Robert C. Bowman, M.D.
Despite a number of efforts over past decades the United States has managed to create another health policy environment toxic to primary care. Billions invested in primary care, nurse practitioners, and physician assistants are wasted when practitioners fail to remain in the specialty area of their training, fail to remain in primary care, and fail to remain in areas outside of major medical centers and in rural and underserved locations. One specialty stands out with 98% retention in specialty, 90% levels of office based care for decades of service, and 50% remaining outside of major medical center locations. This allows family physicians to dominate all other locations with the greatest proportion of physicians, including those in most need of health care access. Primary Care Retention
Another difficulty with physician distribution involves complicated state and federal health policies. Nurse practitioners, physician assistants, and international medical graduates all require significant legislation, licensure, special funding support, and health policy adaptations for optimal distribution. Despite these adaptations, concentrations of all practitioners within major medical centers have become the rule. Current health policy, health care cost factors, reimbursement distributions, and major medical center hiring and support practices are far too strong to overcome. This means it takes more and more work and more and more dollars to distribute physicians, primary care, and practitioners to rural and to underserved locations. Much of this focus is also a temporary outcome, with practitioners transitioning back to Major Medical Center careers and locations over time.
Consistency in distribution is a marker of lack of dependence upon obligations. One type of practitioner maintains primary care, rural location, urban underserved location, rural underserved location, isolated rural location, and isolated underserved distribution consistently over time. Family physicians were categorized by year of medical school graduation and practice location to compare consistency in distribution.
|
MS Class Year |
Total Family Physicians |
Urban Under-served |
Rural Under-served |
All Rural |
Rural Not MMC |
Major Medical Center |
Isolated Rural |
Isolated Under-served |
Military |
|
1987 |
3092 |
4.1% |
6.4% |
21.3% |
18.2% |
51.3% |
3.6% |
1.2% |
1.2% |
|
1988 |
2883 |
5.4% |
6.5% |
20.5% |
17.7% |
49.8% |
3.9% |
1.5% |
1.5% |
|
1989 |
2686 |
5.3% |
6.3% |
20.9% |
17.8% |
50.4% |
3.7% |
1.3% |
1.4% |
|
1990 |
2635 |
5.2% |
6.6% |
22.0% |
18.6% |
51.1% |
3.5% |
1.4% |
1.4% |
|
1991 |
2606 |
4.7% |
6.1% |
22.0% |
18.1% |
51.4% |
4.0% |
1.4% |
2.1% |
|
1992 |
2794 |
5.5% |
6.4% |
20.9% |
18.3% |
50.4% |
3.8% |
1.3% |
2.5% |
|
1993 |
2969 |
5.0% |
7.0% |
22.2% |
19.1% |
49.1% |
3.3% |
1.4% |
2.1% |
|
1994 |
3398 |
5.3% |
6.9% |
21.5% |
18.7% |
48.4% |
3.8% |
1.8% |
2.1% |
|
1995 |
3598 |
4.9% |
6.8% |
21.8% |
18.1% |
50.3% |
3.3% |
1.4% |
3.2% |
|
1996 |
3758 |
4.6% |
6.4% |
21.2% |
18.1% |
52.1% |
3.1% |
1.4% |
2.8% |
|
1997 |
3778 |
5.0% |
6.4% |
21.3% |
17.5% |
50.9% |
3.4% |
1.3% |
3.5% |
|
1998 |
3674 |
4.7% |
5.9% |
20.2% |
16.9% |
50.8% |
3.4% |
1.1% |
4.2% |
|
1999 |
3284 |
4.8% |
6.2% |
19.1% |
16.3% |
53.3% |
3.6% |
1.1% |
3.9% |
| Distri-butions | |||||||||
|
Pop % |
280 mill |
10.7% |
7.1% |
20.0% |
17.2% |
33.7% |
4.2% |
2.0% |
0.7% |
|
FP |
41155 |
4.9% |
6.4% |
21.1% |
17.9% |
50.7% |
3.5% |
1.3% |
2.6% |
|
Not FP |
248054 |
2.6% |
2.0% |
8.0% |
5.4% |
77.5% |
0.6% |
0.2% |
1.7% |
|
All docs |
289209 |
2.9% |
2.7% |
9.8% |
7.2% |
73.7% |
1.0% |
0.4% |
1.8% |
The levels of family medicine distribution are consistent over the years and are the most consistent with the distribution of the population of the United States. A nation that has produced hundreds of thousands of additional physicians, taken hundreds of thousands of physicians from other nations, and produced over 200,000 nurse practitioners and physician assistants to attempt to solve primary care, rural, and underserved access problems should consider the consistent and enduring success of family medicine, despite the current policies.
Five Periods of Health Policy and Physician Career Choice
Major Medical Centers - for categorization of locations
Academic Medicine's Season of Accountability and Social Responsibility