Over the past decades, few have examined the impact of birth origin upon admissions. Rabinowitz and Boulger have used this association to build highly successful rural medical education programs that have served their states (PA and MN) and regions well. Birth origin dictates choice of family medicine.
The key changes have been birth origin, and origin within the state
Rural origin students are down 47 - 55% over the past 25 years. Not only are rural background students more likely to choose rural practice, students that are even a bit more rural as compared to the most urban origin students, are more likely to choose FP. This is not a matter of demographics. Rural origin students have a 50% probability of admission to medical school as compared to urban origin students.
Students born in a state are down 17 % over the past 25 years. Students born instate choose FP 17% as compared to 11% for those born outside a state. Instate Medical Students and FP Choice
Older students are more likely to choose FP. Every year older when graduating from medical school means a higher FP choice. Age and Physician Specialty
FP Choice since 1975 by RUCA coding of birthplace
|
Students born in |
Choose FP |
| isolated rural towns | 0.261 |
| medium rural towns | 0.246 |
| large rural towns | 0.203 |
| urban/urban focused cities | 0.130 |
| using RUCA coding |
The categories most likely to choose FP have not changed. Those least likely, such as urban, have increased.
Admissions during medical school expansion were students born in the most urban codes 1 and 2 in the nation, leaving students from the rest of the country born in codes 3 - 9 counties in the dust.
The changes in those born instate and out of state have been dramatic. The following notes the choice of FP by instate and out of state over time, including the "managed care years where the gap widened and more urban instate students decided for FP.
Students born in the same state as their medical school also choose FP more often. Over the past 30 years 11.7 % of out-of-state medical students chose family medicine as compared to 16.4% of those born in-state. In-state birth origin admissions peaked in 1981 with 8303 or 49 % medical students, declining to 6300 or 35% in recent years. Out-of-state medical students have continued to climb to over 11000 or 65% of recent graduating classes (Bowman). Students attending medical school can meet in-state residency requirements in only a few months in some states. Connections to state, community, lifestyle, and family appear to be important in career choice. More conservative in-state residency requirements could improve student choice of family medicine as a career. Such policies could also stimulate medical schools to become more involved in improving state and local education quality.
Compare to choice of all specialties with tables and graphs at Age and Physician Specialty
| US Med Grads since 1965 | NonFP Docs | FP/GP Docs | % Choosing FP/GP | Number in Age Group | % of all US Grads |
| 15-24 | 12552 | 1361 | 9.8 | 13913 | 2.84 |
| 25 | 43599 | 5409 | 11.0 | 49008 | 10.01 |
| 26 | 154497 | 22575 | 12.7 | 177072 | 36.15 |
| 27-28 | 114372 | 20842 | 15.4 | 135214 | 27.61 |
| 29-30 | 41261 | 8369 | 16.9 | 49630 | 10.13 |
| 31-34 | 34615 | 8328 | 19.4 | 42943 | 8.77 |
| 35-36 | 6890 | 1957 | 22.1 | 8847 | 1.81 |
| 37-38 | 4088 | 1339 | 24.7 | 5427 | 1.11 |
| 39-41 | 3271 | 1154 | 26.1 | 4425 | 0.90 |
| 42-45 | 1705 | 680 | 28.5 | 2385 | 0.49 |
| 46 & up | 604 | 332 | 35.5 | 936 | 0.19 |
| Totals | 417454 | 72346 | 14.8 | 489800 |
Moving the curve even a bit older, shifts medical student choices by a few percent.
There is a slight but steady increase in older medical students, the only trend in a positive direction for more FP doctors.
This makes the following not a surprise. FP physicians are at risk of falling behind total US population increase. Admissions changes are critical!
Every other decade data for space saving, full graphic on powerpoint presentation
In particular, the Asian ethnic group, a 97% urban core city origin group, has replaced the rural background group in admissions. This group chooses family medicine 5% of the time and rural family medicine 0.15% of the time as compared to rural background students with over 20% choice of FP and 10-15% overall choice of rural family medicine.
It may be that the urban birth and exposure and income and parenting is the key area, or it may be that urban students have a paucity of important experiences that are common in rural, and particularly the most rural areas, like early student exposure to a continuity medical home.
The managed care "natural experiment" tells us that it will take more than curricular and reimbursement changes to get more family physicians, since the 1994 - 1998 US medical school graduates had the even greater stimulus of not having a job other than in FP and primary care. This temporary gain of 30% more FP or 600 a year was soon returned into the baseline of decline in 1999 and 2000.
You can even predict the FP match by background and ethnicity, since the major groups hold steady over the past 30 years.
In FP we have had the privilege of having experienced a continuity medical home from others in rural areas (medium or isolated), in stable suburb areas like me having a mom for an FP nurse, or in some inner city locations. Also we have had a chance to see this in practice, in programs, or through teaching.
We have a frame of reference, and so do our kind of students, the ones we must get admitted. However the majority do not have this frame of reference and this is why it is difficult. There is, however, hope in the steady gains of that little green line above the rural pop baseline. (see second graphic above) As that line crawls ever upward toward 50% of the total US pop, by whatever means it takes, then we will steadily gain others who share our frame of reference.
Further studies considered the probability of medical school admission given urban or rural birth. Across the nation, students born in rural areas gained entry to medical school half as often as those of urban birth. The range for rural birth admission was 30 - 90 per 100000 rural people per decade. Students of urban birth were admitted at 70 - 300 students per 100000 urban dwellers per decade in the state of birth. Only 3 states approach parity in urban:rural admission ratios. Another 12 have ratios of 1.2 - 1.7, some 18 states have twice the probability for urban origin admission, and another 6 have 2.5 to 4 times more urban admissions (Bowman). Comparing recent admissions with past decades, the rural-urban gap in admissions is widening. States such as SD, NE, NM, ID, WV, MT, KS, MN, AK, AR, and HI have higher rates of rural birth admission. Such states tend to have better education opportunity, higher per capita education expenditures, and specific efforts to link origin, education, and medical education.
Robert C. Bowman, M.D.
search Google on "Admissions and Origin"
Robert C. Bowman, M.D.