can only involve the early years before rural origin students must depart for education or training. When rural or underserved life experiences last too long, it can be difficult to gain college or medical school. Already those who have rural or underserved origins have to begin the path to a medical school in their early teens and must continue the path for more years before and after college to gain admission. Those beginning the process late do not show up as admitted medical students. Underrepresented minority students also have to begin the pursuit of a medical career earlier and are older at medical school admission.7 Rural interested medicals students also share top rates of interest in underserved careers and probably share the greater level of awareness of underserved populations found in those who are more likely to arise from underserved life experiences.8
Rural experiential place influences are disturbed by college and by medical school and residency training life experiences that are among the most urban in addition to being super center and major center in focus. In some cultures the necessary higher education component is passively or actively opposed. Native American parents can perceive higher education as an exit from home and family life experiences. Perceptions of the female as limited to family and child raising roles can also limit higher education and professional opportunities. Hispanic cultures tend to be oral and English is often not a first language, standardized testing acts as a barrier to higher education and medicals school and to health access. In MCAT tests about 6 fewer questions were answered correctly out of 40 due to English as a second language. With only small margins determining admission to medical school and with testing that fails to adjust for the wide variety of human experience impacting standardized test performance, those more normal and less exclusive face difficult barriers to admission.
Returns to rural or underserved locations can also be challenging. After the few years of medical education those returning to a rural location must make another series of adjustments to adapt themselves, their family, their training, and their career to a specific rural location. Transitions can be as challenging for those adapting to underserved populations. Physicians departing training must adapt from locations with top health resources to locations that have the least. Health access careers involve also involve transitions. The vertical orientation of training locations is very different than the horizontal health access focus outside of concentrations.
The impact of life experiences can be seen in studies of retention of physicians within the same state of practice. The most powerful influences involve the most recent practice experiences or graduate training. Odds ratios of instate practice location can be 50 to 100 times higher for those with instate residency training in family medicine. Medical school location also contributes. Life experiences from birth to admission still contribute. Even birth origin data can be related to 2 � 3 times greater probability of rural, underserved, or instate locations. When studies do not include a birth to final decision framework of experiential place, there is significant missing data to consider all along the physician life cycle.
The simplest experiential place studies require a defined place and consideration of the life experiences. The geographic markers that are extreme such as rural versus urban are often easiest to consider but are not the only considerations in experiential place.
New studies identify concentrations of physicians as the dominant physician practice locations. These can be defined as locations with 75 or more physicians at a zip code, an experiential place with at least 70% of United States physicians. An even more exclusive super center location can be defined by 200 or more physicians at a zip code with 46% of US physicians or 50% when including residents in training. The locations that are defined by top physician concentrations are not just locations that impact medical students and residents. Medical students are admitted at higher levels when they are born and raised in close proximity to medical schools and other concentrations of physicians. Those not associated with medical schools, physicians, or concentrations of physicians or professionals have the lowest probability of medical school admission. Those with the highest probability of admission are the least likely to distribute outside of concentrations. Those with the lowest probability of admission that do gain admission have the highest probability of distribution outside of concentrations.
Origins associated with concentrations as well as rural, rural underserved, and urban underserved origins can be identified and can also be linked to physician practice location. These studies can be applied to various groups of physicians at the national, state, type of medical school, or individual medical school level.
Of course when certain medical schools eliminate those with rural, lower income, or middle income origins, it is difficult to demonstrate differences since the admitted medical students are so similar in the life experiences, career choices, and practice locations. Arising from consistently top concentrations, training in top concentrations, choosing family medicine at only 2% levels, and supported by the exclusive health policies that dominate the United States, they are most likely to be found in zip codes with 200 or more physicians.
Origins inside, training inside, admissions, and career choices are all related to one another and to concentration as physicians. Origins outside, training outside, the family practice career choice that is most likely to be found outside, admission probabilities, and physician distribution outside are all related to one another.
Beyond experiential place involving geographic location, experiential place involves environments. Super center and major center concentrations of physicians are concentrations of professionals, income, people, and education. Children with these characteristics can be considered to be influenced by experiential place associated with concentrations. Only direct studies can reveal their parents to be professionals or physicians but the levels of dual professional parents, professional parents, top income, most urban, and highest scoring students are now at record levels.
The flip side of admission of more physicians associated with concentrations and combinations of concentration is continued declines in rural, lower income, and middle income medical students. In 1997 medical students divided into 4 quartiles with the bottom 4000 arising from parent incomes of less than $40,000 and the top quartile 4000 arising from parent incomes of over $100,000. From 1997 to 2004 there were 3000 fewer admitted from the bottom three quartiles and 3000 more admitted from parents making over $100,000. Lower and middle income American income increases were flat during this time period while the upper status Americans extended advantages in income and many other dimensions.
There are consequences for such changes in admission as those lost over the past and previous decades are the students most likely to be found practicing in the 38,000 zip codes with 65% of the population and only 23% of physicians. They are also the most service oriented, the most people oriented, the most likely to choose health access careers, and the physicians most likely to have an awareness of those in most need of health care. Since those most connected to concentrations are the most likely to shape future generations of physicians and medical education, when physicians are less and less aware, it is difficult to shape health care for an entire nation. The American health care design fits those most exclusive while the 65% left behind fall further behind in health care and other dimensions.
In a physician workforce pool that already includes the most exclusive from United States and foreign origins that have the least common ground shared with most Americans plus the most exclusive science of all generations of physicians, trained in the most disease and technologically focused methods, there are consequences for those left out of the current design
Most Americans would be shocked to see the magnitude of change in physician origins in recent decades. Few understand the declining opportunity when only 60% of the physicians entering the United States workforce come from families that were in America in 1980 and less than 20% come from lower and middle income American families that are over 65% of the nation�s population. Few have even considered what this means to cost, quality, or health care access.
Of course there is little or no representation of these changes in the medical literature, the medical education literature, or the media. Occasional reports document the changes and highlight some of the consequences. Child well being is 21st out of the 22 wealthiest nations in UNICEF reports indicating deficiencies at the very start of life.9 Numerous deficiencies in family structure, nurturing, and child development contribute. While other nations complement child development when parents work, the United States penalizes working parents. Census studies already indicate child poverty levels of 30% in working parents, married, with high school degrees and this level will soar in the next few years. This is a great contrast with those who see poverty mainly as a function of those not able or willing to work. Studies from Mortenson regarding Post Secondary Education indicate that 90% of upper quartile children attend college while only 30 � 65% of the lower 3 quartiles access college. Only 3% of lowest quartile children fill the top 146 college positions, the most direct route to medical school admission.10 This is a contrast with the 74% of positions taken by top quartile children.1 Also college health professional advisors have observed a narrowing of admission into fewer of the elite colleges. With exclusive children gaining admission to the more exclusive colleges with fewer colleges shaping physicians, this represents a problem regarding a physician that can relate to most Americans. This is not a new situation in professional schools. The Supreme Court has been dominated by Harvard trained graduates for decades.
In recent decades the top colleges have sweetened the financial package to compete for these top status children with top scores while lower and middle income students face greater barriers.11 Those who design and maintain standardized testing have indicated the challenges to come in publications such as America�s Perfect Storm,12 but there are no changes on the way to reshape a future for lower and middle income American children or future generations of Americans.
The Context of Experiential Place in the Medical Literature
Medical education leaders have called attention to accountability and social responsibility for medical education and medical educators,13 but movement has been in the opposite direction.
Medical education in the 21st century is moving in the opposite direction from 100 years ago. The Flexnerian revolution forced improvements in the quality of training, the quality of physicians, and the stability of medical schools. Medical education requirements forced changes across secondary education and higher education that were beneficial to efficiency and effectiveness in America. Now the most exclusive are rewarded and the health care design rewards the most exclusive. Even with maximal efforts, it will take decades to restore the primary care necessary to establish basic access to health. Health care leadership has tolerated the active destruction of primary care, including the conversion of internal medicine to 90% specialists. The relatively new creations of nurse practitioners and physician assistants are already 65% specialists and expansions of graduates no longer are able to increase their primary care contributions at a time when populations are more complex in multiple dimensions (elderly, underserved, child well being declines, increasing shortages of primary care).
American newspapers, legislative staff people, journal editors, magazines, and politicians are hanging on to sources of primary care and health access that no longer work. Distortions of primary care are commonplace. This includes the most basic distortion of internal medicine as primary care training when 90% of internal medicine graduates fail to choose primary care. Nurse practitioner training results in less than 35% primary care and physician assistant training results in less than 30%. In a few years pediatric training will also yield less than a majority leaving family medicine as the only truly permanent primary care training source.
The reason for the decline is quite simple. Exclusive health policy that rewards exclusive careers and locations results in 10% or 20% greater salaries as seen in nurse practitioners and physician assistants and much higher salary increases for internal medicine specialization. Pediatric gains with specialization have been modest and this has resulted in less departure. Now that the nation is desperate for basic health access, locums, urgent, and emergent careers are more common choices for the 10% or greater gain. Of course this worsens basic health access in more than a few ways and also results in greater health care costs for lower quality in a number of ways.
There are also major consequences of current destructive US policy with regard to primary care. In specialty and hospital employment, physician assistants and nurse practitioners can generate revenue at much higher levels and in some cases nearly as much revenue as physicians. The non-physicians also cost far less than specialty physicians and can capture market share and funnel procedures to the systems and specialists that employ them.
Departures to the careers most associated with concentrations leave 65% of the nation�s population behind. Those remaining more normal in origins, in training, in career choice, and shaped by policies distributing resources normally are found outside of concentrations where physicians are most needed.
It is more obvious that the defining characteristic for physician origin, for physician location, for career choice, and for health policy is concentration. The concentration factors include the first years of life, education, college, medical school, graduate training locations, population density, income, and professionals. Birth origin measures provide a proxy for geographic and income origins. The proxy secondary variable of proximity to medical schools or super center and major centers can be measured across birth origins, high school location, medical school, graduate training, and practice. It is very difficult to separate these characteristics from one another in individuals, types of students, types of medical schools, types of career choices, or practice locations. The students born and raised in these concentrations have the highest probability of medical school admission. A 70% rule of thumb can be applied regularly. About 70% of physicians are found in super center and major center concentrations. About 70% of medical students arise from the top 20% in income. Over 70% of admitted medical students were born in a city or county with a medical school. Those most connected by parents and origins to super center and major center locations remain connected decades later. Even when loaded together in regression studies, each of the variables continues to contribute. They work together as measures of concentration and also represent combinations of concentration. Admission favors those with combinations of concentration.
In addition to advantages in admission, the physicians most associated with concentrations never have to transition to another type of environment for education, college, medical school, or graduate training. The top private schools or education systems, the top colleges, and the various environments and advisors that are needed to improve the probability of medical school admission are easily found in close proximity to medical schools. Those admitted at the highest levels nearly always have the career advice and support of a professional parent.
The advantages of admission are contrasted with consequences in physician distribution. Given 30 years of unbroken life experience connections, distribution outside of super center and major centers may be a most difficult endeavor. With family medicine rarely seen in the most concentrated super center environments (5% or less) and with most family physicians found outside of concentrated medical center environments, children who are raised and trained in concentrations have little exposure to the one consistent factor that has demonstrated the ability to distribute them beyond physician concentrations confines.
There are also consequences found in professionals such as physicians with a narrow range of origins and a potentially limited awareness regarding interactions with people. The challenges can be greatest when those of the most limited life experiences at the top status encounter patients, staff, and colleagues who have very different experiential place in socioeconomic and geographic and other dimensions.
There are a variety of reasons behind the traditional linkage of experiential place to rural origins. The initial �Decision for Rural Practice� studies explored the concept.14-17 Health policy efforts and physician outcomes have long been linked to rural location. Other locations have not been defined in simple descriptive ways that allow detailed studies and comparisons.
With physician origins defined with the same methods as physician practice locations, studies can compare factors across origins, admission, training, and practice location.
The discovery of significant birth origin data in the Masterfile, the largest secondary database on physicians in the world, represented a new beginning. Birth origin studies allow a consistent measure of experiential place to be directly compared to practice location in 95% of the graduates of
With consideration of the higher status, most urban, most connected to concentrations, the opposite end of the spectrum could be considered � those most socially and geographically different and distant. The birth origins needed to be studied to see if they truly represented a categorical or continuous variable.
Studies comparing movements from birth location to high school location revealed that the most rural origin students remained in the most rural locations with a few moving to small rural high schools and slightly fewer moving to large rural high schools and a very few moving to the most urban and major medical center environments. Those of the most identifiable professional proxy origins such as birth in a college town or birth in another country did indeed move to the largest metro areas and their children were more likely to enter the private high schools with the highest ratios of medical school admission in
Rural locations and major medical center locations contrast at opposite ends of population and resource distributions. Super center and major center locations can also be contrasted with urban underserved locations that also have different concentrations and characteristics. Rural locations have had geographic markers that compliment divisions of location. New coding methods allow zip codes to be readily converted to urban underserved location.(categorization)
One of the problems of geographic coding is that urban areas are more confusing. A birth origin such as
Birth county income, race, and ethnicity studies can also be used to compare across social and socioeconomic isolation dimensions. Social organization levels could well be the real driving force behind admissions, training, health policy, education, child development and most of the factors that shape society or leave society less organized. Contrasts also allow comparisons across physician origins, training, and practice location. Sadly the danger of race and ethnicity is that people then use the terms and fail to understand the complexity or range of origins or life experiences involved. The same is true for rural characteristics that can represent the poorest and most isolated locations or practices to the most concentrated super center locations in the nation.
The influence of the birth to admissions process is readily seen with a different framework. The previous career and location concepts giving must be expanded beyond the limitations of influences during medical school.
Taxonomy, themes, and theories should be compatible with role modeling, controllable lifestyle, economics, and health policy influences as well as changes in medical students and medical schools over the decades.
Physician origins, training, career choice, practice location, and health policy are a matrix of complex interactions, as complicated and complementary as the interactions that shape health care access, cost, and quality. Studies of health care quality also offer a role for experiential place. A consistent theme of greater quality or greater perception of quality is common ground shared between patient and physician. This has included matches across race, ethnicity, gender, socioeconomic, language, culture, and geographic characteristics. The concept of shared experiential place is compatible with quality, cost, and access considerations.
A taxonomy or framework for origins, training, and practice location can facilitate understanding of the concept of experiential place, the different dimensions of experiential place, and the relationship of experiential place to the distribution of physicians.
Themes and theories involve major medical center relationships, spectra involving geographic and social isolation, multiple dimensions of connection relationships, and the consistent role of family medicine.
Some definitions, illustrations, and limitations shape the taxonomy of experiential place.
A Framework for Experiential Place
I. Theme: Geographic and Related Demographic Dimensions
II. Theme: Super Centers and Major Centers: Inside or Outside
III. Theme: Retention within State, Province, or Nation
IV. Theme: Spouse and Family Experiential Place
V. Theme: Socio-Cultural Experiential Place
VI. Theme: Experiential Place Impacts on Career Choice
VII. Modifications and Limitations of Experiential Place Involving Career Choice
VIII. Modifications and Limitations Involving Health Policy
IX. Practitioner Interactions: Facilitations and Limitations of Experiential Place
I. Theme: Geographic and Related Demographic Dimensions
The most easily understood experiential place terminologies involve themes of geographic or social isolation. Income, education, population density, social organization, distances, and concentrations of professionals can be used as measures of experiential place. There is also no reason to believe that any of the categories are exclusive.
Any given study may involve overlapping dimensions of experiential place. These studies are limited only by our ability to grasp associations that are often complementary and facilitate each other, but sometimes conflict, limit, or obscure. Some of the facilitation and limitation examples are listed.
Qualitative studies can also make contributions in specific areas such as life experience intensity, duration, or timing. Elements of integration (practitioner to community), similarities, distances, and differences are also seen in retention studies.
II. Theme: Major Medical Centers: Inside or Outside
Experiential impact themes include a dichotomous relationship of major medical center versus non-major medical center experiential place. Over 70% of medical students can be tracked to major medical center origins using a basic categorization such as birth in a city or county with a medical school. This 70% level of medical school origin is consistent for those born in the
Combinations of factors are more likely in major medical center origin medical students such as younger age (fewest barriers to admission), professional parents, the most population dense origins, top income levels, highest levels of education, and exclusive education. Single dimensions of comparisons fail to capture the magnifying impact of combinations. The contrasts are greatest in the socioeconomic and geographic differences and distances. This is also related to the higher scores in the most exclusive origins with lower scores in those most different. The factors that shape test scores and admission to college and medical school also shape the probability of physician distribution.
Asian and foreign born populations, students, medical students, and physicians are more likely to have combinations of these characteristics. The Asian and foreign born US MD Grads and those born in the top income and most urban counties are also the least likely to choose careers outside of major medical centers including family medicine, primary care, rural, and underserved careers. The same combinations are also present in students of all other races and ethnicities and origins; however the important data is only released by race and ethnicity. There are also exceptions such as Vietnamese and Mexican origins among the Asian and foreign born group that have broader distributions of income and parent education and higher choice of family medicine, primary care, and underserved locations.
Another characteristic of exclusive major medical center origin medical student populations is 2 � 10 times higher probability of medical school admission. This magnitude is accompanied by the same degree of lower probability of distribution outside of the major medical center reference point in the past 20 years of medical school graduates.
Those with origins outside of major medical centers in urban underserved or rural locations have half of the probability of medical school admission. The humble origin students that do manage to gain admission follow their origins to rural or urban underserved practice locations at double the national average rates. This higher level of distribution is doubled or tripled by choice of family medicine to the top levels of rural or underserved distribution (4 � 6 times physician averages).
The Vietnamese component is interesting. Despite a broad range of parent income and education compared to other Asian and higher status white populations, Vietnamese share the three times probability of medical school admission found in other Asian populations. Humble origins theories would predict lower levels of admission. Life experiences may shape a different path as a displaced (recent refugee) population moves toward the higher status levels present in
Major medical origins, major medical center admission, major medical center training, and major medical center focus of health policy all combine to concentrate physicians. Those born outside, raised outside, with life experiences outside, admitted from outside, trained outside, and influenced/supported outside of major medical centers by health policy are found outside at the highest levels.
There are very few factors that can change patterns of distribution. Extremes of health policy are one option. Another option is an extreme of career choice. All other physicians have 70 � 95% located in major medical centers. Family physician distributions are 50% inside and 50% outside. Family medicine represents an extreme career choice in location as well as an extreme in a permanent choice of primary care.
Family medicine as the preferred career �outside� can facilitate distribution involving primary care, even in students without experiential place involving rural or underserved origins.
Even when rural location appears to be limited below national averages, such as 8% rural for Asian family physicians (far below the 20% for urban origin FPs), geographic influences help explain the difference. Over 30% of recent graduate (1997 � 2003 FM residency graduates) Asian family physicians were found in
Family medicine is unique in the facilitation of distribution. There is no comparable multiplication of distribution in the specialty physicians, in general pediatrics, or in general internal medicine. Distributions of specialties beyond family medicine are more limited to experiential place, training influences such as location, and health policy. With declines in rural origin, lower income origin, and middle income origin; with declines in origins outside of major medical centers; with all specialties unwilling to distribute training or facilitate decentralized training; and with health policy rewarding concentrations of resources, patients, and physicians; physician escape from major medical center locations is less and less likely.
For specialty care involving rural areas outside of major medical centers only the graduates of a few allopathic medical schools admitting distributional types of students, osteopathic graduates, and certain types of international graduates make significant contributions. These needs involve areas such as cardiology, nephrology, endocrinology, orthopedics, general surgery, urology, and psychiatry.
Medical education leaders remain poorly aware of these areas but are increasingly tired of criticism regarding the failure of medical education to address physician distribution. In addition, the nurse practitioner and physician assistant distributions are falling prey to the same basic problems. Medical education leaders can no longer assume that others will fix the problem for the nation. The traditional excuses regarding �Why Doctors Don�t Go� to rural or inner city areas include poor economics, security issues, and lack of education, or a perceived �paucity of cultural outlets.� 18 Current leadership is willing to allow rookie primary care physicians new to practice, new to a location, and new to patients to do the most complex physician tasks in rural and inner city locations. Until medical education leaders understand that
Without this understanding, medical education and medicine will continue to make poor recommendations for the nation�s health care. Others promote international medical graduates that may address gaps in major medical center training programs, but fail to share experiential place with the populations that they will serve for a few short years of a J-1 Visa Waiver. Others point to the small percentage of rural origin students or rural interested students in an additional attempt to quiet pesky distributional advocates.19
The current medical leadership even has literature backing that can be used to demonstrate the �impossibility� of areas such as rural physician distribution. The most widely published studies reinforce the narrow combination of rural background plus family medicine for rural distribution.20
See the Perspective of Impossibility
While elite schools do require the presence of both for distribution, this impact is limited to a few schools with the most exclusive selections. In national studies of all but the elite schools, even the single factor of rural origins and the single factor of family medicine is enough to double rural distribution above national averages or back to the 20% level of rural population in the nation. Only schools with the most exclusive admission and training such as
Distribution is much more than the narrow few with rural or origins, more than the few hundred with rural practice interest as senior students or the lower level of African American and Hispanic medical students, or the 400 a year with rural origins choosing family medicine. Urban family physicians average 20% rural location or twice the rural average. Rural origin physicians also average 18 � 20% rural location. Medical school graduates older than 29 years also have 17% rural distribution. With origins or with training outside of major medical centers, distribution remains above the current 11% of physicians found rural areas. Similar doubling and tripling impacts are seen for lower income origin physicians to underserved locations including the most challenging locations. Those born in predominantly black or Hispanic or Native rural counties are 3 � 4 times more likely to return to such locations, a level that is still doubled by physician choice of family medicine.
When considering physician locations across the nation, 46% of physicians are found in
Studies of the top 51 income counties with a medical school were also revealing regarding physician distribution.
|
|
Birth |
|
GME |
Practice |
|
Allopathic Private |
33.2% |
31.0% |
45.3% |
35.9% |
|
Allopathic Public |
21.1% |
23.3% |
28.1% |
21.5% |
|
Osteopathic Private |
15.8% |
19.4% |
33.5% |
22.2% |
|
Osteopathic Public |
10.4% |
0.0% |
21.2% |
15.6% |
|
|
11.4% |
0.0% |
34.7% |
31.5% |
|
Distant International |
1.8% |
0.0% |
35.0% |
29.8% |
|
All |
19.4% |
19.2% |
34.4% |
27.0% |
|
Source |
1987 � 2000 Graduates in the 2005 Masterfile |
1987 � 2000 Graduates in the 2005 Masterfile |
Residents Captured in 2005 Masterfile |
1987 � 2000 Graduates in the 2005 Masterfile |
The stacking of residents is seen in just a few counties. Over 40% of some types of residents are found in just 51 top income counties with medical schools, locations with only 20% of the population.
With the experiential place of residency location stacked heavily in favor of just 1% of the land area of the
|
|
Not Top 51 |
Top 51 Practice |
Total |
% Top 51 Practice |
|
Office Based |
167,999 |
58,535 |
226,534 |
25.8% |
|
Locum Tenens |
218 |
62 |
280 |
22.1% |
|
Resident |
64,510 |
33,566 |
98,076 |
34.2% |
|
Last Year Resident |
17,888 |
9,632 |
27,520 |
35.0% |
|
Hospital |
14,068 |
4,423 |
18,491 |
23.9% |
|
Medical Teaching |
1,129 |
389 |
1,518 |
25.6% |
|
Administration |
538 |
297 |
835 |
35.6% |
|
Research |
1,068 |
705 |
1,773 |
39.8% |
|
Other |
285 |
198 |
483 |
41.0% |
|
Inactive |
1,424 |
483 |
1,907 |
25.3% |
|
Not Classified |
22,126 |
10,859 |
32,985 |
32.9% |
|
|
291,253 |
119,149 |
410,402 |
29.0% |
The distributions vary by primary practice activity. Residents and last year residents are not the only physicians stacked into the top income counties. Administration and research are stacked in these locations. In addition the physicians listed in �other� categories and those who are not classified share the top concentrations of residents and administrators.
A similar finding for research and graduate medical education is found with half of researchers graduating from the top 21 research schools. These are also schools that receive about 50% of graduate medical education dollars. All facets of medical education, including leadership, are concentrated in a small segment.
When the top 51 counties are considered with top concentrations of people and income, these 51 counties have top concentrations of physicians. About 92% of physicians in these 51 counties are found in zip codes with over 75 physicians and 78% are found in zip codes of over 200. These are locations with about 4 � 5% family physicians and less than 20% of physicians in primary care, the lowest percentages in the nation. Health access, primary care, family practice, and generalists are missing. Also many of the nation�s leaders in political and health care dimensions are in these same counties. A perspective of outside versus inside is useful regarding awareness of the populations left behind outside of concentrations.
The top 51 counties represent the origins of 33% of medical students though the origin represents 20% of the population. In addition 47% of the entire Asian population of the
Extreme concentrations of physicians
Reliance upon extreme concentrations of education, test scores, and parent income to admit physicians only complicate the process.
III. Theme: Experiential Place: Retention within State, Province, or Nation
Governments invest in professionals in a variety of ways across education, higher education, and professional training. Physicians are among the most expensive human capital investments. Efficient government requires retention of investments within state or national borders. The medical students born instate do have greater instate retention levels. Selection of the physicians most connected to a state is likely to result in better instate retention, improved health care services, and better state economics. A coordinated approach from birth to practice can facilitate the impact of experiential place in favor of instate health care.
Studies linking physician location to graduate medical education location21 also illustrate the older framework with a perspective involving the domination of medical education in career and location decisions. The studies fail to control for the past life experiences. The medical school location is critical. Also the birth to admission experiences, as noted by physician birth origins, also shape career and location choice. Some level of understanding is also needed regarding the limitations in practice location for narrow subspecialty career choices.
Also there are other experiential connection considerations. The greater retention of physicians in the larger states such as
When physicians are selected that have fewer connections to a state or the most needed careers and locations in a state, instate retention levels are likely to decrease. Retention is higher for students with more life experience contact points in a state, rural origins, and choice of family medicine.22
Combinations of medical school and graduate training are the most powerful for future instate practice location. This is seen in accelerated family medicine training programs with 6 years in the same training location, combined tracks involving medical school to graduate training, and osteopathic training with a greater connection via the OPTI system. The WWAMI programs also increase state contact with the first year of medical school remaining �instate� and significant training provided instate in the clinical years.
There are conflicts that can develop to limit physician distribution that are important to understand.
IV. Theme: Experiential Place of Significant Others: Spouse, Family
Experiential dimensions involving the spouse impact practice location. Family impacts involve the beginning of life and continue with spouse and children. Family impacts can be powerful as recruiters have taught for decades. Studies demonstrate that the humble origin students must make an early decision for medicine to hope to gain admission at all.7 An early decision is often shaped by family, mentors, and early education. Family can represent barriers. For those married young that are often of lower and middle income origin, marriage and family can be a barrier that prevents becoming a physician. After admission to medical school, marriage and family can have advantages although not necessarily for the spouse or family. Spouse education, family, and employment factors can guide college choice, medical school location, career choice, practice location, and practice retention. As the children of practicing physicians approach critical stages such as middle school or high school, insufficient local education can stimulate departure from a rural or underserved location. This may be a more powerful influence for those raised in private schools that may not be available in rural areas. Again when states have significant gaps in education quality for socially and geographically isolated locations, distributions of professionals can be more difficult.
States or medical schools can shape physician distribution using spouse and family factors. Admissions tracks can retain college students within a state although care must be taken to invest in students that are also most likely to remain in a state, not just the most elite. The initial rural college track in Nebraska involved 3 years of rural college prior to admission but was extended to a full 4 years, a change that increases the probability of a rural compatible spouse. In the WWAMI program, an additional first year of medical school is added. These connections during college or medical school appear to be geographic, but can also increase the probability of a spouse that shares the desired instate or rural experiential place. The
The impact of the rural spouse is seen in rural interested medical students. About half of the married rural interested students had a spouse who graduated from a rural high school. About half of the rural interested senior medical students had rural high school location. 25 Rural medical school locations and long term rural rotations may also influence experiential place. The rural program in
Spouse and family factors also overlap into studies now commonly associated with physician retention. In these studies, increased retention is seen as better integration or involvement. This can be a two way street with efforts on the part of the physician or on the part of the community.
Physician retention can be visualized as interactions between community, practice, physician, and family. Integration and involvement involve both parties. Some fail to mesh well and some have needs that cannot be met. If the life experiences regarding local schools and education do not meet the expectations of either parent, retention of physicians will be poor. At one rural medical center an active disciplined focus on retention and improved relationships between the facility (Guthrie System in Pennsylvania) and the physician has also been accompanied by improvements in quality although a direct relationship is unknown. In rural, underserved, or any location, new and inexperienced physicians, administrators, or staff can be viewed as challenges or they can be viewed as opportunities.
Studies that fail to consider spouse and family factors and spouse/family experiential place will fail to understand distributions. Communities that fail in these understandings face worse. They will face the loss of health care and a significant component of the community itself.
V. Theme:
It is in this dimension that prior life experiences, experiential place, and life course constructs intersect significantly. http://en.wikipedia.org/wiki/Geert_Hofstede
The children of professionals are encouraged in an ever expanding range of opportunities. The most marginalized populations face barriers of income and education that limit opportunity progressively over time. For infants, children, and teens the shaping forces can include basic shelter, nutrition, security, and survival. At one end of the spectrum the opportunities open wide like an inverted funnel. At the other end, the funnel narrows the outcomes and opportunities. One group has fate determined by parents and eventually by their own abilities. Even those with great potential in the humble origin group may not reach anything close to their full potential. Studies demonstrate the variations with children of professionals at top performance early in life. Catching up after age 8 when the velocity of learning is much the same for all, is very difficult.27 This is another reason why those that do catch up are often older, spending additional years catching up from an early life of barriers involving income and education.
The dimensions of human experience involving language, culture, race, ethnicity, religion, status, and various relationships can be bewildering, but there is one unifying theme. Each of the differences and the degrees of differences between those who are different and those most likely to gain medical school admission shape admission probability and the same factors also shape the probability of physician distribution for those that do manage to gain admission.
Those most likely to gain admission are least likely to distribute. Those least likely to gain admission are most likely to distribute. The impediments to medical school admission shape physician distribution. The same factors that shape admission also make it difficult to distribute physicians to practice in the most needed careers and locations.
Each of the differences and the degrees of difference also shape standardized test scores. With greater geographic, social, cultural, language, and other differences, the students tested will have lower scores not because of achievement or potential, but because they are different. Intelligence tests such as the Medical College Admission Test can be sensitive enough that gender alone has forced changes in the test to prevent speeded bias. Other studies noted that the MCAT fails to separate students sufficiently for admission purposes in studies that allowed students additional time. It is likely that the additional time allows those who have different parents, income, language, race, ethnicity, and pathways to medical school to catch up to those with wealthy parents, top advisors, private schools, colleges that prepare to the test, and specific training in standardized test performance. What is common to standardized tests is a limited prediction of performance limited to a year or two and the inability to predict long term performance. The developers of intelligence testing such as Thorndike specifically mentioned this regarding the initial forms of the MCAT test.2 A narrow academic focus in admission can shape physicians with a narrow range of life experiences, physicians least likely to share common ground with the more distant lower and middle class populations.
The pathway to medical school most commonly involves private schools, urban schools in the highest property value areas, and top colleges. About 74% of the students in the top 146 colleges in the United States have parents in the top quartile of income.1 Recent admissions have also matched this exclusive level with 70% of medical students from the top 20% income level after decades at the 60% level.28 Admissions policies based on ranking students by scores or colleges appear to favor the wealthy, the children of professionals, those youngest at admission, and the urban born. In geographic terms, medical school admission at the county level is highest in the counties with the highest income, the most professionals, and the highest level of education. Counties with medical schools and nearby exclusive suburbs have the highest levels of admission. Major medical center county impacts with top admission are also seen in counties dominated by the major medical center economic contributions such as Mayo Clinic,
Studies have outlined the importance of integration within the community as important for improved physician retention. 29, 30
Physicians occupy an unusual spot in the social structure of rural communities. From an economic standpoint, they are successful entrepreneurs, well-paid business people similar to bankers and lawyers. On the other hand, they are also social servants like policemen or teachers, just as essential to the welfare and functioning of the community but paid for through a fee-for-service mechanism outside of local community control. This anomalous status requires some fairly innovative interpersonal and structural relationships to strike a workable balance.31 Rosenblatt and Moscovice 1982
Integration may be most difficult when physicians are different than the community or patients that they will encounter. The numbers of differences and the degrees of differences are greater. Many urban underserved locations demand a superior command of the combination of English and Spanish languages. This can be seen in the graduates who are indeed found in urban underserved locations at the greatest levels, those born in the
Again the facilitation of distribution is seen. The African American, Hispanic, and Native American family physicians and the family physicians born in the lowest income urban counties have the highest levels of urban underserved and total underserved location of all physicians in the
Socio-cultural experiential place involves more than admission probability, health access, and the cost and quality parameters involved when patients match up to physicians in race, ethnicity, geographic origins, and socioeconomic background. Studies indicate that those most disadvantaged have the greatest awareness of the health access needs of the disadvantaged. The African American, Mexican American, and Native American medical students previously were considered underrepresented minority students to separate them from the white or Asian students admitted at greater probability relative to population distributions. Awareness of the needs of others most different was also related to origins and other factors such as income level within specific origins
Awareness in Medical Students By Origins
|
Statement and percentage strongly agreeing |
All Underrepresented Minority Medical Students (About 10% of students) |
All Others (About 90% of students) |
|
Access to care is still a problem |
78% |
56% |
|
Everyone is entitled to adequate care |
83% |
66% |
|
Physicians can influence health promotion disease prevention |
67% |
56% |
|
Physicians are obligated to care for the poor |
55% |
45% |
Compiled from the AAMC Minorities in Medicine XI Report, p 15, Data originally from the 1996 Matriculating Student Questionnaire7 with over 13,000 responding
Medical students most closely associated with disadvantaged populations are more aware of the needs of those in most need of health care, but they are least likely to gain admission. In many ways the URM data represents lower and middle income populations including most rural populations that share higher levels of lower and middle income people, challenges in education, economic maldistributions, and awareness of those left behind. Rural interested students and underrepresented minority students both are more likely to have more than four times the interest in serving the underserved (40 to 60% compared to 10% for 1995 senior students).
Privileged medical students are most likely to gain admission, but are least aware of the challenges related to health care for those who are normal and are out of touch with those who are different and distant in multiple ways. The matriculating students are only a beginning point. Studies indicate that medical student attitudes toward access and indigent care are less charitable later in training. (Coombs, 1978; Maheux and Beland, 1987; Crandall et al., 1993)32-34 In addition about half of the physicians entering the workforce have either just arrived in the United States or have families that have only been in the United States since 1980. Unlike the depictions of most immigration, those who become physicians enter at the top strata of social structure in the United States just as they were at the top in other nations prior to entry.
In many ways those who lead the nation are a concentration of those with the highest probability of admission, life experiences most different than the rest of the nation (if not extremely different), and therefore the least awareness in a number of dimensions. A pattern of admission that progressively narrows the admitted group of students is a problem.
An additional problem is found in the schools that have traditionally provided a greater proportion of leaders for medical education and associations. Narrowing is most present in the top medical schools, schools that admit the most foreign born and the most Asian students who have been in America the least time and are 50% found in 1% of the land area, schools that admit 90% of students from cities or counties with a medical school and the fewest who are truly socially or geographically different or distant. Even the few older graduates in elite schools are shaped by elite research interests that are quite different from the older medical students across the nation that have increased family medicine, psychiatry, rural, and underserved career choice. Even the African American and Hispanic medical students in exclusive schools are shaped by exclusive origins, training, and scores. While it is true that these top ranking research/prestige/MCAT/board score/subspecialization/graduate medical education/oldest medical schools do provide important contributions in a number of areas, those responsible for the leadership of a nation also must provide the training that raises leaders who are aware. This involves selections, training, and sophisticated efforts involving underserved communities and peoples. In fact the national design for health care reflects this leadership, and the current design reflects failure in awareness most of all.
The one unifying theme regarding entry to medical school was defined by Flexner. If medical schools raise entry requirements, the parents and advisors and prospective students will modify their behavior and preparation in ways to accomplish the desired change. This was a major reason for improvements in US education and college efforts 100 years ago. No less is required today. The best impetus for needed change in US medical education is a rejection notice given uniformly to the potential medical students, regardless of parent or other influences, who are not able to communicate well, do not have reasonable awareness of others, and are unable to balance the needs of self with others. It is a true nightmare developing in medicine when words such as these must be written as the admitted medical students have moved far away from the most important qualifications to become physicians. Communication skills evaluations are the only testing and screening that demonstrate the ability to improve physician quality.35 Communication skills testing has been delayed for at least 5 years. The top priority has clearly been to computerize the MCAT, an effort in itself likely to narrow the types of medical students admitted (also these consequences have not been assessed). During this time period a reasonable estimate is over 20,000 admitted to medical school that have higher probability of problems as physicians.
The awareness survey regarding senior medical students noted above was compiled over a decade ago. There have been many changes in medical students during this period of time. It is possible that many of the students who responded with greater awareness have been eliminated from the current pattern of admission. Medical students have become a more exclusive group with even higher levels of income, professional parents, and connections to major medical center environments. The Asian and most of the foreign born additions have been at the highest income levels. All races and ethnicities have experienced a near doubling of those with parent income over $100,000. Nearly half of the 4000 lowest income students, those with parents making less than $40,000 from all races and ethnicities, have been eliminated. The Mexican American medical students admitted today compared to 1997 are a different group with over twice as many (over 125% gain) with parent income over $100,000. African American gains in highest income origin students have also been nearly double.
One thing is certain about lower and middle income children that must be realistic about their choices of careers as they do not have the second, third, fourth, or fifth choice found in higher status children. They are not going to waste time, effort, and resources attempting a career that they feel is not possible. There are indications that many are no longer attempting admission. The disadvantaged students are also the ones that are most committed to a medical career and decide for medicine at an early age. Those that do gain admission begin earlier and take years longer to gain admission. This is also seen in the URM students and is likely to be true in those interested in rural, underserved, and family medicine careers that share older age and barriers to admission. The barriers are such that a late decision for medicine is just not possible. The barriers involving education, income, and parent differences have become more difficult to overcome, so difficult that many that made it to a medical career in the past appear to be deciding not to attempt the effort. It is entirely possible that changes in medical students reflect widening gaps in society between the richest and all others, and also accelerate the divisions. Even medical education experts are increasingly concerned regarding the future illustrated in the changing medical students.36
There have already been episodes involving these great divisions between medical schools and their surrounding neighborhoods. Medical education represents a route to top concentrations in America. The fact that many of the older medical schools are surrounded by major poverty and unemployment illustrates the widening gap. Attitudes of medical students and medical school leaders reflect this gap. There have also been medical students that have refused to participate in training involving populations most different than themselves citing any number of excuses other than the real cause � the fact that they have had little contact with such people from birth to admission.
The incidents apparently were too much for medical school leaders to handle. Once again the social organizational skills of those with professional parent origins can magnify the difficulties, particularly without a unified medical school leadership. Medical education with its fragmented nature is ill prepared to make the changes that result in awareness and the ability to address health care for an entire nation.
As has been the case for generations, the consequences of failure to act can be severe. The few medical students that have experienced disadvantaged situations were completely disgusted by the entire situation. They have experienced difficult situations from birth yet the exclusive children that have become their classmates cannot experience even a few hours. One of the best indications of lack of awareness is fear of the unknown. With greater divisions in the nation and in the nation�s physicians and in the need to train physicians in a variety of different locations, the difficulties will only increase. On the other hand there were also Harvard medical students that realized the limitations of their traditional medical education. They were given the opportunity to leave hospital training situations where they are often marginalized. They were trained in community continuity primary care settings. They were able to be a part of a team caring for patients in need of care during their learning experience. To their credit, they refused to be taken away from these experiences to return to their traditional forms of training. It is entirely possible that a medical training process that marginalizes medical students and tolerates marginalization regarding different types of patients, also results in physicians that marginalize patients, and various forms of health care. This includes most Americans left behind and the primary care that they most need.
Some responsibility for the treatment of medical students must be shifted to the federal government that has interpreted student surveys as research, resulting in fewer students responding to surveys. This can be crucial in certain areas, such as reports of abuses. Some recovery has been instituted, but the damage has been severe. Without guidance over this time period, the federal government was responsible for declines in awareness and helped medical education fly blind into a storm.
A federal government that continues to increase the barriers to training physicians is making the entire situation unmanageable including audits costing millions, changed regulations involving use of residents (especially surgery) that drive physicians away from faculty positions to more efficient subspecialty hospitals, threats of legal actions involving admission, and top levels of federal funding (NIH, GME) given to the schools that do the least regarding the careers and locations most needed for the nation.
Grant funding is the name of the game in medical education and the grant funding mechanisms are not limited to just research. Medical schools have found a variety of ways to expand their influence. These include �creative� uses involving federal shortage area designations and special programs designed for underserved health care (CHC, NHSC, FQHC, J-1 Visa, bonus payments for shortage area physicians). Many physicians and clinics supported by state and federal dollars now share zip code locations with the largest concentrations of physicians in the nation. It is difficult to consider this an efficient use of funding to concentrate more physicians in such locations. The zip codes with top concentrations of physicians and health care dollars also have the highest concentrations of income, economics, education, and health care coverage. A physician and medical education leadership that was more aware would perhaps make different decisions or advise the nation regarding different policies. At a minimum medical education would have shifted the locations and environments of training to more normal settings instead of the most exclusive top concentrations.
These past uses and some abuses have led to greater regulation, making the entire grant or funding process even more complicated and again excluding those most geographically or socially isolated, and in need of more assistance.
Experiential place cannot be separated from medical school admission with the current policies and practices. Some students begin with an experiential place that facilitates medical school admission. From this place an admission that is much less complex to engineer for students and parents. In the students at the top status levels with up to 10 times probability of admission, the real question is not whether admission is possible, but which professional career they will choose. This is not a probability of admission so much as it is a decision for a career. The Asian Indian top levels of admission appear to involve top status as well as top preference for science careers and careers in medicine. With these shaping influences also come top levels of the �science� physician career choices as well, including the highest levels of internal medicine subspecialization and less than 2% choice of family medicine, the lowest in the nation.
With only slightly greater barriers to admission involving life experiences and parents, admission is only 2 or 3 times as likely. This is a group with combinations involving highest income, professional parents, youngest age, most urban origins, and closest proximity to medical schools and major universities. The students with birth in a city or county with a medical school have 1.5 to 2 times probability of admission, a county level determination that includes those with the highest and lowest probability of admission mixed together. All other populations that are less connected to major medical centers have lower than average probability of admission. This includes the single category groups of those born in the
Other students have experiential place that comes with the disadvantage of obstacles to medical school admission. This includes urban underserved, rural underserved, and marginal rural populations, basically those outside of major medical center locations rural or urban. Concentrations of income, education, professionals, economics, property value (funds education), health care coverage, health facilities, and physicians are lower in these locations. These separations and obstacles can delay or prevent admission, even in some of the most dedicated. Nations that fail to resolve these gaps will fail to resolve health care access, cost, and quality problems from both sides of the equation � physicians that arise from a wider range of origins and patients that fail to have the development, education, and orientation necessary for efficient, effective health care.
Full exploration of experiential place involves many different dimensions. Asian physicians are the most likely to be found in major medical center locations. Not surprisingly they have the highest rate of major medical center origins. Over 50% of Asians in
Although there are contributions involving race, ethnicity, culture, language, and other factors, there are also similarities in all of the populations with the same highest income, most urban, major medical center origin.
VI. Theme: Experiential Place Impacts on Career Choice
Career choice is most often viewed from a narrow perspective of the few years of medical school. This ignores decades of life experiences prior to admission. Generalist, primary care, and family medicine career choices are greater for the medical students with the most socially and geographically isolated origins.
Birth Origins, Admission Ratios, Career Choice, and Distribution
|
1970 |
1970 |
1994 � 2000 |
1994 � 2000 |
1987 - 1998 Medical School Graduates |
|
|
|
|
|
Pop Density of |
Population |
US Born |
Admit per 100,000 per class year (FP/Total) |
Super/Major Center (over 75) |
Rural |
Under-served Urban/Rural |
Office Primary Care |
Family Practice General Practice |
|
1 to 16 |
5,863,912 |
1,937 |
1.31/4.72 |
31.5%/61.5% |
24.8% |
3.3%/7.2% |
37.9% |
25.5% |
|
16 to 32 |
7,719,603 |
2,586 |
1.13/4.79 |
32.8%/62.6% |
22.8% |
4.2%/7.1% |
37.7% |
23.5% |
|
32 to 62 |
17,071,584 |
5,389 |
0.96/4.51 |
35.6%/64.7% |
20.5% |
3.9%/6.5% |
36.5% |
21.2% |
|
62 to 125 |
18,948,981 |
7,384 |
1.08/5.57 |
37.9%/66.5% |
18.1% |
4.4%/5.8% |
34.6% |
19.3% |
|
125 to 250 |
21,750,406 |
7,806 |
0.88/5.13 |
40.1%/69.7% |
14.0% |
4.3%/3.7% |
31.4% |
16.6% |
|
250 to 500 |
24,533,878 |
10,168 |
0.99/5.92 |
40.5%/69.4% |
11.6% |
4.1%/3.2% |
31.7% |
16.0% |
|
500 to 1000 |
22,386,252 |
11,040 |
1.03/7.05 |
43.8%/71.8% |
10.6% |
4.2%/3.3% |
30.9% |
14.4% |
|
1000 to 2500 |
48,245,786 |
24,324 |
0.97/7.20 |
46.1%/74.0% |
8.5% |
3.7%/2.2% |
30.1% |
12.7% |
|
2500 to 5000 |
15,185,926 |
7,419 |
0.88/6.98 |
47.0%/75.3% |
8.4% |
3.5%/2.0% |
27.6% |
11.4% |
|
5000-10000 |
9,841,413 |
5,170 |
0.88/7.50 |
49.7%/76.7% |
6.5% |
3.8%/1.7% |
28.1% |
11.3% |
|
10000 or up |
11,608,158 |
13,019 |
1.29/16.02 |
53.8%/79.6% |
5.2% |
3.1%/1.2% |
25.2% |
7.7% |
|
State Data |
|
1,422 |
|
48.0%/76.8% |
12.3% |
4.6%/1.8% |
28.8% |
9.3% |
|
Military Born |
|
1,273 |
|
44.5%/71.5% |
13.1% |
4.3%/2.6% |
33.8% |
13.3% |
|
Foreign Born |
19,000,000 (in 1995) |
19,037 |
1.36/14.31 |
38.7%/68.5% |
5.5% |
4.6%/4.2% |
29.5% |
14.6% |
|
Unknown |
|
1,136 |
|
43.4%/72.5% |
|
7.4%/2.6% |
27.5% |
14.6% |
|
US Born Total |
203,155,899 |
109,707 |
1.18/6.96 |
44.7%/72.9% |
11.0% |
4.1%/3.0% |
30.1% |
13.4% |
Linear relationships for admission and for distribution are seen across population density categorizations of birth counties. The physicians from the rural and lower income birth counties are more likely to choose family medicine, primary care, rural, and underserved locations. Distribution is complicated by the fact that fewer are admitted from humble origin counties. Those most likely to gain admission have origins in the most densely populated counties and are the least likely to distribute to primary care, rural, and underserved locations.
One of the more interesting findings is that the admitted medical students that later become family physicians are admitted at a relatively constant 1 per hundred thousand per class year, regardless of geographic origins or county income levels. In the lowest income populations the 1 family physician joins three others for a 25% family medicine result. In the highest income, most population dense counties, the non-family physician admissions component doubles, further indication of the shaping forces of parents, origins, and concentrations of income, education, and professionals. The theoretical minimum family medicine choice would be 7 � 8%. There are medical schools that consistently graduate 40 � 50% family physicians and there are those with 2 � 5%. Some schools manage to admit and train medical students that exceed the theoretical maximum while other schools manage to admit and train below the minimum. The broad origins of family physicians may also shape the broadest distribution across origins, medical school, training, and practice.
It is also important to understand that the career and location choices are relevant only for the 1975 � 2000 graduates, those who had the benefit of reasonable policy support. The
With changes in admission largely involving the same types of students with triple the current probability of admission and half the probability of rural location and family medicine choice, greater challenges in physician distribution are likely.
Rural origin physicians are more likely to be found in rural locations and contribute to underserved urban locations also, a likely function of lower income origins. The birth county method is insufficient for urban underserved populations (Black, Hispanic, and White � 69% of the population in poverty is white) where populations are more divided into highest and lowest status populations. Without actual parent income levels, the actual lower level of admission for lower and middle income whites in urban areas are not able to be calculated.
In separate calculations and studies the African American population has half the probability of admission compared to the national average, black males have half the admission probability of black females, African American medical students have twice the urban underserved location rate, and those choosing family medicine have top levels of urban underserved location at 20% or 4 � 5 times the national urban underserved average. Graduates of family medicine programs with higher levels of Hispanic and Black medical students and those with inner city mission also exceed the 15% underserved average for all family physicians and are typically triple the 7% level of underserved physicians in the nation. Graduates of Historically Black medical schools have had lower scores, indicators of more with lower and middle income origins, and higher levels of urban underserved location that are doubled by family medicine. Unfortunately they are also 80% less likely to choose family medicine in the past decade. Health policy changes may be magnified in students from such origins. Black males confirm the theme of lower admission probability and greater distribution. Even with more taken for military careers, they are more likely to be found in underserved locations. Academic programs may help in this by taking significant numbers of African American females as faculty.
Clearly the combined effort of origins, admission, training, and career choice is important in delivering the most needed health access. About 25% of physicians born in predominantly black counties that are rural counties are found practicing in these counties. This increases to 50% with choice of family medicine. Unfortunately these are the counties that share the lowest ratios of admission with others most left behind. The hope for self sufficiency in physician workforce begins with the War on Poverty now abandoned and upon closing many of the gaps that have widened in past decades.
Hispanic populations born outside of Central America have generally higher status and average or above levels of admission. Using ratios of admissions compared to those of medical school age, Hispanic populations have 20 � 35% of the average probability of admission, greater choice of family medicine driven by 20% levels for Mexican American medical students) and the same or slightly greater levels of urban underserved distribution compared to African Americans or African American family physicians. Mexican American family physicians have top rates of retention within 50 miles of their training programs.
Lower and middle income students are more likely to be found in public schools from birth to medical school admission, instate schools, and schools that graduate more family physicians and primary care physicians. Lower scores make admission a challenge and also shape career choices with lower board scores in family medicine, psychiatry, and women�s health. Again scores are not a reasonable measure of physician performance, but even a slightly lower score can marginalize career opportunity.
Status, scores, experiential place, marginalization, and career choice continue to shape physician distribution in a consistent and reinforcing fashion. This is also seen in comparisons at the medical school level where the percentage of graduates with rural origins has a 0.92 correlation with the percentage of the same graduates found in rural locations. This does not mean that each admission ends up in rural practice. Across the nation the 10% of rural origin graduates result in 30% of rural physicians. The 90% of urban origin (including foreign born) graduates contribute the remaining 70% of rural physicians. What is important to understand is how the various factors reinforce one another. In the schools with more rural admissions, there are more older graduates, more lower scoring graduates, more middle and lower income origin graduates, and more family practice graduates. In addition the state locations of these medical schools have greater percentages of rural population and rural physicians in the workforce. The higher scoring students tend to have different origins, different scores, different schools with different missions, different career choices, lowest choice of family medicine, and different practice locations. Each distance and difference shapes the final result and the extreme correlation of 0.92.
Inherent in geographic origins (as well as within the same geographic origin) is variation in lifestyle. The
Role modeling impacts of generalist faculty are considered to be important for a few weeks of interactions. Now granted some of these interactions are at critical points such as the first weeks of medical school or clinical training, or during the final career decision. However the sheer amount of contact time pales when compared to decades of life experiences immersed in the generalist lifestyles of rural or underserved areas. The professionals found in socially and geographically isolated locations are also more likely to be generalists: teachers, nurses, public servants, and family physicians. As Rosenblatt and Moscovice already noted, rural physicians �are also social servants likely policemen or teachers, just as essential to the welfare and functioning of the community.�31
Given the level of service orientation for the rural students, rural practice interested senior students, rural physicians found in underserved areas, and greater choice of the careers oriented to service to people in primary care and choice of family medicine, it would seem that the early life experiences may have some impact.
Many also forget that the rural areas of the nation also have lower income levels and children are raised in more humble circumstances, but the characteristics of children of professionals and rural children raised in or around medical schools, major colleges, or major medical centers may be somewhat different, as are their career and location choices. Even in towns of the same size and population density (RUCA 5, population 5,000 � 13,000 in Nebraska), the children born in towns within 50 miles of a major metropolitan area have career and location choices much closer to urban born than rural born medical students. Incidentally this is outside of the current RUCA commuting code range, indicating that urban influences may extend beyond zip codes with 30% of the workers commuting. This may have relevance for health access and physician distribution as locations in close proximity to major metropolitan areas may have greater appeal, greater potential for growth in the future, and the ability to attract rural and urban origin physicians. Of course there is the problem of nearby metropolitan areas sucking resources away and impairing the development of health care as local residents bypass local businesses and services.
Role modeling impacts in family medicine would be difficult to separate from previous life experience. The concentration of family physicians steadily increases across the gradient from most rural to most urban physician origins and the same is true for practice location concentrations. Concentrations of family physicians are progressively higher with greater distance from major medical centers. Family medicine choice is 6% for those born, raised, and trained, or located in the most elite major medical centers with 200 or more physicians. In more typical major medical centers about 14% are family physicians and about 9 � 12% of those born or raised in such locations choose family medicine. About 20 � 30% of the physicians in marginal urban and underserved areas are family physicians and 15 � 22% of the physicians from similar populations are found in family medicine. Family medicine choice is a similar 20 � 26% for rural origin medical students. About 30 � 100% of physicians in rural areas are family physicians.
For family physicians born on Native reservations the rural location rate exceeds 50% and would be much higher if 10% were not taken by academic positions and a similar contribution to urban underserved locations. The same is true for African American and Hispanic family physicians where 6 � 12% are found in faculty positions. In addition the males have 6 � 10% in military family practice for the most recent 7 years of graduates. These family physicians along with the rural born family physicians with the highest levels of military service, a level only exceeded by the family physicians born in military bases at nearly 20% levels. Some coordination would appear to be in order so that all of the various health care needs of the nation are met. The current policies involving tuition, debt, and repayment insure that the oldest graduates, those most likely to be geographically and socially isolated, have their spouse, children, debt, and personal needs met only by the comprehensive packages found in the military.
Of course poor coordination is the rule rather than the exception for a nation that depends upon the service oriented pool for teachers, nurses, family physicians, and public servants, but fails to invest in the lower and middle income children that could replenish and expand the pool.
There are at least three interpretations involving role modeling and experiences before and during medical school.
Changes in career choice can also be tracked to lifestyle preference.
Choice of family medicine remains lowest in the medical students born in counties with medical schools. During the 1990s, family medicine choice increased 46% with health policy changes, peaking in the 1995 � 1997 class years of US MD Grads. In the medical students born in the same county (or metropolitan statistical area) as their medical school, the increase was 70%. One interpretation is that medical students most interested in a practice location associated with 30 years of previous life experience switched to family medicine, a career choice that for a brief period of 3 years was a much better choice to retain a major medical center practice location than the typical hospital based careers. Major medical center hiring of family medicine also peaked for these class years. The health policy and managed care reforms dissipated rapidly and the medical students returned to their previous low choice of family medicine or even lower. Health policy can use the concept of experiential place to modify career choice, even when the career choices involve a move to a lower income level.
VII. Modifications and Limitations of Experiential Place Involving Career Choice
Modifiers of experiential place expression involve at least three levels by physician career type. The most general and broadest scope career choice in the
The second level of modification or limitation regarding career choice involves physicians who specialize but have reasonable patient care volume such as general internal medicine, general pediatrics, general surgery, general orthopedics, and cardiology. Cardiologists enjoy a greater volume of patients. In orthopedics, some level of rural distribution is possible due to greater concentrations of elderly or those prone to trauma (occupation, recreation). In the specialties with reasonable volume, it is possible for experiential place to be a factor in physician distribution. Interactions can also be seen with health policy. When Medicare coverage was extended for the population with renal failure, the nation supported more nephrologists and greater distribution of nephrologists.
In these higher volume specialties, rural birth origins do result in improved rural distribution.
The final level involves ultimate subspecialties. In these subspecialties, there is little impact of experiential place. The career choice determines the major medical center location without the opportunity for experiential place impact. Researchers, pediatric cardiologists, and thoracic surgeons have very limited career location choice. It is still possible to have rural location, but this is usually when the major medical center is in a rural area, as in the case of about 2 - 3% of the physicians in the
Family medicine can be seen as a specialty that facilitates the expression of experiential place impact upon location choice. There is only one factor that seems to limit family medicine. It is the factor that actually has the most impact on physician distribution. This factor is health policy.
VIII. Modifications and Limitations Involving Health Policy
Health policy is the ultimate modifier of experiential place. Even the most superior admission and training efforts would fail to distribute physicians without sufficient health policy. Choice of family medicine during these time periods has reflected (in order) a first period of lack of policy, a second period of improving capacity, a third period of adequate policy, a fourth period of optimal policy, and the most recent period involving insufficient policy.39
Five Periods and Family Medicine Choice Graphic
Period 1: Prior to 1965, the
Period 2: From 1965 � 1978, the nation addressed all of these health policy needs with the initiation of Medicare, Medicaid, family medicine, federal and state funding for medical school expansion, special programs, and emphasis on primary care. During this period the choice of family medicine and primary care increased steadily, eventually rising to the level of rural born admissions and passing this marker. The rural origin admissions level is a marker for all of the different types of medical students more likely to choose family medicine when they can gain admission.
Period 3: The health policy from 1979 � 1992 was adequate for distribution with family medicine choice rising below the rural birth origin percentage. This indicated that adequate health policy was available to support choice of family medicine �above the line� of rural born admissions.
Period 4: During the 1990s, distributional health policy reached a peak level, completely departing a relationship with birth origins. The combination of reforms in primary care reimbursement, managed care policies and workforce predictions, and widespread faculty discussion insured a very different environment, but for a brief period of time.
Period 5: In the past ten years, the nation has reversed course 40 years back to policy insufficient for physician distribution, or distribution of health resources in general. The layering choice of family medicine (table) seen during the 1975 � 2000 period is beginning to blur with family medicine choice not as easily differentiated by older age or lower income origins. What is rarely seen is the long term progressive decline in admissions of family medicine likely students (suddenly obvious after managed care departed) and the long term diversion of Medicare and Medicaid away from primary care. This increasing competition shrinks primary care with each passing year, most obviously in the nurse practitioners falling below 50% of active graduates in primary care, physician assistants below 40%, internal medicine below 30%, and pediatrics below 60%
Changes within programs that favor concentration of physicians are steady and substantial. The massive rise in the cost of delivering health care penalizes those with the greatest overhead and the most fixed and lowest reimbursement. Increasing reliance upon temporary grant funded programs give the appearance of addressing need, but actually create great holes as those more organized gain funding and those least organized do not (lower awareness, fewer resources, less specialized personnel). The real improvements in areas such as health access and education involve regular funding, not special funding that forces groups to spend most of the resources of the grant to maintain funding. Community Health Centers and Federally Qualified Health Centers and National Health Service Corps sites are moving to major medical center locations with poverty levels less than the national average and the greatest concentrations of physicians rather than areas with the highest poverty levels, the lowest concentrations of physicians, and the greatest need for the economics and leadership provided by physician professionals. Studies have demonstrated that the rural physicians in shortage areas leave 2 million in bonus area payments on the table each year while those not eligible and those who were not the target of the funding collect the bonuses. The major medical center and medical school uses of the J-1 Visa programs are growing.
States with greater divisions between rich and poor are rewarded for their inequities and states with better distributions fail to qualify for assistance. One group needs better organization, better distributions of existing resources, and better coordination. The states with greater divisions need to address these basic divisions from birth to age 8 in a number of areas simultaneously to improve their situations and budgets. States with better distributions of income and education fail to benefit from federal programs such as CHC, NHSC, and bonuses as their intensities of need fall just below federal guidelines. Other states that fail to make suitable investments in lower income and middle income peoples do have populations that easily meet federal requirements. These are also populations moving away from inequitable locations with the highest cost of living, especially the greatest concentrations of people, professionals, populations, and medical schools.
Rewarding those that fail to address these areas is a poor overall policy choice. States such as
Modifiers of experiential place involve local, state, and national policy support for health care for lower and middle income populations and those who serve them:
a) Low potential for support and physician distribution regardless of origin or training as in Periods 1, 2, and 5,
b) minimum support allowing birth origin and training emphasis to result in distribution with at least achievement of the potential provided by admissions as in Period 3, a period when changes in family medicine were shaped predominately by the steady decline in rural, lower income, and middle income admissions (reflected in rural origin line),
c) optimal support as in Period 4 allowing maximum levels of distribution including the largest groups of students that would not usually have distributed (complete departure above birth origins).
These policy modifiers include health policy, but also involve distributions of income, education, jobs, economic development, and other forms of support. The health policy modifiers can be transient, as in the 1970s and 1990s in the
Without sufficient birth to admission policy involving child development and education, without sufficient education policy involving higher education and broad higher education opportunity, without sufficient medical school investments and access for the widest range of medical students, without sufficient focus on generalist training for rural and for underserved areas, without sufficient health policy support for health care (and education, etc.) for lower and middle income populations, physician and practitioner distribution is limited. With maximal coordination of all of these areas, distribution is maximized, as is distribution of economics, leadership, education, and opportunity.
The distribution arguments are important to understand, but the quality and cost arguments may be even more important. If the
IX. Practitioner Characteristics: Facilitation and Limitation of Experiential Place
Physicians that match up best to patients by race, ethnicity, geographic origin, language, culture, and socioeconomics have the greatest potential to optimize health care access, cost, and quality areas. This is an ideal plan not likely to be reached.
It would also be optimal to have communities and practice environments that exhibited flexibility and adaptability. This is also variable.
In the absence of the best possible matches, it is possible to make selections of physicians or modify training that will develop greater versatility and adaptability in workforce. The
Medical education (less aware than ever regarding such areas given the changes in leadership, physicians, and survey tools) attempts to resolve the problem with �professionalism training.� This is unlikely to be successful. Those who were raised differently are likely to have the necessary qualities. Service orientation is an example. Service orientation can be trained, but is more likely to be maintained in those who have service orientation prior to medical school.41 Tolerance of ambiguity is lacking in those younger at medical school admission as noted in studies of Johns Hopkins medical students. 42 Older medical students are still fewest in the elite medical students and elite medical schools but are linked to service orientation, maturity, most needed health access career choices, life and health experiences, and paradoxically also are often are the first to know that they are interested in medicine. An easier contrast is those with most exclusive life experiences that are youngest, least likely to choose serving careers, have the least life and health experiences, are most likely to have higher income or professional parents, 7, 41, 43have much more of their admission shaped by parent influences, and are the last to decide upon a medical career with late teen and college decisions for medicine.8, 44-47
Physicians have moved into the most academic and intellectual range. Brilliant people that fail to develop sufficient ability to communicate, adapt, relate, and manage are painful reminders of the need to have a balance in academic and people skills. Without integration of relationships with those different, people skills, management, and other areas important for great physicians beyond academics accomplished during critical periods of development, physicians or any professionals are unlikely to fully develop. Studies already identify the most exclusive physicians as those least satisfied, but not why.48 The pattern involves the most specialized and those least involved with direct continuity patient contact. It is entirely possible that this group of the highest scoring, those from the most elite schools, those with the most subspecialized careers, those youngest at admission, and those preferring direct patient interactions least, are painfully poor choices for a career that involves interactions with the widest variety of peoples throughout training and practice as a physician. The patients that they marginalize, the medical students that they marginalize, and the government efforts that they marginalize all pay the price. Of course their medical training did prepare them to become physicians, as they themselves were marginalized in the process. In many ways medical education can magnify the best of humankind or the worst, and usually a mix of both.
The most important studies needed in physicians involve the outcomes in physicians in 10 or 20 years, not admissions focus on highest scores that impact only the first two years of medical school performance.
Professionalism, awareness, service orientation, and cultural competence are nice concepts, but training may be little more than a temporary exercise without a lifetime of experience and dedication. Selection of those with optimal characteristics remains an important priority.
Maturity and versatility are important factors to consider regarding health care access, cost, and quality. Versatile, mature physician can adapt to a location, deliver better care, and deliver health care at lower cost. Certain types of students have birth to admission experiences that force them to be versatile. Overcoming obstacles to admission can delay admission and add maturity.
Training can involve different locations and situations to stretch adaptive capability in physicians. Policies in higher education can shape professionals. For example top graduate schools of business require 2 or more years of business experience between college and professional school. In such situations, graduates gain real world and business experience that is valuable in shaping higher education and specific direction toward a specific type of business career. Top medical experts do promote the admission of older and mature medical students.49 One of the most important lasting contributions of the 1970s medical school expansion involved the rise of older medical student admissions. Older students, given a chance when expansion doubled medical student positions, proved their worth. Levels of medical students older than 29 years at graduation have increased from 7% to 23% in the past 4 decades; however, further increases seem to be stalled. The elite schools continue to admit the youngest students and the fewest who are socially and geographically different and distant.
Primary care is a career that demands great maturity and versatility. Older medical school graduates are more likely to be found in primary care, family medicine, rural, and underserved locations. Family medicine choice doubles over the usual age range of medical school graduates and is highest in the osteopathic medical school graduates, a group that is nearly twice as likely to be older than US MD Grads. Some academicians may consider family medicine a less rigorous career choice. However the complexities of integrating the biopsychosocial model appear to be too much for those youngest, most academic, and most oriented to science and technology and a better fit for older medical students with more years of life and health care experience, greater levels of tolerance of ambiguity, greater levels of service orientation, parents least likely to be professionals, and experience in establishing relationships such as marriage (previous references).
Primary care also demands years of training shaped by clear intention to practice primary care. The contrast in primary care is actually quite dramatic. The primary care practitioners shaped by the
The recent decades of primary care graduates favor the permanent selection of primary care (family medicine) and primary care retention after training in those who did choose and integrate primary care intention into their training much earlier than the final year of residency.
The Special Role of Family Medicine � Not Being Special or Least Exclusive
Family physicians are more likely to have origins outside of concentrations of people, income, professionals, college graduates, and physicians.. They are more likely to move away from major medical center locations across the time period of birth to practice location. Studies can match birth origin locations to practice locations.
The birth origin data is provided in the Masterfile in city and state fields while practice data is more detailed with practice zip code. This is not a problem for rural locations but urban cities and counties are a mix of urban major medical center, marginal urban, and urban underserved locations. In the largest counties rural and rural underserved locations are also found. By selecting the counties with 75% or more of physicians found in each of the six main categories, these counties can be used as indicators of the career and location choices for this birth origin.
Birth Origins and Practice Locations By Choice of Family Practice or General Practice
|
|
Total |
Marginal urban |
Urban Under-served |
Marginal rural |
Rural Under-served |
Urban MMC |
Rural MMC |
|
Birth Location Not FPGP |
|
|
|
|
|
|
|
|
Marginal urban |
2482 |
13.8% |
2.5% |
5.8% |
2.3% |
69.3% |
3.6% |
|
Urban Underserved |
704 |
10.8% |
5.1% |
4.1% |
4.1% |
69.5% |
4.0% |
|
Marginal rural |
7865 |
11.0% |
2.0% |
8.5% |
2.4% |
68.0% |
5.5% |
|
Rural Underserved |
5713 |
10.1% |
2.7% |
5.2% |
6.2% |
67.8% |
6.0% |
|
Urban MMC |
116593 |
11.8% |
2.2% |
2.9% |
1.4% |
77.4% |
2.2% |
|
Rural MMC |
2189 |
10.9% |
1.8% |
6.6% |
3.0% |
67.0% |
8.5% |
|
|
135546 |
11.7% |
2.2% |
3.5% |
1.7% |
76.1% |
2.7% |
|
Birth Location for FPGP |
|
|
|
|
|
|
|
|
Marginal urban |
613 |
25.1% |
2.4% |
13.5% |
8.3% |
41.9% |
4.4% |
|
Urban Underserved |
174 |
12.1% |
14.9% |
10.9% |
9.8% |
45.4% |
5.7% |
|
Marginal rural |
2626 |
19.6% |
2.3% |
30.7% |
7.8% |
32.1% |
5.0% |
|
Rural Underserved |
1845 |
16.4% |
4.5% |
16.4% |
21.6% |
33.6% |
5.5% |
|
Urban MMC |
18197 |
24.5% |
5.0% |
10.0% |
5.6% |
49.2% |
2.9% |
|
Rural MMC |
596 |
16.9% |
2.5% |
21.5% |
6.5% |
36.4% |
13.6% |
|
|
24051 |
23.1% |
4.6% |
13.1% |
7.1% |
45.6% |
3.6% |
Urban major medical centers dominate practice locations for all groups, especially physicians that are not in family medicine or general practice. For this group, the second most common location is marginal urban, another indication of similarities between major medical center and marginal urban locations. Family physicians are consistently seen at higher levels outside of major medical center locations. The second most common location for family physicians is their birth origin category, an indicator of the shaping force of birth origins and experiential place. Note also that experiential place impacts are not limited to rural locations. The return of marginal rural origin family physicians is approximately the same as major medical center location.
Birth origin impacts are seen for all types of physicians with a return to the same or similar location most likely. Escape from major medical center practice locations is most likely for those with origins �outside� or the family medicine career choice that remains outside at the highest levels.
The multiplier effect of family medicine regarding distribution is important to understand. Choice of family medicine consistently doubles or triples practice locations outside of major medical center locations, including the underserved locations.
This method is weakest for the marginal urban and urban underserved locations. A better choice for coding origins is likely to be parent income, occupation, or high school attended. A better choice for physician distribution to urban underserved areas is provided by race and ethnicity combined with parent income and occupation. Decreased access to this data is likely to preclude such considerations.
Birth Origins and Family Medicine Distributions
Birth origins are important determinants of career and practice location. The geographic considerations are important, but lack the detail of the new categorizations. The geographic coding for origins does have the advantage of complete coding for origins.
Matching Birth Origins and Physician Distributions
|
|
|
|
Practice Locations for 1987 � 1999 Graduates | ||||
|
Birth Origins for 1987 � 1999 Graduates of All Schools |
|
Total |
Urban |
Large Rural |
Small Rural |
Isolated Rural |
Military |
|
Not Family Practice or General Practice |
|
|
|
|
|
|
|
|
Urban US Born |
|
135993 |
91.7% |
5.4% |
1.4% |
0.5% |
1.1% |
|
Large Rural US Born |
|
11233 |
82.8% |
12.7% |
2.3% |
0.7% |
1.5% |
|
Small Rural US Born |
|
5727 |
81.2% |
11.8% |
4.3% |
1.4% |
1.3% |
|
Isolated Rural US Born |
|
1954 |
78.6% |
13.9% |
4.2% |
1.8% |
1.5% |
|
Puerto Rican Birth |
|
3023 |
88.3% |
3.3% |
3.1% |
5.0% |
0.4% |
|
Foreign Born, Puerto Rican School |
|
424 |
81.4% |
2.8% |
5.7% |
9.9% |
0.2% |
|
Foreign Born |
|
27023 |
94.6% |
3.7% |
0.8% |
0.3% |
0.7% |
|
Foreign Born IMG |
|
31628 |
90.8% |
5.8% |
2.2% |
1.1% |
0.1% |
|
US Birth, State Known (not city) |
|
1702 |
90.1% |
6.1% |
2.2% |
0.8% |
0.8% |
|
Military Base Born |
|
1965 |
85.4% |
9.0% |
1.2% |
0.7% |
3.8% |
|
Unknown Birth IMG |
|
25015 |
93.7% |
3.7% |
1.7% |
0.8% |
0.1% |
|
Unknown Birth |
|
6301 |
85.9% |
8.4% |
3.0% |
1.3% |
1.5% |
|
Total |
|
251988 |
91.1% |
5.7% |
1.6% |
0.7% |
0.8% |
|
Family Practice General Practice |
FPGP |
|
|
|
|
|
|
|
Urban US Born |
14.4% |
22866 |
78.8% |
9.4% |
6.6% |
3.5% |
1.7% |
|
Large Rural US Born |
21.7% |
3118 |
60.1% |
22.2% |
11.2% |
5.1% |
1.3% |
|
Small Rural US Born |
26.1% |
2020 |
54.5% |
17.5% |
19.9% |
6.9% |
1.2% |
|
Isolated Rural US Born |
27.9% |
757 |
51.3% |
20.6% |
14.4% |
12.5% |
1.2% |
|
Puerto Rican Birth |
11.5% |
393 |
78.9% |
5.9% |
7.4% |
7.1% |
0.8% |
|
Foreign Born, Puerto Rican School |
24.2% |
135 |
75.6% |
4.4% |
8.1% |
11.9% |
0.0% |
|
Foreign Born |
10.5% |
3175 |
86.9% |
6.0% |
4.1% |
1.5% |
1.6% |
|
Foreign Born IMG |
8.8% |
3033 |
84.9% |
7.9% |
4.8% |
2.1% |
0.3% |
|
US Birth, State Known (not city) |
23.6% |
526 |
77.4% |
10.6% |
8.4% |
3.2% |
0.4% |
|
Military Base Born |
16.4% |
385 |
71.4% |
11.7% |
7.5% |
4.2% |
5.2% |
|
Unknown Birth IMG |
9.9% |
2757 |
90.7% |
5.0% |
2.9% |
1.2% |
0.2% |
|
Unknown Birth |
29.5% |
2641 |
76.3% |
11.1% |
7.3% |
3.7% |
1.6% |
|
Total |
14.2% |
41806 |
77.3% |
10.4% |
7.2% |
3.6% |
1.4% |
Urban locations continue to dominate physician location choice. Birth origins do shape practice location although specialization reduces the magnitude of impact. Family medicine demonstrates the increased return to birth origins and the multiplier impact across rural locations. Family medicine is the most common choice for students of the widest range of origins. There is one exception to this. Family medicine is not the most common choice for the most exclusive origin medical student types that dominate admission. Family practice, rural, and underserved physicians arise at constant rates according to population based studies, but in the populations most likely to gain admission, more gain admission who make exclusive choices resulting in a higher probability of admission as well as a lower probability of most needed health access careers.
Family Medicine, Birth Origins, and Admission Rates
Rural Physicians, Birth Origins, and Admission Rates
Underserved Physicians, Birth Origins, and Admission Rates
The limitations of geographic coding are seen. It is difficult to see that the reason for poor physician distribution to urban underserved or to rural locations is that the various physician types are concentrated in major medical centers. This is particularly true of family medicine and for those with origins outside of major medical centers. The physicians that distribute to underserved areas at greater than the national averages of 5.7% have underserved origins or family medicine career choice. The physicians that distribute to rural areas at greater than the 10% rural workforce average have rural origins or family medicine choice. Family medicine is the major factor that can convert even the most resistant birth origins to urban underserved or rural underserved locations.
It is difficult to distribute physicians against their birth origins. It usually takes a combination of different admissions, different training, and different health policy support. The medical students born in other nations who attend US schools or international medical schools have consistently higher choice of urban locations that are most likely to be consistent with their own urban origins in other nations. Asian populations continue to have over 90% urban origins in the census, in international graduate origins and locations, and in Asian family medicine origins and locations. Asian physicians dominate foreign born US Graduates and international graduates. Asian students dominate
Those with the greatest probability of admission have the lowest probability of family medicine, primary care, rural, and underserved careers. One of the simplest explanations is that these are physicians with major medical center origins who have never had to leave major medical center locations for the first 30 years of life, making it unlikely that they would choose a location outside of a major medical center or the family medicine career with a majority outside of major medical centers. Major medical center also represents a lifestyle. The so-called controllable lifestyle studies may actually be documenting medical student efforts to choose careers to maintain a certain lifestyle location. It is not a surprise that they would choose a location where physician and major medical center rules dominate access to patients through the narrow vertical arrangements found. Family physicians reside in different environments more accessible to patients and have few restrictions to the types of patients seen. There are also role modeling elements in birth origins. Family physicians are also least likely to be seen by major medical center origin physicians who have spent their entire lives in locations with few family physicians and who tend to choose medical schools without much primary care or family medicine emphasis. Major medical center concentrations of family physicians are the lowest at 8% and most of these have the reduced primary care patient care loads associated with teaching, research, administration, or hospital based careers. Those born outside of major medical centers are born and raised in a world where 25 � 100% of the physicians are family physicians. Unless their parents have a very different view of health care and physicians, the estimated 30% born and raised outside of major medical centers will experience different physicians and health care patterns compared to the 70% with origins inside.
A focus on geographic origins illustrates the rural value of family medicine. A focus on physician practice locations including major medical center locations illustrates that family medicine is the primary means of physician distribution to any location outside of major medical centers.
The nation faces greater difficulties distributing physicians with declines in admission of medical students with origins outside of major medical centers and with declines in family medicine. No other physician origins are found in the most needed locations at greater than national averages. No other specialty has the distribution, the facilitation of distribution, the scope, or the flexibility across locations.
Summary
Nations can choose to address the barriers to health care or they can ignore them. What kind of rating would the
The
Selection of the most academic, the highest scoring, the most specialized, the least aware, the least experienced, the least service oriented, the least people oriented and possibly those with the least management and communication ability for a lifetime involving people, service, management, and communication skills could result in a number of problems, including many currently seen in physicians involving cost, quality, and access.
A framework of experiential place could help medical education to understand what is most necessary to improve physician distribution, health access, and restore a balance in physicians between academic and people skills. Physicians with superior ability to relate to patients, the people that they work with, communities, governments, and each other are a good start toward a more efficient, more effective, and more united
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Basic Health Access Concepts To Review Beyond Policy Declines: Other Influences Moving Primary Care Up or Down
Experiential Place and Health Access Considerations
The Counterproductive and Untrue Perspective of the Impossibility of Health Access
Nebraska: A Practical Application of Experiential Place and Workforce
Why Physician Workforce Needs New Tools (and a health access perspective)
www.physicianworkforcestudies.org
