Birth Origins Articles

Origins Project

Original Research Increasing General and family physicians In and for the Nation through Selections

Robert C. Bowman, M.D.   [email protected]

www.ruralmedicaleducation.org

Birth Origins and FP Choice

Age at Graduation and Physician Specialty

Birth Origin and Ethnicity of Family Medicine Graduates

Birth Origins and Distribution Tables

Birth Origins Limitations - coding notes and assumptions

Bowman FP Grad Studies 2004 - variables and definitions and databases

Physician Workforce Studies - main source of newest studies on site

Student choices of medical school, physician specialty, and practice location are related to birth origin factors such as age, gender, ethnicity, income levels, education, and birth location. These are all factors known to admission committees long before the decision for admission. The older, rural born, instate born, and lower income students students least likely to gain admission in allopathic medical schools are 40 - 80% more likely to choose family medicine when admitted and also are more likely to choose key primary care and psychiatry careers involving distribution. Admissions of the students most likely to distribute have been decreasing for decades at a rate similar to declines in choice in family medicine. This rate is just less than 1 percentage point a year for either instate born or rural born students. Medical school parent income levels rise yearly and represent more dramatic changes. Each year 400 fewer students are admitted in the lowest income quartile, the group most likely to choose family medicine.  They are replaced by 400 of the highest income most urban origin students born in the US or anywhere else in the world.

The rise in choice of family medicine was most dramatic from 1965 - 1978 with the creation of Medicare and Medicaid which pumped billions of dollars into rural areas, poor areas, rural hospitals, and primary care physicians. The only interruption in the decline in choice of family medicine has been significant health policy reforms. The allopathic classes graduating from US schools in 1995, 1996, and 1997 proved that the United States (US) could resolve physician maldistribution. Each of these years the US graduated over 750 into rural family medicine and over 750 additional primary care physicians into office-based poverty locations. Currently physician distributional choices for new graduates are less than half of the peak levels of only a few years ago These studies involve the career decisions of 220,000 US allopathic graduates of 1987 – 2000 using AMA Masterfile data provided with the assistance of the Robert Graham Center..

for basics: 

Physician Workforce Studies 
Distribution Theory
Family Medicine Physician Distribution
Birth Origins and Distribution Tables

Birth Origins and Physician Distribution

Robert C. Bowman, M.D. [email protected]   www.ruralmedicaleducation.org

Birth Origins and Distribution Tables

Choosing school and work close to home. About 40% of graduates attended medical schools within 100 miles of their birth place. For the 10000 medical students born in counties with over 25000 people per square mile, 60% attended a medical school less than 100 miles from their birthplace and 42% returned to a practice location within 100 miles of their birthplace. About 40% of the most urban and 40% of the most rural students returned to practice in a county with the same or similar population density compared to their birthplace. In the middle group of population density about 25% return to same or similar population density counties. Some thoughts on this from an urban point of view might include the increasingly competitive nature of medical school admissions and the need to have strong family structures with two contributing parents. This plus increased cost of medical school may increase the potential for a return to birth origins for medical school, residency, and practice.

Origins and choice of family medicine   The choice of family medicine was 2% for students who had the highest urban and socioeconomic origins and over 50% for students from the most frontier counties. Older students (Age and FP Physicians), students born in the same state as their medical school, and rural born students all have 50% greater choice of family medicine compared to younger, out of state, and urban born students. Cooter demonstrated that 22% of students chose family medicine from the lowest income quartile and 13% from the highest. Cooter R Economic Diversity in Medical Education (password might be needed if not academically linked) For the relationship between student characteristics, medical school types, and distributions, see Birth Origins and Distribution Tables

The same factors that predict choice of family medicine also predict physician distribution in primary care and psychiatry careers. Broader admissions policies that admit more rural origin students, more older students, more lower income students, and more students with connections to a state (by birth or living there for years) also result in greater graduation rates for rural general surgery, rural internal medicine, rural family medicine, office-based primary care, office-based primary care in poverty locations, all psychiatry careers, and all physician careers in rural locations.  Side Effects of Selecting for Family Medicine

Specific rural practice predictors, rural birth and family medicine choice   No single specialty other than family medicine has a significant rural distribution The urban born family physicians choose rural locations 17% of the time and rural born FPs have 40% rural choice. Family medicine graduates overall have a stable 22% distribution to rural locations. Internal medicine is next at 9% of graduates and this rate declines significantly when including all who started out in internal medicine residency training who later specialized.

There is a common socioeconomic theme for choice of family medicine and distributional careers. Family practice physicians tend to have lower income origins. They tend to train in newer schools and schools less associated with prestige, income, and status. Family physicians also tend to return to lower status populations to practice. FP docs are the most common choice as primary physician for the poor, those less educated, rural peoples, Hispanics, and nonwhite citizens or residents (Mold/Graham Center 2002). The physicians who share lower socioeconomic origins are more likely to return to such peoples for practice.

Accelerated family medicine residency graduates had 3 years medical school and 3 years FP residency and choose rural locations or urban poverty locations at levels of over 80% with an even higher 88% in the 10 public school programs. Internal medicine rural choices are 11% in rural areas when considering only the internal medicine physicians who have self-designated the office-based primary practice activity.

Distribution and Admissions   Those interested in physician distribution must understand the impacts of birth origins, socioeconomic levels, and various factors influencing decisions regarding specialty. The distribution of various medical school types is related to the types of students admitted, their locations, and their missions. The distribution of physicians is more likely for any student born in the US in a county of less than 1 million people, lower income students, service-oriented students, and those choosing family medicine. The 22% of allopathic students who are Asian, the 16% who are born in other nations, the 47% born in counties of over 1 million, and the younger medical students (who are the most urban, foreign born, and have the highest MCAT scores) are the least likely to choose family medicine and distribute to primary care and primary care poverty locations. The Asian and foreign-born groups have increased the most in recent years and the urban born increased the most in the medical school expansion involving the classes of 1970 - 1980. Indian-Pakistani students have the highest income and education levels, the lowest choice of family medicine at 2.2%, and the least distribution as physicians. Vietnamese, Mexican American, and rural born students have the lowest income levels and the highest choice of family medicine at 20% and above.  Admissions Ratios and US Medical Students

Low Priority in Admissions for the Students Most Likely to Distribute - Studies demonstrate a significant relationship between applicant pools and admissions of the students most likely to distribute. The last great decline in admissions involved the latter part of the 1980s. During this time there were great increases in older, rural born, and underrepresented minority students admitted to allopathic medical schools. More might have been admitted, but some allopathic schools circulated concerns about the quality of the applicant pool and a few reduced class sizes (Cooper, Medical College of Wisconsin). With increased application numbers, rural, URM, and older students all declined in admissions. The cyclic changes over brief time periods also confirm the lack of willingness on the part of admissions committees to choose such applicants. Changing Patterns of Admission   

The decline in admissions most likely to distribute in allopathic schools is not due to reduced applications. AAMC studies also confirm no decreases in the 16 % applying from rural origins from 1991 - 1999. Little Change in Applicants

The key to selection of family physicians and physicians who will distribute is socioeconomics.  Those of lower SES distribute to rural and poverty locations better also.  Cooter found 13% choice of family medicine for the highest quartile of income compared to 22% for the lowest student income origins.  Rural, older, instate born, instate determined, and lower income students all share strong positive correlations with choice of family medicine and negative correlations with the Medical College Admission Test in studies at the medical school level.  

Socioeconomics Consistent in Prediction of FP Choice  The relationship between family medicine and age, rural/urban measures, and income by county or state or medical student parent income levels are all linear. At the medical school level choice of family medicine is linear with the percent of students who are older, Asian, foreign born, rural born, instate born, or instate. The MCAT level by medical school has a particularly strong and negative correlation with choice of family medicine (-0.68) and strong and significant and negative (at least -0.5) with all of the previous factors associated with lower socioeconomics (rural, instate born, instate determined, older).  The percentage of students who are Urban, higher income, Asian, or Foreign-Born predict lower choice of FP, higher school MCAT, NIH funding, GME funding, increased researchers, increased subspecialists, and poorer distribution of the physicians graduating from the schools to rural locations and primary care poverty locations, even when controlling for rural population levels in the states of the medical schools.

Birth origins can be proxies for socioeconomic status. Medical students of lower socioeconomic status include those students born in rural areas, those who are older, those born instate, or those of lower income levels. Those most likely to distribute well as physicians are more likely to have lower socioeconomic origins and are the students least likely to be admitted (Bowman Birth Origins). Students with rural practice interest were more likely to have rural origins, older age, and family and had the highest rates of interest in serving the underserved at 60% compared to 40% for underrepresented minorities and 10% of usual medical students (AAMC GQ 1995 seniors). Characteristics of Rural Interested Students

Admissions based on lower socioeconomics begins with inner city magnet schools, rural high school admissions to medical school, and admissions involving small colleges and rural students (Butler, Basco, Wheat, others). The method has been successful in statewide applications, in individual medical schools (Duluth, Mercer, others), in medical school types (osteopathic, newer allopathic, Caribbean, traditional black), in nations (Australia rural and aboriginal), and in special programs (Jefferson Physician Shortage Area Program, RMED Rockford). Working with small colleges and college advisors has been a particularly successful method in the US for those states with superior education. For states and areas with less education investment and/or poor distribution of education funding, the efforts must begin much earlier. Involvement at earlier levels builds admissions rates and improves graduation rates from 70 to 90% (Crump).

The trends in admissions are directed away from the physicians most likely to distribute to rural and underserved areas and have been so for decades. The declines in the percentage of allopathic students choosing rural location have been constant over this same period. The changes have been most dramatic in admissions: the decline of rural born students, the decline in those born in the same state as their medical school, and the rapidly rising parent income levels of medical students accepted for admission. The loss of rural students and the loss of instate born students is slow but progressive at just below 1 percentage point a year and extends back over at least 30 years. Rural students still attempted admissions at a constant 16% from 1991 - 1999 according to AAMC data, they are just having difficulties getting in, as noted by Basco, Wheat, and others.  Rural born admissions are declining most in the states with 40% or more citizens in rural areas and especially in those without a mission for rural health.

 Data from AAMC Minorities in Medicine XII

The changes in income distribution represents a 30 - 50% decrease in the the number of lowest income students (from families earning less than $30,000) in the accepted applicants of 1997 compared to 2001. The Asian and white comparisons would be similar if not for the lower income contributions of Vietnamese. This group of more recently (and suddenly) displaced peoples have the broadest income distribution of any group and choice of family medicine that exceeds 20%, just like rural born, older, and Mexican American students.

The challenge in admissions for the purpose of distribution involves a careful balance between attrition levels and physician distribution. Rural, low income, and older students all have much better distribution but lower MCAT scores and higher attrition rates. Studies note that disadvantaged (Crump), small college (Wheat), and lower income students (Cooter) have a lower graduation rate ranging from 90 - 95% compared to more privileged students at 95 - 99%. The rates of graduation are higher with programs reaching out into secondary and college education (Crump) and in states with better high school graduation rates, a marker of breadth of education investment and higher graduation of family medicine also. These same studies plus studies on primary care physicians (who are more likely to share these origins - Cooter, Veloski) note no differences in physician performance long before trainees become physicians. Some studies actually show superior USLME 3 performance for those selected based on rural background and prepared in a special rural track with the assistance of small college health advisors. Rural college attendance also predicts long term rural practice retention (PSAP, Rabinowitz). Verby also noted that rural interested students had below average predictors and improved to average or above by medical school graduation in the Rural Physician Associate Program spanning 9 - 12 months of rural preceptorship training. Sadly many University of Minnesota medical students now believe they would be losing ground if they chose such a track even though the data have demonstrated other outcomes and there have been deteriorations in academic training and little changes in rural preceptorships. Selecting students broadly and planning on increased attrition rates is a better solution to the dilemma of MCAT vs USMLE performance (Cooper, Bowman, AAMC Physician Workforce Conference 5/2005 DC). This would likely improve the quality of physicians and their distribution.

Admissions is losing rapidly in choice of students interested in rural practice. The best family medicine medical school in the nation (Duluth) could only manage 15 students for the Rural Physician Associate Program instead of 30 - 35 out of 60 total students just a few years ago. About 25% of all medical school applicants in the nation apply to Jefferson. Out of this group, only 7 were admitted to the Physician Shortage Area Program that normally admits 14 or 15 students. Only 4 allopathic schools met the criteria for any award for choice of family medicine with at least 20% of graduates and there may be only 1 left in the next year. Osteopathic choice of family medicine is also falling.

The challenge at the state level for physician distribution is broad distribution of education funding as compared to concentration of funding: breadth is better than depth of investment. Breadth of investment results in more family physician graduates, better retention of graduates in the state, better health access, lower health care costs, and improved health care quality. Concentration of resources, gifted tracks, awarding college scholarships regardless of income level, and research emphasis results in more emphasis on science and technology, more younger medical school graduates, and more researchers and subspecialists. There is a +0.8 correlation between state % of college graduates and graduation of researchers from those born in the state. The graduation of family physicians correlates with college graduation at -0.49 (higher college grad rate means lower FP grad rate) and correlates with high school graduation at +0.48 (more for both).  It is difficult to reconcile this dilemma between high school and college graduation rates other than a focus on improving levels of first time college attendees and improving medical school admissions of those from areas of lower income and education levels. It is known that medical students of higher educated and professional parents have the lowest levels of choice of family medicine.

Breadth vs Depth at the State Level   States with the best high school and college graduation rates graduate family physicians (21.5%) and researchers (1.6%) including ID, MT, CO, UT, New England, MN, IA). States with lower high school graduation rates and higher college graduation rates graduate slightly more researchers (1.2%) and fewer family physicians (12.1%) including the Eastern states, IL, CA. States with lower high school and college graduation rates (South, not AR) graduate low levels of family physicians (17.9%) and researchers (0.6%). States with higher college graduation rates and lower college graduation rates (Midwest, WV, AR, not MN or IA) graduate family physicians (22.4%) but not researchers (0.7%). There was no significant correlation between high school graduation rates and graduation of researchers but states with higher college graduation rates graduated more researchers at an extreme +0.8 correlation. There was also a -0.52 correlation between % of the population in nonmetro areas and % with bachelor’s degrees or more.

The higher the state share of public education (as compared to local share based on property taxes) the higher the state high school graduation rate and the higher the production of family physicians. These all correlated with one another at +0.3 to +0.45 correlations. The states with the greatest gaps (lower funding for poor vs rich school districts) have the lowest FP graduation rates (+0.44 correlation). Increasing reliance on local taxes and property taxes is not likely to raise high school graduation rates or production of family physicians. As the federal government and state government "leave" rural and inner city education to predominantly local efforts, the graduation rates will likely worsen. Increased breadth of education is also likely to improved health care costs, decrease utilization, reduce abortion rates, improve infant mortality rates, and decrease costs for social programs and prisons.

The advantage for the state in funding education for physician distribution (such as more funding for rural and inner city areas) involves increased graduation of family physicians and more retention of physicians in the same state. There are side effects of such investments such as lowered state costs in the long term in health care and in prison costs. The current dynamics at the state level are in the opposite direction as states, facing recession and no new taxes and increases in health care and prison costs, are decreasing education investment. This tends to have a more pronounced impact on rural and inner city areas which often have the lowest property values and the least taxable land areas and the least ability to adjust to state and federal cuts in education.

The students admitted in increasing numbers are the most unaware of serious problems in health care. According to AAMC data reported in Minorities in Medicine XI reports (from 1996 Matriculating Student Questionaire),

The numbers on access to care are income-related with lower income level students more likely to recognize the problems and nonURM the least likely of all to recognize the problem. These are the White and Asian students that represent the groups most likely to be admitted and to some degree the URMs of higher income as well. Birth origin studies indicate that the physicians born in the lowest income counties were also the most likely to choose careers involving the care of the underserved, rural and urban.

Increased focus on college graduations, gifted children, and admissions of the highest income level students increasingly born in other nations are likely to produce leaders for the United States who are both

1. Less likely to serve the underserved

2. Less aware of the challenges faced by the underserved, and the nation that they will attempt to advise regarding national solutions for the underserved. 

Those most likely to be aware of the massive health problems in our nation as children, during their education, during college, in medical school, and afterwards are more likely to choose family medicine and distributional careers. Unfortunately most of these will be satisfied with a career dominated by service, and fewer will attempt additional leadership responsibilities.

Rates of increase in demand and supply    From 1970 – 2020 the nation will have a 63% increase in population, a 63% increase in schoolteachers, a 56% (or less) increase in family physicians, and a 270% (or more) increase in total physicians. Black and Hispanic physicians will also have increased at a rate lower than their population growth (3000 By 2000 NEJM) Rural populations have also had increases and rural born students have had declines in admission. The probability of allopathic medical school admission for rural, black, Mexican American, and Hispanic students is less than half that of the national average. The probability of admissions for Asian students least likely to distribute to rural areas is 10 times the national average. Black male applications for medical school have been flat for decades at 1500 a year and black males in college equal those of the same age in prison. Rural males admitted have declined and black and rural females have increased slightly. Young rural male prison rates and death rates have been rising. Only one time has the proportion of medical students admitted to a medical school equaled the rural distribution of the population. This occurred in 4 medical schools in the nation under the influence of Post WWII and the GI bill (University of Alabama, Kirksville, Illinois, Tulane). This was a likely impact of the strong determination and maturity of these young survivors, the GI Bill, and the recognition of the admissions leadership in these medical schools of the stellar qualities of these students. During the accelerated graduation period of WWII the graduates had much higher choice of family medicine and general practice with marked declines after this period. The only significant interruptions in the decline in male entry to higher education in the past 100 years have been the postwar periods of major wars.
 

Declines in Admissions and Declines in Choice of Family Medicine Those most likely to choose family medicine share common lower socioeconomic origins and with the decline of admissions from such populations (rural, older, instate, lower income), the decline of family medicine is not a surprise. In the past 100 years only 3 “interventions” have increased FPGP and primary care physician numbers (AMA Masterfile source of data)

Effective Treatment for Maldistribution is no longer experimental, but proven:

1.      Health policy 1965 - 1978 - The creation of Medicare/Medicaid greatly increased the funding of primary care and the creation of family medicine increased the available market area for physicians to include smaller rural areas. Areas with larger numbers of poor and elderly patients benefited the most from this health policy (rural areas). This era was associated with an increase from 16% to 31% for office-based primary care for allopathic classes of 1965 compared to 1978. FP graduates had over a 30% rural graduation rate before settling to 22% a decade later.

2.      Managed care/health reform/primary care interventions of the 1990s - These interventions resulted in increased choice from 30% to 39% for office-based primary care with over 700 rural family physicians & over 700 additional office-based primary care physicians for poverty locations each year for the classes of 1995, 1996, and 1997. Office based primary care in poverty locations peaked at 5.4% of allopathic US graduates with the reforms and increased choice of primary care and family medicine and the marked changes of choice in urban born students toward primary care (urban born students are 70% of US allopathic students). These levels, if continued, were more than enough to address most shortage area needs in primary care in addition to assisting in mental and public health and in the financial health of hospitals and other facilities. Since 1998 the levels of office-based primary care for each graduating class has plunged to levels of less than 350 that are more consistent with levels of graduating classes of 30 years ago. Declines in funding to rural areas (Medicare, Medicaid, insurance, rural hospitals), declines in FP choice, slow rural recovery from recession, and loss of training intensity and specificity (rural medical education) in medical education is closing the rural market for even family physicians.

3.      Admissions of students with lower socioeconomic origins.

Basically the US with a combination of health policy and admissions had the first effective treatment for the disease of maldistribution. The treatment worked for rural and underserved and poverty areas. Sadly no one realizes it.

Consideration of Birth Origins helps explain two important areas involving physician distribution, in admissions and in choice of specialty

1. During managed care the group most likely to increase choice of family medicine was the most urban group. This group involves at least 50% of medical students and had a 50% increase in choice of family medicine for the 1995-1997 classes. In this group there was a decreased choice of subspecialties, especially those locating practice within 60 miles of birth or medical school, and an increased choice of family physicians locating practices within 60 miles or birth or medical school. This suggests that the most urban students, the ones with the greatest tendency to stay within 60 miles of medical school or birthplace for practice, made the move to family medicine during the managed care era to maintain the ability to stay close to home. A nation that desires to distribute physicians well must impact the most urban students in a way that encouraged choice of primary care and family medicine. Improved reimbursements and "panic-driven" restrictions on specialty choice accomplished this during the managed care era.

Managed Care Comparison Table

2. Students from the most privileged backgrounds have the highest MCAT scores and easily gain admission, but then tend to have lower USMLE 1 scores and grades than predicted in the first two years of medical school. The students who become primary care and family physicians tend to have lower MCAT scores but increasing USMLE 1, 2, and 3 scores. In some groups the USMLE 3 scores of this group are better than non-primary care students. The major differences in the Asian students and primary care students are related to birth origins. Asian students have the highest levels of income and education, and are 98% urban and the youngest students admitted. The primary care group is the oldest group, has 8 to 10 times as many rural born students, has more born instate, and includes a significant number of lower income students. This lower socioeconomic/primary care group does have a higher attrition rate, but removed of this group and given a level playing field (many for the first time in their lives) during medical education, the students have continually improving performance. They may also have an advantage in maturity, marriage, and life experiences as compared to higher income students. All of the lower income group have had to develop significant versatility, study skills, and focus to make it to medical school. The higher income students may have cruised on previous knowledge throughout high school and college and may have to learn study skills and focus during the major challenges of medical school with significant increases in volumes of information and integration of information in multiple dimensions. The psychosocial, ethical, and financial dimensions may be a real challenge for students with privileged origins. The older, rural, instate, and lower income students have had to overcome significant obstacles of education and income and are more likely to have developed a broader range of skills that assist them in medical education and practice.

Birth Origins and Distribution Tables

Limitations of Birth Origin Studies

Age, Birth City and State, rural-urban, instate, are all available for 90 - 98% in each data category for allopathic US Graduates. Use of 1987 - 2000 data with locations as of 2004 minimizes first practice location (due to obligations) and maximizes retention effect. Since the 1994 - 1998 groups had such different choices, this effect is also minimized when using 14 years of graduates. Physician location is the most subject to error in the Masterfile. Rural areas in particular are known to have undercounts. Updating is somewhat irregular in the Masterfile and delayed for osteopathic and international physicians, but there is no evidence that it is inconsistent across a national group or even in a medical school group over a 14 year period. The author (RCB) spent 8 months tracking city and state Masterfile entries and coding for birth origins using multiple internet and other sources. The data area of most concern is New York City because of large numbers listing "New York" as the birthplace but not knowing whether this meant New York City or New York state.

Not every rural student chooses rural practice. The real focus of such studies is large groups and probabilities, not individual outcomes. Broader admissions policies that admit more rural or older students are likely to attract and admit more students who are higher income, but different in terms of attitudes and expectations and career choices. This is very clear in the allopathic private schools who have students with distributional predictors, but no distributional outcomes.

Allopathic private schools appear to have different admission policies and the fewer students who are rural, older, or lower income do not have the same distribution. Since many medical education leaders come from such schools, many may have the belief that “different” students do not distribute. The same focus on research that works for the 22 medical schools that graduate half of physician researchers with a 4% average graduation rate for researchers is not likely to work on the other 100 schools graduating less than 1% (0.66%) into research.

The same factors related to choice of family medicine also predict the proportion of students choosing office-based internal medicine at a medical school as compared to all internal medicine careers (such as hospital, research, teaching, resident, administration). The 20 allopathic private schools least likely to graduate family physicians averaged 64% of internal medicine physicians in office based practice compared to 73% for the other 106 allopathic schools. Exchanging office-based proportions of IM graduates in multiple linear regressions involving choice of family medicine still explains 40% with the same variables of MCAT and longitude contributing. In the FP equations, MCAT, longitude, high school graduation, and population density of the medical school county explain 70% of the choice of family medicine in 111 allopathic schools.

In summary, US allopathic schools are admitting more and more of the students that are least likely to distribute to rural and underserved locations. The nation has been successful in physician distribution with health policy interventions and with admissions of students who have lower socioeconomic levels. The nation is almost completely unaware that it actually successfully addressed physician maldistribution in the classes graduating 1995 - 1997. The levels of distribution for new graduates are now some of the worst in 40 years.
 

In development, if you would like to assist in the research and writing, [email protected] 

I.	Birth origins and FP written   
also Choice of Family Medicine: Past, Present, Future
II.	Age, birth origins and FP – age and FP physicians4   Age and FP Physicians
III.	Birth origins, socioeconomics, and FP   Pendulum or Vortex
Medicine, Education, and Social Status  Socioeconomics and Physician Distribution
IV.	Managed Care and Primary Care Career Change  Managed Care Comparison Table
V.	Birth origins, FP and admissions – birth origins short 1.doc
VI.	Admissions, MCAT, and FP              also Research By the Ages
History of the MCAT
VII.	Admissions dependent medical specialty choices
VIII.	Choice of family medicine – multiple regression
IX.	Birth origins, ethnicity, gender, FP, and distribution – Choice of family ethnicity
Birth Origin and Ethnicity of Family Medicine Graduates
X.	Choosing for fp chooses for distribution – Side Effects of Selecting for Family Medicine  side effects States and medical schools focusing on broader admissions are more likely to retain education and medical education investments within the state and also are likely to improve health access, costs, and quality.  
XI.	Flawed Workforce Beliefs
XII.	Education, socioeconomics, college, and admissions  Understanding Higher Education and Income
XIII.	Medical schools and Physician Distribution 
XIV.	Accelerating Cycles Promoting Maldistribution 
XV.	Counties that Graduate Medical Students and Those that Graduate Family Physicians
XVI.	Accelerated programs, facilitating distributional tendencies of students and career choices
Short and Sweet on Accelerated Family Medicine Training Programs
XVII.	Why the Termination of Accelerated Programs Reflect Serious Problems in Medical Education
XVIII.	The case for family medicine medical schools
XIX.	Why Primary Care Must Have Different Accreditation
XX.	Physician workforce studies - see web  Physician Workforce Studies 
XXI.	Ethnicity, education, and choice of family medicine - use graphic
XXII.	Socioeconomics and Physician Distribution (Advisor 7)    Socioeconomics and Physician Distribution
XXIII.	Ranking Medical Schools in Primary Care Based on Objective Results   Ranking Medical Schools and FP Residency Programs
XXIV.	Distributional family medicine - ranking and reasons
XXV.	Expansion Years and Physician Distribution
XXVI.	Retaining State Investments with Family Medicine
XXVII.	Regional Variation in Choice of Family Medicine: Education and Income
XXVIII.	Choice of Family Medicine is all about Trust - Trust is family medicine
XXIX.	Physician Distribution Is All About Choice of Family Medicine
XXX.	Rural interested senior medical students Characteristics of Rural Interested Students
XXXI.	Family Medicine: Converting the Converted and Recruiting the Unrecruitable    AAFP Student Attendees 1998
XXXII.	Family Medicine: Missing Students and Priorities - response to stfm.doc   
XXXIII.	Who Most Needs Revision, Family Medicine or US Education and Health Care?

Physician Workforce Studies

Physician Distribution in the United States

www.ruralmedicaleducation.org