Robert C. Bowman, M.D.
Newer data at Five Periods of Health Policy and Physician Career Choice or Changes in Specialty Choice 1987 - 1999
As the remaining permanent primary care form, family medicine graduates of all class years can be used to track health policy impacts. All of the factors before, during, and after medical training bear upon the medical students making such a permanent choice. Their perceptions can become the reality of improving health access, or further decline. Medical students bypassing family medicine lose 10 - 25 Standard Primary Care years and the most needed health access locations.
Students from allopathic medical schools were impacted differently by health policy favorable to primary care. The nation had a sudden change if health policy and a sudden change in choice of primary care and family medicine in a short time. Students had far different career choices during the 1995 - 1997 graduating classes than the past 20 or more years. Those most likely to change career choice appear to be those who had a vested interest in staying connected to current locations. Those born instate and those born in the same county as their medical school and those locating nearest their FP residency after graduation had the greatest increase in choice of family medicine (65 - 75%), a choice at the time that allowed the most ability to determine future career location. Those born in medical school counties that did not attend a local medical school did not have higher choice of family medicine than the national average.
Unfortunately the impact was not sustained and the nation may actually have the worst primary care health policy, and primary care physician location in rural and poverty areas in the nations post Medicare era.
The common theme behind the changes involve socioeconomics. Those of lower income origins were less likely to change. Urban, higher MCAT, younger are all markers for higher income levels of students. Older, rural born, and those born in lower income counties represent more humble origins.
Policy, Origins, Medical School Type, FM choice
Policy, Origins, and FM Choice
| Allopathic Med School Students by Urban Influence Code (1993) of County of Birth | Not FPGP 1990-1993 | FPGP 1990-1993 | Total | FP Choice 1990-1993 | FP Choice 1995 - 1998 | Increase |
| 1 metro over 1 million pop | 27604 | 3282 | 30886 | 10.6% | 15.6% | 47.0% |
| 2 metro less than 1 million | 12036 | 2099 | 14135 | 14.8% | 20.3% | 36.5% |
| US born urban 3 - 9 details below | 4782 | 1255 | 6037 | 20.8% | 26.1% | 25.8% |
| Birth State data only | 162 | 22 | 184 | 12.0% | 15.1% | 26.6% |
| PR, GU, VI | 977 | 97 | 1074 | 9.0% | 11.2% | 23.9% |
| Foreign | 7941 | 747 | 8688 | 8.6% | 11.3% | 31.2% |
| Military Base | 425 | 73 | 498 | 14.7% | 20.5% | 39.6% |
| Missing | 622 | 47 | 669 | |||
| Totals | 54549 | 7622 | 62171 | 12.3% | 17.0% | 38.5% |
| More detail by Urban Inf code | ||||||
| 3 adjacent metro over 10000 pop | 352 | 77 | 429 | 17.9% | 24.8% | 38.0% |
| 4 adjacent less than 10000 pop | 113 | 28 | 141 | 19.9% | 29.0% | 46.1% |
| 5 adjacent small metro > 10000 | 1074 | 229 | 1303 | 17.6% | 23.6% | 34.4% |
| 6 adjacent small metro < 10000 | 643 | 193 | 836 | 23.1% | 28.7% | 24.1% |
| 7 not adjacent > 10000 | 1529 | 365 | 1894 | 19.3% | 24.7% | 28.4% |
| 8 not adjacent 2500 - 10000 | 844 | 289 | 1133 | 25.5% | 27.7% | 8.6% |
| 9 not adjacent less than 2500 | 227 | 74 | 301 | 24.6% | 37.3% | 51.9% |
Codes 1,2,3,5,7 have greater education levels and more colleges and doctors and health facilities
| Distance from Medical School to Practice location for all allopathic students born in counties of over 1 million | 1992 | 1993 | 1994 | 1995 | 1996 | 1997 | 1998 | 1999 | 2000 | Differences in Managed Care Choices | |
| Choice Not FP | |||||||||||
| 0 - 60 miles | 908 | 902 | 801 | 743 | 719 | 683 | 694 | 701 | 783 | 11680 | -120 |
| 60 - 100 | 137 | 137 | 122 | 106 | 96 | 91 | 91 | 89 | 97 | 1674 | -46 |
| 100 - 250 | 360 | 283 | 312 | 267 | 257 | 260 | 188 | 211 | 208 | 4043 | -40 |
| 250 - 500 | 234 | 216 | 209 | 193 | 194 | 212 | 201 | 210 | 196 | 3099 | -22 |
| 500 - 1000 | 234 | 215 | 206 | 184 | 195 | 207 | 174 | 187 | 188 | 3062 | -27 |
| 1000 and up | 326 | 273 | 306 | 250 | 260 | 229 | 252 | 212 | 188 | 4003 | -71 |
| 2199 | 2026 | 1956 | 1743 | 1721 | 1682 | 1600 | 1610 | 1660 | 27561 | -517 | |
| Choice of FP | |||||||||||
| 0 - 60 miles | 79 | 84 | 107 | 136 | 136 | 119 | 113 | 94 | 100 | 1387 | 57 |
| 60 - 100 | 16 | 14 | 23 | 24 | 25 | 31 | 21 | 11 | 19 | 281 | 15 |
| 100 - 250 | 36 | 40 | 47 | 41 | 59 | 68 | 56 | 45 | 25 | 595 | 32 |
| 250 - 500 | 21 | 28 | 42 | 31 | 35 | 38 | 21 | 29 | 37 | 400 | 17 |
| 500 - 1000 | 19 | 18 | 19 | 20 | 31 | 28 | 24 | 23 | 15 | 295 | 9 |
| 1000 and up | 32 | 38 | 32 | 41 | 43 | 41 | 35 | 36 | 35 | 479 | 9 |
| 203 | 222 | 270 | 293 | 329 | 325 | 270 | 238 | 231 | 3437 | 122 | |
| 2402 | 2248 | 2226 | 2036 | 2050 | 2007 | 1870 | 1848 | 1891 | 30998 | -395 |
Those staying within 60 miles of their medical school "changed places" during managed care with fewer subspecialists staying close and more FPs staying close. This is supportive in of the hypothesis that the most urban born students chose a return to birth origins and the urban lifestyle of living over choice of specialty during the impact of the health care reform/managed care era. Other data in support involves no overall change in continued urban practice choices of allopathic physicians despite managed care. However there were more rural family physician graduates of 1995 - 1998 and less rural physicians of other types in 2004 practice locations.
Complex table comparing urban/foreign, MCAT, age, and in vs out state
FP Unlikely is born in counties of over 1 million or outside of the 50 states
Generally instate, younger, high MCAT, and FP Unlikely had less percent change with managed care
Normal instate have higher choice of FP and the other three have lower choice of FP
The instate, urban born students were the ones who changed choice to FP and PC, a likely response to maintain urban practice location upon graduation
| FPGP Choice 1987-2000 | FPGP Choice 1988-92 | FPGP Choice 1995-99 | diff | Percent increase | FPGP total | |
| FP Unlikely, MCAT 11 younger, out of state | 5.1% | 3.9% | 5.9% | 2.1% | 53.1% | 854 |
| FP Unlikely, MCAT 11 younger, instate | 8.3% | 5.9% | 11.3% | 5.5% | 93.5% | 609 |
| FP Unlikely, MCAT 11 older, out of state | 9.5% | 8.7% | 10.9% | 2.2% | 25.2% | 295 |
| FP Unlikely, MCAT 11 older, instate | 14.7% | 12.2% | 16.1% | 3.8% | 31.5% | 199 |
| FP Unlikely, MCAT 10.25 younger, out of state | 8.4% | 7.1% | 9.8% | 2.7% | 37.3% | 1103 |
| FP Unlikely, MCAT 10.25 younger, instate | 9.2% | 8.2% | 11.4% | 3.2% | 39.8% | 680 |
| FP Unlikely, MCAT 10.25 older, out of state | 14.8% | 13.5% | 17.2% | 3.7% | 27.7% | 515 |
| FP Unlikely, MCAT 10.25 older, instate | 16.4% | 12.2% | 21.8% | 9.7% | 79.3% | 289 |
| FP Unlikely, MCAT 9.9 younger, out of state | 10.7% | 8.8% | 11.8% | 3.0% | 34.4% | 1412 |
| FP Unlikely, MCAT 9.9 younger, instate | 11.8% | 9.8% | 14.9% | 5.1% | 52.1% | 915 |
| FP Unlikely, MCAT 9.9 older, out of state | 15.5% | 13.7% | 16.8% | 3.1% | 22.4% | 646 |
| FP Unlikely, MCAT 9.9 older, instate | 17.2% | 15.7% | 20.6% | 4.9% | 31.4% | 298 |
| FP Unlikely, MCAT 9.6 younger, out of state | 10.9% | 8.7% | 13.3% | 4.5% | 51.9% | 1384 |
| FP Unlikely, MCAT 9.6 younger, instate | 11.6% | 9.0% | 14.9% | 6.0% | 66.7% | 1003 |
| FP Unlikely, MCAT 9.6 older, out of state | 15.3% | 13.6% | 18.4% | 4.8% | 34.9% | 650 |
| FP Unlikely, MCAT 9.6 older, instate | 16.4% | 13.8% | 18.9% | 5.1% | 36.9% | 304 |
| FP Unlikely, MCAT 9.3 younger, out of state | 14.9% | 12.6% | 17.3% | 4.7% | 37.4% | 1426 |
| FP Unlikely, MCAT 9.3 younger, instate | 13.9% | 11.9% | 16.3% | 4.4% | 36.8% | 751 |
| FP Unlikely, MCAT 9.3 older, out of state | 19.1% | 16.7% | 21.2% | 4.5% | 26.7% | 702 |
| FP Unlikely, MCAT 9.3 older, instate | 20.9% | 17.1% | 25.3% | 8.1% | 47.6% | 241 |
| FP Unlikely, MCAT 9 younger, out of state | 17.7% | 13.6% | 20.0% | 6.3% | 46.5% | 1195 |
| FP Unlikely, MCAT 9 younger, instate | 18.6% | 16.2% | 21.0% | 4.7% | 29.1% | 822 |
| FP Unlikely, MCAT 9 older, out of state | 24.0% | 18.7% | 28.4% | 9.7% | 52.0% | 658 |
| FP Unlikely, MCAT 9 older, instate | 24.0% | 24.6% | 25.4% | 0.8% | 3.3% | 250 |
| FP Unlikely, MCAT 8 younger, out of state | 28.5% | 27.9% | 28.8% | 0.9% | 3.3% | 2554 |
| FP Unlikely, MCAT 8 younger, instate | 30.3% | 33.0% | 28.5% | -4.5% | -13.5% | 545 |
| FP Unlikely, MCAT 8 older, out of state | 37.3% | 39.7% | 34.8% | -4.9% | -12.5% | 2070 |
| FP Unlikely, MCAT 8 older, instate | 38.1% | 43.6% | 33.1% | -10.5% | -24.1% | 327 |
| FP Likely, MCAT 11 younger, out of state | 7.5% | 7.3% | 7.6% | 0.3% | 4.2% | 398 |
| FP Likely, MCAT 11 younger, instate | 11.8% | 10.3% | 13.7% | 3.4% | 33.5% | 219 |
| FP Likely, MCAT 11 older, out of state | 12.5% | 10.3% | 14.9% | 4.6% | 44.3% | 151 |
| FP Likely, MCAT 11 older, instate | 19.3% | 14.6% | 24.0% | 9.4% | 64.0% | 62 |
| FP Likely, MCAT 10.25 younger, out of state | 12.5% | 9.8% | 14.7% | 4.9% | 50.1% | 568 |
| FP Likely, MCAT 10.25 younger, instate | 16.0% | 12.8% | 19.2% | 6.5% | 50.6% | 427 |
| FP Likely, MCAT 10.25 older, out of state | 18.6% | 17.8% | 22.5% | 4.7% | 26.3% | 277 |
| FP Likely, MCAT 10.25 older, instate | 21.2% | 18.6% | 26.5% | 7.9% | 42.4% | 114 |
| FP Likely, MCAT 9.9 younger, out of state | 16.2% | 13.6% | 18.2% | 4.6% | 33.8% | 808 |
| FP Likely, MCAT 9.9 younger, instate | 20.8% | 17.2% | 23.9% | 6.7% | 38.6% | 1116 |
| FP Likely, MCAT 9.9 older, out of state | 20.1% | 19.1% | 21.1% | 2.0% | 10.4% | 383 |
| FP Likely, MCAT 9.9 older, instate | 25.3% | 23.6% | 28.7% | 5.1% | 21.7% | 279 |
| FP Likely, MCAT 9.6 younger, out of state | 14.6% | 11.7% | 16.0% | 4.3% | 37.1% | 597 |
| FP Likely, MCAT 9.6 younger, instate | 18.6% | 15.1% | 22.5% | 7.4% | 48.8% | 947 |
| FP Likely, MCAT 9.6 older, out of state | 20.1% | 17.5% | 23.4% | 5.9% | 34.1% | 349 |
| FP Likely, MCAT 9.6 older, instate | 23.0% | 18.1% | 29.0% | 10.9% | 60.0% | 270 |
| FP Likely, MCAT 9.3 younger, out of state | 18.1% | 15.1% | 21.2% | 6.1% | 40.5% | 941 |
| FP Likely, MCAT 9.3 younger, instate | 20.3% | 17.5% | 23.1% | 5.6% | 32.1% | 1552 |
| FP Likely, MCAT 9.3 older, out of state | 26.0% | 21.9% | 30.8% | 8.9% | 40.6% | 576 |
| FP Likely, MCAT 9.3 older, instate | 25.2% | 22.0% | 27.7% | 5.7% | 25.7% | 449 |
| FP Likely, MCAT 9 younger, out of state | 19.9% | 16.2% | 22.9% | 6.8% | 41.8% | 647 |
| FP Likely, MCAT 9 younger, instate | 22.7% | 17.7% | 26.8% | 9.1% | 51.5% | 1619 |
| FP Likely, MCAT 9 older, out of state | 26.5% | 22.5% | 29.4% | 6.9% | 30.7% | 372 |
| FP Likely, MCAT 9 older, instate | 28.0% | 23.3% | 32.4% | 9.2% | 39.5% | 502 |
| FP Likely, MCAT 8 younger, out of state | 34.6% | 34.2% | 34.4% | 0.2% | 0.6% | 722 |
| FP Likely, MCAT 8 younger, instate | 36.9% | 38.1% | 37.5% | -0.6% | -1.5% | 580 |
| FP Likely, MCAT 8 older, out of state | 43.2% | 47.2% | 38.5% | -8.7% | -18.4% | 728 |
| FP Likely, MCAT 8 older, instate | 45.1% | 44.2% | 44.0% | -0.2% | -0.3% | 361 |
| 16.1% | 14.0% | 18.2% | 4.2% | 30.2% | 38711 |
The percentages appear above. The actual numbers of graduates were compared and did not vary greatly when the percentages of the actual numbers were used as compared to % choice of FP.
All Medical School Graduates, Ranked by most changed groups
The following include osteopathic, international graduates, in addition to allopathic. The total impact of managed care was generally greater on allopathic graduates. The medical school type is used instead of MCAT. International graduates are listed in two types, North American and Distant. Largest groups in bold type. Not as much change in the smaller groups in the bottom below the US mean.
Age means much less in allopathic private schools. In allopathic public age is a much better distributional indicator.
Bold print has largest groups of students
| FPGP # for 87t00 | FPGP 1987-2000 | FPGP 1987-1993 | FPGP 1988-1992 | FPGP 1995-1999 | Increase with Managed Care | % Increase With Managed Care | |
| FP Likely, allo priv younger, instate | 470 | 13.8% | 10.3% | 10.0% | 18.4% | 8.5% | 85.0% |
| FP Likely, allo priv older, instate | 143 | 21.2% | 17.3% | 16.2% | 29.1% | 12.9% | 80.0% |
| FP Unlikely, allo priv older, instate | 371 | 12.7% | 10.0% | 9.5% | 16.5% | 7.1% | 74.4% |
| FP Unlikely, allo priv younger, instate | 1098 | 7.6% | 6.2% | 6.1% | 10.0% | 3.9% | 64.0% |
| FP Unlikely, allo pub younger, instate | 3656 | 13.0% | 10.9% | 10.5% | 16.8% | 6.3% | 60.2% |
| FP Likely, allo priv older, out of state | 432 | 14.6% | 11.7% | 11.7% | 18.3% | 6.6% | 56.5% |
| FP Unlikely, allo priv older, out of state | 927 | 11.4% | 9.5% | 9.4% | 14.4% | 5.0% | 52.5% |
| FP Unlikely, allo pub younger, out of state | 4848 | 12.9% | 10.9% | 10.4% | 15.5% | 5.1% | 48.8% |
| FP Likely, allo priv younger, out of state | 1099 | 10.1% | 8.3% | 8.1% | 12.0% | 3.9% | 48.4% |
| FP Unlikely, allo priv younger, out of state | 2408 | 6.9% | 5.8% | 5.7% | 8.3% | 2.6% | 46.7% |
| FP Likely, allo pub younger, instate | 5407 | 20.5% | 17.7% | 16.9% | 24.5% | 7.5% | 44.3% |
| FP Unlikely, allo pub older, instate | 1164 | 19.7% | 17.2% | 16.9% | 24.0% | 7.1% | 41.7% |
| FP Likely, allo pub younger, out of state | 2895 | 17.2% | 15.3% | 14.4% | 20.2% | 5.8% | 39.9% |
| FP Unlikely, Distant younger, out of state | 3479 | 7.2% | 6.3% | 6.3% | 8.8% | 2.5% | 39.8% |
| FP Likely, allo pub older, instate | 1537 | 25.5% | 23.0% | 21.9% | 30.2% | 8.3% | 38.1% |
| FP Unlikely, allo pub older, out of state | 2420 | 18.5% | 16.7% | 16.6% | 21.7% | 5.2% | 31.2% |
| FP Likely, allo pub older, out of state | 1671 | 23.7% | 21.5% | 21.1% | 27.3% | 6.2% | 29.2% |
| FP Likely, Distant older, out of state | 13 | 17.1% | 15.1% | 13.2% | 16.7% | 3.5% | 26.7% |
| FP Likely, NorthAM younger, out of state | 101 | 23.9% | 22.4% | 21.3% | 26.0% | 4.7% | 22.2% |
| For all graduates these years totals | 45943 | 14.8% | 13.0% | 12.6% | 14.8% | 2.2% | 17.6% |
| FP Unlikely, osteo pub younger, out of state | 666 | 30.4% | 29.9% | 29.0% | 33.8% | 4.8% | 16.4% |
| FP Unlikely, NorthAM younger, out of state | 1697 | 15.5% | 15.0% | 14.5% | 15.7% | 1.2% | 8.3% |
| FP Likely, osteo pub younger, out of state | 143 | 33.3% | 34.7% | 30.5% | 31.9% | 1.5% | 4.8% |
| FP Likely, osteo priv younger, out of state | 545 | 38.9% | 40.5% | 39.7% | 41.5% | 1.7% | 4.4% |
| FP Unlikely, osteo priv younger, out of state | 2054 | 29.5% | 30.8% | 30.3% | 31.4% | 1.1% | 3.7% |
| FP Unlikely, Distant older, out of state | 384 | 14.2% | 12.7% | 13.4% | 13.9% | 0.5% | 3.5% |
| FP Likely, osteo priv younger, both | 2438 | 23.7% | 24.1% | 23.9% | 24.8% | 0.9% | 3.7% |
| FP Likely, osteo priv younger, instate | 320 | 38.1% | 39.7% | 37.7% | 38.2% | 0.5% | 1.2% |
| FP Likely, osteo priv older, instate | 160 | 43.1% | 42.5% | 42.7% | 42.3% | -0.3% | -0.8% |
| FP Unlikely, NorthAM older, out of state | 1043 | 26.1% | 25.7% | 26.5% | 26.2% | -0.3% | -1.2% |
| FP Likely, NorthAM older, out of state | 193 | 39.1% | 38.1% | 36.5% | 35.7% | -0.7% | -2.1% |
| FP Likely, osteo pub younger, instate | 263 | 37.4% | 39.4% | 40.8% | 38.6% | -2.2% | -5.4% |
| FP Unlikely, osteo pub older, instate | 138 | 41.7% | 45.8% | 46.7% | 42.6% | -4.0% | -8.7% |
| FP Unlikely, osteo priv younger, instate | 561 | 30.1% | 33.7% | 32.2% | 29.3% | -2.8% | -8.9% |
| FP Unlikely, osteo priv older, out of state | 1639 | 37.7% | 41.8% | 41.1% | 37.0% | -4.1% | -10.0% |
| FP Likely, osteo pub older, out of state | 229 | 47.2% | 51.4% | 52.3% | 47.0% | -5.3% | -10.1% |
| FP Unlikely, osteo pub older, out of state | 573 | 36.9% | 40.9% | 39.7% | 34.5% | -5.1% | -12.9% |
| FP Likely, osteo priv older, both | 802 | 44.7% | 48.9% | 49.2% | 44.0% | -5.2% | -10.6% |
| FP Unlikely, osteo pub younger, instate | 203 | 30.3% | 32.1% | 33.8% | 29.0% | -4.9% | -14.3% |
| FP Likely, Distant younger, out of state | 24 | 11.8% | 11.8% | 10.9% | 9.3% | -1.6% | -14.6% |
| FP Likely, osteo pub older, instate | 197 | 45.7% | 46.6% | 45.9% | 39.0% | -6.9% | -15.1% |
| FP Likely, osteo priv older, out of state | 504 | 43.7% | 48.0% | 48.5% | 39.8% | -8.7% | -17.9% |
| FP Unlikely, osteo priv older, instate | 268 | 35.4% | 39.9% | 40.5% | 32.2% | -8.3% | -20.6% |
Socioeconomics and Physician Distribution
Broad Distributions of Parent Income
Changes in Specialty Choice 1987 - 1999
Parent Income and Ethnicity and FP Choice
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