Robert C. Bowman, M.D.
Comparing by class year can indicate long term changes due to education and admissions as well as the short term changes due to health policy.
The usual studies of physician workforce focus on choice of discipline and location. These studies are often limited to first practice location choice or a certain type of geographic area.
The studies of physician workforce are usually presented with the most recent influences being the most important. For example, there are many studies that demonstrate the important impact of final residency training location and practice location. However, there are relatively few that assess birth location and practice location. The most recent influences are also the easiest to remember. Looking back to past decades is much more difficult that considering the most recent years of graduates.
Class year changes are more subtle and are usually steady year to year. It is very unusual to have abrupt changes such as those impacting the 1990s graduating classes where there was an abrupt increase and then decrease in choice of family medicine and primary care.
Class year changes considered year to year alone may miss long term trends. This is one of the reasons that the nation has not realized the major changes in allopathic medical student admissions. Asian students have increased from a tiny fraction to 22%.
The percentage of allopathic medical students born in rural areas has decreased from 28% to 10%, but this has been a 52 year process or basically 1 percentage point change each 3 years. The change has been steady and never more than a 1 point change from year to year. Decreases in rural population certainly appear to be part of this change from 28% to the current 24%, but changes in population do not explain the further decline to 10%.
Changes in education, college access, admissions, medical training, and health policy are the likely factors. Students from rural areas once had access to medical school that was not much different than urban students. Now there is little difference in access for rural students compared to black, Hispanic, or Mexican American students. Not only are rural admissions poor, this underserved group is declining while rural populations continue to grow. Rural populations grow at 10% a decade compared to 16% for metro areas.
At least the numbers of Black, Hispanic, and Mexican American medical students are increasing, although their rate of growth is below the rate of growth of their respective populations. The decline in rural born medical student candidates is likely to have more impact that disparities of other underserved groups. The graduation rates of rural physicians from a medical school have a +0.92 correlation with admissions of students born in rural locations. Medical students face strong forces that return them to similar birth origins and population densities. In addition rural areas share poverty problems, have serious challenges with increasing numbers of elderly, and have worse health problems than urban areas. The isolation of rural areas also makes them more invisible and easy to ignore.
Admissions Ratios and US Medical Students,
Admissions Ratio By Birth Origin
Health policy changes can have abrupt, moderate, or long term impacts upon career choice. Health policy changes can involve a number of areas important to career choice and physician distribution.
Moderate Changes
Health policy can open up new regions of the country to physician services. This was the impact of Medicare to improve physician distribution to areas of the nation with large numbers of elderly. It was also the impact of Medicaid as millions who could not afford care at all now could support physician services. For rural areas with large concentrations of elderly and poor patients in need of care, the total impact of 1965 legislation was to open up new markets to physician services. Unfortunately the nation no longer had a general practitioner to accommodate rural needs. This area was addressed with the creation of family medicine in 1970. The first family physician graduates had over 30% choice of rural locations. Again evidence of moving into a new market. The later family physicians have settled into 22% choice of rural locations, the only specialty that distributes to rural areas at the same percentage as the rural population distribution of the nation.
Abrupt Impacts
Health policy can have abrupt impacts upon medical student decisions. This type of change has more to do with changes in information and expectations, similar to changes in stock market prices. Such information can have a basis in reality or fantasy.
The primary example of abrupt changes was the massive change in career decisions during the 1990s. The classes of 1995, 1996, and 1997 had a 50% increased choice of primary care and family medicine compared to classes a few years before or after. Other than the long delayed creation of Medicare and Medicaid, no other area has generated the controversy that managed care did, especially regarding the impact on physician autonomy. This controversy was spread to every medical school, particularly those where students had the greatest choice of subspecialty careers. The controversy was also backed up with reality during the same time period as primary care reimbursements were consistently increased and subspecialty reimbursements were decreased.
There were other health policy items caught up in this controversy. Unreasonable expectations regarding hospital bed space resulted in virtual cessation of new construction in this area and hospital facilities were revised toward outpatient services. Now many areas face a critical shortage of bedspace. Hospitals and medical schools also transitioned to primary care and outpatient services. These new services were difficult to manage effectively and were not consistently supported by health policy, resulting in financial losses. Separating fantasy from reality can be a difficult challenge.
In the book, Collapse by Jared Diamond, there is a discussion of the autocatalytic process. In this process the products of a reaction catalyze or facilitate increase reaction levels. Nuclear fission is such a reaction. Humans have demonstrated autocatalytic reactions with the speed of such reactions limited only by the speed of human communications. The first Vikings to raid England brought back evidence of their success and catalyzed numerous future raids that continued for 300 years until changes in coastal villages and strong emerging government in England and Germany ended the potential for such success. (Diamond) The Barbary Pirate efforts were similar in success and England and France used the pirates to keep trade advantages. Major nations were big enough to avoid major problems but smaller nations such as the emerging and distant United States were constantly harassed until Jefferson sent a fleet in his first week as President. Even so the process required a more major and second effort to end the threat