Physicians By Practice Location Zip Codes Using Physician Distribution by Concentration Coding: Active Physicians Excluding Residents and Physicians Not Classified, Unknown, Other, or Inactive unless noted

	Percentages By Type of Practice Location		Physician Concentrations Per 100,000 Population
	FM	Office Primary Care	FM	Office Primary Care	All Active	Add GME per 100,000	All per 100,000
					669,871	765,444	933,835
All Super Center 200 or More Physicians	6.2%	28.6%	49.6	230.3	804.1	1103.0	1191.3
Medical School	5.0%	26.6%	41.8	222.7	837.5	1313.2	1452.6
Urban Super Center	7.1%	30.2%	55.0	234.9	778.9	954.2	1007.0
Rural Super Center	5.7%	29.4%	67.4	350.2	1189.4	1667.4	1762.9
All Major Center   75 � 199 Physicians	11.0%	35.2%	35.9	114.9	326.5	409.7	434.6
Medical School	8.6%	33.3%	15.2	58.6	176.0	306.0	346.2
Urban	10.7%	35.2%	35.5	116.7	331.6	415.6	440.9
Rural	14.8%	35.7%	47.8	115.2	322.9	379.9	396.5
All Marginal or Half Served Locations (Half the National Average in Physicians and in Sufficient Primary Care	19.4%	42.1%	25.3	55.0	130.6	165.6	177.0
Urban Marginal or Half Served	17.0%	40.7%	22.6	54.1	132.7	168.9	181.8
Rural Marginal or Half Served	28.0%	46.9%	37.1	62.1	132.4	162.0	168.3
Isolated Marginal	39.5%	56.5%	32.4	46.5	82.2	112.4	116.5
All Underserved	22.1%	46.6%	18.5	37.0	83.7	92.3	98.7
Urban Underserved - One-Fourth Served - or fourth priority	16.2%	42.7%	11.9	31.3	73.3	88.4	95.7
Rural Underserved or One-Third Served, or Third Priority	26.5%	50.4%	30.2	57.4	114.0	115.3	121.0
Isolated Underserved	37.7%	62.6%	23.3	38.7	61.8	55.3	58.7
Military Base	20.9%	32.2%	55.7	85.8	266.8	318.1	342.7
Military Super	5.6%	16.7%	108.6	325.9	1955.1	2839.2	3043.9
Total	12.0%	35.1%	29.5	86.6	246.4	320.6	343.5

Marginal or Half Served locations have half of the nation's 300 physicians per 100,000 and half of the nations recommended 100 per 100,000 primary care physicians. One-Third Served locations have one-third of the national average and one-third of the primary care recommendation. One-Fourth Served is seen in the urban underserved locations with the lowest physician and primary care physician concentrations. This is also seen in rural iunderserved areas that are lowest poverty or isolated.

The lowest percentages of family physicians are found in super centers, especially medical school super centers. Despite lowest percentages, family physicians are the most likely to be found as medical teachers with about 1.8 � 2.2 times odds ratios as compared to other forms of primary care with 1.3 or lower odds ratios. Holding steady in primary care and in generalism is not enough. Family physicians also must prop up medical education in the nation.

Family physicians assume greater and greater roles in primary care in the locations in most need of primary care. Internal medicine and pediatric physicians are predominantly found in major centers and super centers where primary care levels are saturated. This is yet another reason for more to leave primary care. NPs and PAs leaving family practice and primary care are moving toward super centers, major centers, and higher income urban locations. Each departure from primary care is rewarded by increased salary and benefits, in some cases massive increases in salary and benefits. Those choosing "the right careers" to serve the nation where it most needs help in health care are penalized at every turn.

The aging of the United States population is also a major concern. Again pediatrics is out of the equation. Internal medicine graduates have moved away from generalist careers where they serve significant levels of elderly patients and have moved into major medical center careers and locations where the populations have the youngest adults, not the oldest. Geriatric populations avoid the highest costs of health care and the highest costs of living found in major medical center locations. Geriatric populations concentrate in lower and middle income locations, the locations where family physicians concentrate. At the county level the family practice percentage increases along with the percentage of the population over age 65 with a 0.2 correlation that is highly significant (using only 2500 counties with at least 2 physicians).

The current solution for geriatrics for a top ranking medical school is 1 geriatrician (actually only half), 2 family physicians, and 3 remaining in general internal medicine produced from a class of 130. The geriatric solution is very different in Duluth, the consistent leader in family practice percentage of graduates in the nation. The Duluth solution is no geriatricians, 27 family physicians, and 4 internal medicine generalists out of a class of 60. These are graduates that have consistently located in the urban and rural lower and middle income locations with concentrations of people over age 65. Duluth also manages to produce higher levels of rural specialists, women�s health, general surgery, and neonatology. Any real workforce assessment of the nation's health needs would have guided the current expansion in very different directions. The current expansion will only intensify physician concentrations and will fail to address health care for the 65% and growing populations left behind.

The Duluth admissions process is specific for family practice and rural health. The Duluth training includes 30 of the 60 third year medical students each year who take the Rural Physician Associate Program for 9 months in rural Minnesota. The hands-on medical careers apparently are a top choice of Duluth graduates who get the opportunity for hands on training in rural locations. The Duluth model appears to be a solution for most of the nation�s top workforce needs, but the national decisions move in other directions. Osteopathic public models have similar outcomes, yet the only 6 were created also during the 1970s.  The Duluth contributions are consistent with other distributional medical schools that focus on different admission, different training, and specific outcomes serving lower and middle income patients. In the past 100 years the Historically Black and osteopathic medical schools have made top contributions. In each case, the family practice component makes significant contributions to health access.  

Now what would happen if a medical school graduated 100% family physicians? Only 3 - 4 times more primary care for the same cost compared to Duluth or osteopathic, 8 times more for allopathic public, and 14 times more compared to allopathic private. Of course the nation has realized its severe and growing primary care and health access problems and is rapidly moving to graduate more of the physicians most needed in the most efficient and effective manner. Sadly no. Or perhaps the needs for rural specialists, women's health, general surgeons, and primary care could be met by expansions limited only to the Duluth or Osteopathic Model? Sadly again no. The current expansion is a pure strain of medical students admitted from the most concentrated origins, trained in the most concentrated locations, and incented by policy to choose the most concentrated specialties and locations.

Why should family practice spend the time and effort and risk change when all other forms of primary care have moved steadily away from primary care, steadily away from family practice modes of care, steadily away from rural and underserved locations, steadily away from high need growing geriatric populations, and steadily away from the lower and middle income populations most in need of health care? Why should family medicine risk compromise and change when it is the nation that needs changing, changes in birth to admission and in admission so that those who gain admission return back to more normal medical students, changes in training to reflect the needs of the 65% of the population outside of physician concentration, and changes in health policy so that the 65% outside actually can access care?

If a merger is appropriate, why not a family practice merger with the remaining family nurse practitioners and family practice physician assistants that have endured health policy changes and that have remained faithful to primary care as well as distributing much the same as family physicians.

As far as numbers are concerned, there is really not much reason to merge. Family practice residency graduates deliver a maximal level of 29 years of primary care, internal medicine residency graduates now deliver less than 7 years, and pediatric residents deliver 17 years on average. Why potentially dilute a maximal contribution. Family practice primary care years have been steady for decades, limited only by the barriers placed on all in primary care. Internal medicine graduates continue to move steadily away from primary care. The expected expansions in graduate medical education positions are likely to reduce internal medicine to 15% remaining in primary care.  Internal medicine graduates also have one other limitation. Many back into internal medicine when plans for cardiology, gastroenterology, or other fellowships do not materialize.¹ For a best prepared primary care physician, a primary care focus before admission, during medical school, and throughout residency training is essential. Those intent on primary care need to use the entire 7 years of primary care training to become the best primary care physicians possible.

Pediatric mergers are even more problematic. Their generalist retention levels are also falling. Pediatric graduates remain in major medical center locations, the only locations in the nation with adequate primary care. Fewer children, collapsing pediatric markets, more female and international graduates desiring pediatrics, and no declines in residency positions mean saturated markets.^2-4 Unlike the other 4 forms of primary care, more pediatricians cannot branch out to meet primary care in other age brackets. Finally pediatrics fails to meet a most pressing need of the nation, the need to care for an increasingly older population. There is nothing wrong with pediatrics, but pediatrics would need to be reshaped substantially.

In many ways what is going on in pediatrics mirrors all found in major medical center locations in primary care. The saturated markets, increasing graduates, and competitions with well funded systems and medical schools mean marginalization. These also are the prime suspects in the �conspiracy� that results in low primary care reimbursement and few choices other than part time, low pay, or subspecialization.  After all with 60 - 90% of medical students admitted from top status concentrations and desiring to remain in similar locations for practice, many would rather take cuts in pay rather than leave home, family, colleagues, and 30 years of life experiences. Even the basic support of primary care in major medical centers requires funding shifted from lab, radiology, specialty care, hospital care, grants, or other funds to prop up primary care physicians.  

Currently family physicians have a most important escape clause from the saturation, marginalization, and inadequate primary care support found in major center concentrations. Family physicians can and do take other options and these include Community Health Centers, rural health clinics, and full scope family practice. In many ways it is the current peculiar interaction of primary care policy with family practice that drives family physicians to distribute away from major medical center compromises and dependencies. A unified primary care is not going to be any more welcome in major medical centers than before and the risk is great that some of the many advantages of family practitioners would be lost. There are pediatricians and internal medicine physicians who do venture away from medical centers and with or without a merger they can continue to do so. But the great majority of internal medicine and pediatric physicians vote for concentration and are unlikely to change with or without a merger.

Internal medicine physicians have a different focus and a different approach. They are different in origin, different in the medical schools that they attend, and different in their training. Some of those most committed to internal medicine have never been exposed to other options (foreign born, Asian Indian). As with pediatricians they are also more likely to have concentrated upbringing (urban, higher income, top status parents). One major difference in family physicians that separates them from all other physicians is that family physicians have greater levels of lower and middle income origins. To graduate more family physicians, a medical school only has to admit medical students slightly more normal or representative of the United States population. When admissions are stacked to the highest scoring, highest income, and most urban medical students, every other career other than family practice increases and family practice levels are left behind. This is most commonly seen in the ultimate top ranking MCAT schools where even general internal medicine and general pediatrics are left behind as well.

internal medicine also moves steadily toward hospital based careers and locations over the class years and over the years after graduation. This again reveals different tendencies compared to family physicians.

If internal medicine wanted to change, it certainly has the ability to do so. But why should it change? It is well known to all students, it is a dominant force at nearly all medical schools and major medical center locations, it has adequate numbers of medical students interested in internal medicine with additional international medical graduates to fill in gaps, and over 80% of its graduates can obtain salaries above the average for physicians.

So now we have internal medicine and pediatric graduates collapsing into major medical center careers and locations while others are moving into urgent, emergent, hospitalist, hospital-based, or subspecialty careers. We have all forms of primary care competing in a limited market and driving primary care salaries down and forcing flexible forms to leave primary care. Then we have medical schools attempting to run primary care clinics and the dysfunctional result also drives medical students away from primary care. (ref) Of course the dysfunction arises from the fact that residency training is really about hospital focus. It is difficult to serve two masters. Primary care is first and foremost about understanding patients in the context of their environment, and true primary care training should be substantially divorced from hospitals and most firmly attached to community and patient care environments.

And family practice should merge with this?

The Future of Family Medicine and numerous other reports appear to attempt to fix a discipline that is not broken, other than the fact that it is poorly respected in major medical center and medical school environments. Family physicians as well as primary care physicians are at lowest percentages in the nation in these concentrated medical school locations with hundreds of physicians, a simple indicator that speaks volumes about the status of primary care in training locations. If any merger were to happen at the present time, it would involve academic locations. Why would family practice want to negotiate from its weakest position? Perhaps it is not family medicine that should change. What may need to change is for academic family medicine to divorce itself from major medical center training environments.

The example of other nations is relevant, in this case Australia. The general practitioners realized the compromises that were developing and broke free to set up their own schools and even additional schools focused on full scope primary care for frontier, rural, and aboriginal environments. It may be impossible for medical schools to do a good job running primary care clinics. They may have too many conflicts and not enough experience. Moving training to primary care clinics that are run well is one answer. If complex primary care is too much for medical schools, then training should move to Community Health Centers where complex primary care is the focus. Family physicians do well in running primary care clinics all across the nation. There are more than enough examples of better primary care to utilize.

During the one time in history when family practice actually received the support that it needed in the 1994 � 1996 class years, the full potential of family practice training in the United States was reached. When enough medical students were choosing family medicine for the first time in history, family practice demonstrated that it too could specialize, but instead of specializing in organs and technologies, family practice specialized in inner city health, rural health, women�s health, full scope family practice with procedures, expanded behavioral health, and emergent care. Family physicians received the most specific training for their particular primary care focus areas. Family practice was at maximal ability to fill in the gaps in the United States health care system during this time period. These specialized programs and fellowships soon departed when health policy reversed student interest in the permanent form of primary care and the diversified family practice returned to a generic form.  Perhaps it is this decline to a generic form that is most problematic for those who have experienced much more.

While it would be nice to have a separate accreditation and funding mechanism for primary care, the track record of family practice with academic interests is not stellar. Again the initial family practice leaders pointed the way. When deans did not share state funds designed for family practice, family practice leaders set up direct lines of funding from state government.

Family practice needs its own accreditation, its own funding, its own medical schools, and sufficient support for its trainees who deserve full ride scholarships in exchange for the 29 or more years of primary care service to the nation. Family practice even had an optimal low cost, high yield model. In studies of 150 graduates from 12 programs across the nation, the accelerated model with 3 years of medical school and 3 years of residency maximized underserved and rural outcomes, minimized cost, and maximized leadership and inservice scores. Accelerated training also worked with women, urban origin, and foreign born medical students, the three major directions of medical school admissions.

A family practice with its own accreditation might have realized the value of a program that works despite admissions changes, retains over 70% of graduates instate, has top levels of distribution, illustrates the advantages of early commitment to family medicine and primary care, maximizes the previous life and health experiences of older medical school graduates, and fulfills the promise of the family medicine discipline.

Solutions for primary care first of all should involve support of those who provide primary care. In the following projections the numbers of graduates in each form of primary care training are listed. When generating the projections the most recent changes for each form of primary care were integrated into the model. The primary assumption was no changes in health policy with steady slow declines in choice of family practice and steady declines in retention of all other training forms of primary care within primary care.

	FP Res Grads	IM Res Grads	PD Res Grads	NP Grads	PA Grads	FP PC Yrs	IM PC Yrs	PD PC Yrs	NP PC Yrs	PA PC Yrs	FP Share of PC	IM Share of PC	PD Share of PC	NP Share of PC	PA Share of PC
1970	1477	3430	1278	100	100	44310	51450	28116	1250	1292	35.1%	40.7%	22.2%	1.0%	1.0%
1975	2359	5104	1528	1700	1600	70770	71456	32088	19890	19443	33.1%	33.4%	15.0%	9.3%	9.1%
1980	2922	6396	2009	1700	1500	87660	83148	41185	18530	17156	35.4%	33.6%	16.6%	7.5%	6.9%
1985	3139	7115	2184	1700	1200	94170	88938	43680	16660	12595	36.8%	34.7%	17.1%	6.5%	4.9%
1990	2698	6525	2161	1700	1200	80932	78300	41061	15300	11192	35.7%	34.5%	18.1%	6.7%	4.9%
1995	3746	7151	2451	3200	2200	112378	92958	48284	23040	16892	38.3%	31.7%	16.4%	7.8%	5.8%
2000	3352	7445	2762	7300	4200	100565	63282	50542	37960	23698	36.4%	22.9%	18.3%	13.8%	8.6%
2005	2623	7346	2992	6100	6200	78678	50689	50871	23180	25836	34.3%	22.1%	22.2%	10.1%	11.3%
2010	2721	8326	3455	4800	6900	81638	53285	50098	13440	19320	37.5%	24.5%	23.0%	6.2%	8.9%
2015	2815	8739	3669	4200	7252	84454	51560	46969	11760	20306	39.3%	24.0%	21.8%	5.5%	9.4%
2020	3026	9182	3898	4327	7622	90772	49580	46782	12116	21341	41.1%	22.5%	21.2%	5.5%	9.7%
2025	3319	9827	4235	4548	8011	99578	49137	50826	12734	22430	42.4%	20.9%	21.7%	5.4%	9.6%
2030	3625	10515	4596	4780	8419	108737	52577	55151	13384	23574	42.9%	20.7%	21.8%	5.3%	9.3%
2035	3971	11291	5002	5024	8849	119144	56457	60030	14067	24777	43.4%	20.6%	21.9%	5.1%	9.0%
2040	4366	12167	5461	5280	9300	130975	60836	65535	14784	26040	43.9%	20.4%	22.0%	5.0%	8.7%
2045	4814	13156	5979	5549	9775	144432	65781	71751	15538	27369	44.5%	20.2%	22.1%	4.8%	8.4%

One would expect internal medicine and physician assistant graduates to make the most primary care contributions as the most numerous. Of course declines in internal medicine resident retention in primary care and departures of active physician assistants from primary care have been steady for over a decade and will continue at 1 � 2 percentage points a year until some lowest threshold value is obtained. Declines in family practice choice will continue as health policy is not expected to change. The allopathic family practice levels for this graphic were projected down below 8% with osteopathic levels declining below 15%. For the osteopathic graduates that will double from 2004 to 2017 this only adds about 100 family practice graduates or a minimal increase from 600 to 700 unless osteopathic admission and training recovers focus on family practice emphasis. Even with very conservative family practice numbers, family medicine continues to deliver the most primary care years.

Despite the numbers, family practice also delivers an increasing share of the total primary care years.

Primary care years are another way of expressing primary care capacity, but the primary care year figure links the contributions to the class year of graduation. This allows admission, training, and health policy effects to be evaluated. For example the peak primary care year levels of all forms in the 1990 � 2000 class years maximized primary care to about 300,000 primary care years per class year. Rapid declines in family practice choice and internal medicine primary care retention have markedly diminished future primary care capacity in a short time. These two alone account for 80,000 fewer primary care years per class year.  This impact will be felt for the next 30 years as the stabilizing effect of family practice has been greatly decreased. 

These projections do not include additional declines in physician assistants and nurse practitioners such as new specialties added each year and longer term departures from primary care in future years. Both have decreasing levels of first careers in primary care. More graduates with no primary care at all will diminish primary care year contributions. The projection also does not include additional years lost to the new proposal to train nurse doctors. Nurse practitioners of the 1990s had a claim to a being a legitimate solution for primary care. Now with numbers of nurse practitioner graduates falling; with nurse practitioners leaving primary care during training, at graduation, and any year after graduation; and with increasing specialization this claim is no longer valid. What is now most important about nursing is inadequate numbers of nursing assistants and registered nurses, losses of the nursing faculty to become nurse practitioners (further decreasing nursing levels), losses of management nurses, losses of critical care nurses, and losses of the best nurses not to primary care, but to specialization. Of course with nurses having no real income gains in 30 years, the nation faces the consequences of its inactions.

Comparisons of primary care share are most revealing. Despite lower numbers of graduates, family practice continues to improve in share of primary care capacity. This actually is not a good sign since the reason is greater declines in other forms of primary care. Family practice remains resistant to adverse health policy, once family physicians reach the second year of training. Getting enough to that second year should be a primary goal of any interested in improved health access.

Another problem for primary care involves inadequate contributions in powerful states such as California. For primary care alone, California needs about 3000 more allopathic medical school graduates each year. Osteopathic medical schools would cost about 40% less per medical student and would double the primary care levels resulting in the need to train half the number of medical students. A family practice only medical school would deliver 3 � 4 times the primary care for the same cost as an osteopathic school. With appropriate selection of mature medical students committed to family practice, the accelerated model would require only 3 years of medical school for another 25% savings. Thirty years of primary care per graduate with the lowest cost of medical education with maximal physician distribution with maximal instate retention is a very fundable model. States that do not want to fund such a model simply would rather take what they need from other states. Eventually Nebraska, Kansas, Iowa, North Dakota, and South Dakota will tire of investing enough in children, education, and higher education to prop up states that fail to contribute their fair share.

The lesson of these states is important. Just because other states fail to do the right thing, this does not mean that they should change and stop investing in children, education, and higher education (efforts that also result in more family physicians by the way). Family practice should take a lesson.

If the nation does not support family practice, this does not mean that family practice needs to change. Frankly the changes in birth to admission, admission, training, and health policy that are good for family practice are good for all of primary care, good for the 65% of the population outside of major medical centers that depend upon primary care, and good for a nation that depends upon efficient and effective health care to compete in the world.

Please no more Keystone, no more Future Reports, and no more merger talks. The secret of family medicine is really no secret. Family practice is consistent in who chooses family practice, consistent in family practice training, and consistent in full development of primary care in the United States. Family physicians just take care of the people in most need of health care. If the nation wants to learn how to do this, then it should talk to family physicians. If medical students, first year internal medicine residents, first year pediatric residents, or first year residents of any specialty want to do this, they know the specialty that they should choose.

If the United States ignores needed changes, family practice will still be there, the only primary care specialty resistant to health policy ignorance. If the United States decides to support basic health care access along with basic child development, basic fundamental education funding, emphasis on early education, and full development of opportunity for lower and middle income children, family medicine will still be there, but it will be even more efficient and effective, just like the rest of the United States of America.   

Primary care indeed needs a united stand, but it needs the United States to understand most of all.

New Addition - Primary Care Recovery Plan

The United States is set for major deficits in primary care until at least 2050 under current policy and market forces. This has become a health policy period where primary care has been treated as a side effect rather than a focus. 

Health care access does not happen. It must be designed. Because other forms have become inefficient, there really is only one solution and this is a family practice solution. Family practice can be NP, PA, or FP. Unfortunately there is nothing to keep family nurse practitioners or family practice physician assistants in family practice.

Family physicians do stay and have optimal distribution and care for all ages and have top versatility to adjust to the widest range of locations and populations. 

The following table illustrates

• what the nation needs based on population growth
• what the nation needs based on increases in the elderly and most complex patients,
• what is likely to happen,
• what could happen with the health access recovery plan of additional family physicians
• why other forms of primary care cannot make up the huge and widening gap

Column 1 is the year of graduation. The total primary care production in the SPC Year is an estimate assigned to the year of graduation for each form of primary care. Column 2 is the simple Pop Growth Need projection. Column 3 is the SPC YEars without the Intervention or what will happen with current market forces and health policy. Column 4 is SPC Years totalled with the Health Access Intervention of additional FP graduates. Column 5 is a projection of needed primary care production including pop growth and growth of elderly and complex patients (but not addressing previous deficits). Note that the FP Intervention does not overshoot needs with FP grads (Column 6) leveling off at 8300 from the intervention plus current expansion of medical school positions. Column 7 is the additional FP grads for the intervention and beyond expansion projections. Column 8 is the estimate for the IM residency graduate numbers that it would take to do the same health access intervention. Columns 9 and 10 estimate NP and PA to meet the intervention. Finally the FP share of primary care is noted.

	Pop Growth Production Need Estimate (census growth)	SPC Years Without Intervention	SPC Years With Health Access Intervention	Needed Primary Care Production in SPC Years  Growth, Complex, Elderly	Total FP Grads with Intervention	Extra FP Resgrads Required	Extra IM Resgrads Required	Extra NP Grads Required	Extra PA Grads Required	FP Share of Primary Care
1970		126418	126418		1477					33.9%
1975		213647	213647		2359					32.0%
1980		247679	247679		2922					34.2%
1985		256043	256043		3139					35.6%
1990		226785	226785		2698					34.5%
1995		293552	293552		3746					37.0%
2000	280000	276047	276047	300000	3352					35.2%
2005	290000	229254	229254	315000	2623					33.2%
2010	300000	217781	217781	331000	2721					36.2%
2015	311000	215049	258549	348000	4315	1500	8700	14500	8700	48.4%
2020	322000	220591	336591	365000	7026	4000	23200	38667	23200	60.5%
2025	333000	234705	379705	380000	8319	5000	29000	48333	29000	63.5%
2030	345000	253423	391173	391000	8375	4750	27550	45917	27550	62.1%
2035	354000	274475	400625	401000	8321	4350	25230	42050	25230	60.2%
2040	363000	298170	412720	411000	8316	3950	22910	38183	22910	58.4%
2045	372000	324871	426371	421000	8314	3500	20300	33833	20300	56.5%

Deficit primary care production in red or all but a few years.

So as always we have a choice. We can emphasize health access and use the best tools to craft a solution. Or we can hope for the best even with primary care capacity destroyed with each passing class year and each year after graduation. By the way, family practice as a discipline is not the advantage. Other forms of primary care do a good job with primary care delivery. But family practice that remains a permanent form of primary care is the remaining solution.