Robert C. Bowman, M.D.
To boldly go where no one has gone before... “I'm not a magician, I'm just an old country doctor." Dr Leonard H. "Bones" McCoy - "The Deadly Years" Star Trek Episode 41. Dec 8 1967
We have already begun a significant decrease in graduation of rural physicians for the nation.
This graphic considers the three types of rural practice locations in the United States by RUCA coding. Urban and Urban focused RUCA 1-3 and .1 codes not included. Isolated rural is RUCA 10, Rural is RUCA 7 - 9, Large Rural is RUCA 4-6.
Isolated Rural RUCA 10 communities across the nation are in great need of
physicians. These areas also have low population growth rates and are not
connected to other areas that are likely to be able to help them with health
care, economics, or other services
Rural RUCA 7,8, and 9 communities need physicians. These tend to be
towns of 4 - 10,000 with about 5 - 8 FP docs a surgeon, occasionally an
internist and maybe one or two other specialties and of course no psychiatrist.
Large Rural RUCA 4 - 6 communities usually have a wide variety of physicians and
sometimes even have psychiatrists, although many are J-1 in our state and the
turnover is constant. Cities of this size can do well with education and
admissions of their students to medical school. This is more difficult for
smaller towns.Admissions
Ratio By Birth Origin
Gender and Ethnicity in FP Graduates 1997 - 2003
Declines in Rural Born Admissions
See link between origins, socioeconomics, and admissions at
Urban-Rural
Location, Per Capita Income, and Choice of Family Medicine
The blue line indicates the rapid increase in the total number of US physicians,
increasing now faster than the US population growth (brown).
The numbers of FP and GP physicians seems to be closely related to the US
nonmetropolitan population (purple circle).
Public outcry regarding an accelerated decline in the number of FP and GP
doctors (green cross) during the 1960's fueled major studies and resulted in the
latest effort. Formalization of such training into Family Medicine has stabilized the numbers
and has slowly begun to increase this total beyond just the nonmetro population,
at least if students continue to choose family medicine in sufficient numbers
and other countries are willing for us to take physicians from their nations. In
recent years some have not been so willing.
Data from COGME and Colwill, Overbeck, AMA, Public Health Reports (see http://www.cogme.gov/resource_update.htm ) with conversion by this author (RCB) to actual physician numbers. Y axis represents hundreds of thousands of doctors or millions in US population. Year 2000 translates to over 700,000 total physicians, US pop of 280 million, FP/GP of 80,000 and steady non-metro pop of 56 million. Note the decline in FP/GP in 1950 - 1970, then the creation of FP, with steady improvement in 1980 - 2000. However, this has been dependent upon a steady supply of physicians who were willing to choose family medicine. In more recent years, this effort has faltered. In 1983 there were far more white and rural background and male students, the ones most likely to choose family medicine and rural practice. Rural Background white males admitted to allopathic medical schools have declined from 2860 in the year 1983 to 1300 in 1999. The percentage of rural background students below is in blue, matched up to the same cohort as senior students, the FP grads choosing rural. The class that entered in 1978 included 26% from towns of less than 10,000 (AAMC data). Of all of the 17000 in this group, 10% indicated interest in rural practice in 1982. The family medicine group graduating in this same group in 1985 had 30% of all FP residency graduates choosing rural practice.
Decreases in the number of rural background students admitted to medical school (Rural Background) have begun to result in decreases in the numbers of senior allopathic medical students interested in rural practice and also the number of rural FP docs.
Matched by cohort group moving through the medical education pipeline from
AAMC and AAFP data
Urban and urban-focused RUCA 1 - 3 communities are urban, and 4.1, 5.1, 6.1 and
7.1 are really urban or will be in the near future. These are some of the
highest population growth areas of the United States. There is significant
investment in these areas in health and services and more to come. Increased
graduation of physicians will usually supply RUCA 1-6 with enough health care
services, but not 7 and above. This requires adequate FP workforce plus
admissions of rural background, rural interest (RBI) students that select FP to
supply them. Excessive primary care numbers might supply RUCA 7,8,9, but not the
RUCA 10. I doubt we will have excessive and given current trends it is more
likely that they will pack into the RUCA 1-6 areas.
For further info on this or breakdowns by gender and ethnicity see
Bowman FP Grad Studies 2004
Gender and Rural Practice - By Med
School Type 97-03
Gender and Ethnicity in FP Grads
Rural Areas of the
nation depend upon Family Medicine. Of all nonmetro visits in the National
Ambulatory care study, FP provided 37% and IM provided 24%. As the town size
shrinks, the contribution of IM goes to zero rapidly and FP is the remaining
provider. The difference in Nebraska is around a town size of 20 - 25000. This
size town is small enough to be considered non-metro, but in reality is not much
different in terms of workforce than must urban locations.
The isolated rural and rural portions involve 13% of the US population and
this is the part not touched by increasing the numbers of physicians in a
haphazard fashion.
Both graphics to left and below from COGME Workforce Site Jack Colwill http://www.cogme.gov/resource_update.htm
Projections of Adequacy of physicians for small towns with FP/GP graduation considered, the lower prediction has been added due to less than predicted numbers of FP/GP graduates.
To link to a US map to see what shortage areas would look like without FP/GP, try this link below. The nonmetro portion is obvious. http://www.annfammed.org/cgi/content/full/2/suppl_1/s3/F1
From American Medical Association, Physician Characteristics and Distribution in the US, 1996-1997. Chicago, IL: American Medical Association, 1997. (Table A-14) and American Medical Association, Physician Characteristics and Distribution in the US, 1987. Chicago, IL: American Medical Association, 1987. (Table A-6)
These two and other tables and info from Ricketts and Shepps Center Facts About... Rural Physicians
The distribution changes as the size of the town decreases. Area Resource File, Office of Research and Planning, Bureau of Health Professions, Health Resources and Services Administration, Public Health Service, US Department of Health and Human Services, February 1996.
Autothumbnail of older work from 1996 noting rural FP graduation rates compared to total residency grads, inner city
For other info on FP Grads, Rural Grads, Rural Background, see Best Works on Site
The US production and importation of physicians is greatly exceeding population growth. This continues to be fueled by patient demand for more care and more expensive care. According to the work of Starfield and the lesson of businesses in the US and the managed care work, the nation is on a collision course with bankruptcy since we have uncontrolled health care expenditure and little modification of such expenditure by more cost efficient approaches, such as family medicine.
Restoring Rural Background to Admissions
Cost, Quality, Access, and Physician Workforce Expansion
Side Effects of Selecting for Family Medicine