Physician Workforce Studies
Why Medical Students Should Ask Congress to Vote No Regarding Last Minute Expansions of Residents Until Expansion Does Care for the Health Access Needs of the Nation, and For Them
Explaining Primary Care Decline Despite Massive Expansions of Primary Care Graduates (4 panel graphic) The US design for primary care has failed. Unlike other nations, US primary care is not permanent. Even an increase to 28,000 annual primary care graduates (top left panel) is not sufficient when 22,000 of the annual graduates are Flexible Primary Care forms that Leave Primary Care during training, at graduation and each year after graduation. Primary Care Retention is the problem illustrated (top right) in the collapse of flexible primary care with 2 - 3 percentage point average annual declines in primary care retention for 30 years. The departure from primary care has been so rapid in some recent years that the decrease in length of primary care delivery for internal medicine class year to class year was greater than a year of lost primary care delivery - the essence of collapsing primary care. The US demonstrated that it could prioritize primary care as it began health access recovery from 1970 to 1980. During this decade the US quadrupled annual primary care physician graduates and added two new forms of primary care (bottom left). The US did not maintain the permanent primary care design or the necessary support for primary care and all forms except family medicine now graduate less than a majority into primary care careers. The US once received 20 Standard Primary Care years on average for each primary care graduate during the 1970s class years but now each new class year averages just 6 SPC years. The loss of 14 years worth of primary care delivery in a 30 year period of time is also a national collapse of primary care. With the current designs in policy and in primary care, there is no end seen to the declining production of primary care together with the continuing hemorrhage of current primary care capacity.
Physicians and non-physician primary care production has been and will remain flat in the face of increasing US primary care demand from 1980 to 2030. Despite the lack of evidence of increase in primary care graduates in the past 13 years and despite a 50% increase in specialist graduates in the past decade for each of US MD Grads, US DO grads, and international graduates, HRSA Physician Workforce Reports claim increases in primary care currently and in future decades. The current 800 internal medicine graduates, the 1500 primary care pediatricians, and the 2600 primary care family physicians entering the primary care physician workforce are not enough to replace those retiring, dying, or departing primary care each year even without considering the 30,000 internal medicine primary care physicians that have departed for hospitalist careers in the past 6 years. Nurse practitioner and physician assistant annual graduate primary care contributions have been declining even with the doubling of physician assistant graduates from 1998 to 2008.
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Foundations of Basic Health Access
Physician Distribution By Concentration Coding System
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The PDC coding is a versatile tool that illustrates the primary element shaping physician practice locations - concentration of physicians
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The PDC coding is based on Inside Versus Outside.
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Inside of Concentrations is 3400 zip codes in 4% of the land area with 75% of the US physician total and 80 - 92% of specialist physicians
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Outside of Physician Concentrations is 65% of the United States population - those more normal or those not associated with the most exclusive concentrations
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Movement toward more normal and away from most exclusive is the consistent theme for health access recovery. Family medicine choice doubles urban health access and triples rural health access above the contributions of origins and training.
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Health access for most Americans is defeated by increasing concentrations of health funding, physicians, non-physicians, and training inside of concentrations. |
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Family Practice Choice is about Policy, Policy, Policy, Selection, and Training
Unlike simple bivariate studies, this graphic illustrates multiple factors interacting for the most needed health access career choice of family medicine. In logistic regression studies, the most needed health access careers are a function of origins, training, career choice, and policy.
Family medicine choice follows the dictates of policy with selection and training modifying family medicine choice above and below the policy set point. Only the most extreme efforts can overcome policy.
For the given set point illustrated in each medical school class year, family medicine choice is driven down by exclusive origins (top income, foreign born) and exclusive training (MCAT average of school). |
Family medicine choice is increased by more normal origins or more normal training (all not most exclusive).
These studies involve complete populations of US graduates with 95% complete data on birth city, medical school, and career choice from the 2005 Masterfile. Training is also reflected in MCAT as top MCAT schools train in top concentrations of physicians with the least in family practice and primary care.
Selectivity, training, and policy factors can be compared in this graphic. |
The most selective schools admit the fewest of lower or middle income origins and train in locations with the greatest concentrations of physicians. Selection and training excludes family practice choice. Even maximal policy has less impact on those selected and trained for concentration. Selection, training, and policy impacts are much greater in all other medical schools that admit more normal populations and train in more normal circumstances.
The top 26 schools graduate the fewest family physicians (4%) with only about 17% of elite school graduates found in zip codes with 65% of the United States population spread across 96% of the land area.
Admission of the medical student born and raised in concentrations, training in top concentrations, and policy that rewards concentrations of physicians and health care will not address health access needs. |
Physician Workforce Research New Site Basic Health Access A Taxonomy based on Experiential Place demonstrates the principles of health access on complete populations of physicians and non-physicians. Those with origins among the 65% of Americans left outside of the health design are two or more times likely to deliver most needed health access. Older age and health access training also multiply health access. Family practice DO, MD, NP, and PA forms have two or more times greater levels of most needed health access, controlling for origins and training. This site is about workforce reforms that have worked, those that have not, and the common principles that must be addressed for real progress in reducing the Americans left behind by the current design.
Health Workforce Planning - Primary care and Basic Health Access requirements in the United States demand 12,000 to 13,000 graduates a year that remain in primary care at 90% levels for 35 years, that remain 90% active, and that deliver 100% of the volume of primary care of a family physician (gold standard). An easier less disciplined alternative would be 20,000 graduates with 85% of the years (30 years) with 85% remaining in primary care with 85% active and with 85% of the volume of primary care of a current family physician. The 12,000 or 20,000 permanent primary care graduates a year are both able to accomplish sufficient primary care rather than the 28,000 currently or even 45,000 by 2050 that still fail to provide 60% of sufficient primary care delivery.
Once the US commits to sufficient primary care and actually begins this level of permanent primary care production, it will still take 35 years to restore basic access to health, the lifetime of a generation of physicians. A family physician comes closest with 85% remaining in primary care for 35 years, 85% active, and 100% of the volume of a family physician. No other source of primary care even comes close. No other source of primary care remains in primary care with even a majority for a career. No other source of primary care maintains the 20% rural and 15% underserved of family physicians as in the last 38 class years. Currently the US annual produces 28,000 graduates from IM (8000), NP (7000), PA (7000), PD (3000), and FM (3000) that all claim to be training sources of primary care. This is twice the number of annual graduates that would be enough primary care if they only remained primary care. Together the 25,000 IM, NP, PA, and PD graduates produce slightly more primary care (100,000 Standard Primary Care years) than only 3000 family physicians (75,000 SPC years). Increasing family medicine graduates, the remaining permanent primary care form suppressed by policy and policy discussions, is the only solution that can restore health access. Expansions of other graduates with lower percentages remaining in primary care each year is the solution that fails, costs the most, and does the least for the 65% of Americans left behind. If you understand the Standard Primary Care Year, the Physician Distribution by Concentration coding system, other basic concepts in health access, and the impact of policy on health access (currently destroying primary care and health access), you will understand what must be done. You will understand why a Duluth graduate contributes 64 times more primary care than a graduate of the top 20 medical schools ranked by MCAT scores that admit the most exclusive, train most exclusively, graduate few or no graduates, admit the youngest that are consistently most exclusive, and contribute the least to health access in the United States. These Are The Questions That Must Be Answered to Understand Basic Health Access and Health Access Recovery and the answers can be found on this site.
Don't believe the shell games going on. Primary care recovery demands primary care that remains primary care for an entire 35 year career at top activity and volume. Primary care needed by most Americans must be delivered where most Americans reside. Only the broad generalist FP mode escapes concentrations of physicians to serve with 50 - 60% of graduates found in zip codes with 65% of the people and 70% of the elderly. The United States could create a new family practice or another broadest generalist form that may or may not work, or it would still need a permanent family medicine form with the same characteristics as family physicians that has continued to remain committed to primary care despite the worst health access policy in decades. Better yet the US could support the lower and middle income children that are most likely to become family physicians and rural physicians and underserved physicians, so the nation can have better children overall, better teachers, better nurses, better public servants, and better citizens, which arise from better children.
Why an Expansion of 5000 More Family Med Grads Each Year Works for Health Access Recovery and Why Expansions of 15,000 or 20,000 or 25,000 more Internal Medicine, Nurse Practitioner, or Physician Assistant Graduates Fails
Five Periods of Health Policy and Physician Career Choice - the nation has distributed physicians and very effectively by health policy changes. The nation is now returning to an era not seen in 40 years.
Medical Education Futures are about policy, policy, policy, birth to admission, admission, training, and career choice of family medicine.
Recently Published By Dr. Robert C. Bowman
www.basichealthaccess.org www.culturehealthandaccess.org
Experiential Place and Health Access Taxonomy, Themes, Theories Health Access "Proof" Tables
Rural and Remote Health Original Research
Measuring Primary Care: The Standard Primary Care Year http://www.rrh.org.au/articles/showarticlenew.asp?ArticleID=1009
They Really Do Go http://www.rrh.org.au/articles/subviewnew.asp?ArticleID=1035
The Illusion of Minority Status http://www.rrh.org.au/articles/subviewnthamer.asp?ArticleID=1036
Rural Monitor Interview http://www.raconline.org/newsletter/web/fall07.php
Daily Yonder - Doctors Are Where Patients Aren't http://www.dailyyonder.com/author/-robert-bowman-md
Annals of Family Medicine - Integrating Admission, Training, and Policy for Health Access Results http://www.annfammed.org/cgi/eletters/6/5/397#10014
Annals of Family Medicine - Health System Designs in the US and China http://www.annfammed.org/cgi/eletters/6/5/421#10005
Rural Assistance Center Rural Spotlight An Interview with Robert C. Bowman, M.D. One of the country�s leading researchers in rural medical education discusses ways to recruit and retain rural physicians. http://www.raconline.org/newsletter/web/fall07.php#spotlight
These solutions will work in Maryland, Massachusetts, Alaska, Colorado, and all shortage areas.
Others submitted
Rural and Remote Health Letter - The geographic relationships between medical students� birth location and high school location
Rural and Remote Health Editorial - Attempting to understand the primary care and health access crisis in the United States
Book Chapter on Rural Medical Education in "Rural Education in the 21st Century" Primary Author of the Chapter is Rene J. McGovern Ph.D., Obl.S.B. Stephen Laird, D.O. and Tom McWilliams D.O. also as co-authors
Nations, States, Medical Schools and Programs Assisted in Health Access in the past six months with reports, communications, or presentations
AACOM Admission Staff, AACOM Student Leaders, North Dakota, Nebraska, Montana, Canada, Texas, New Mexico, Arizona, West Virginia School of Osteopathic Medicine (Tribute to retiring President Olen E. Jones, PhD), U of North Texas TCOM, Mexico Universidad Autonoma De Guadalajara
National Rural Health Association Annual Quality and Clinical Conference Health Cost, Quality, and Access Have the Same Solutions Robert C. Bowman, MD, A.T. Still University, School of Osteopathic Medicine Arizona http://www.ruralhealthweb.org/index.cfm?objectid=6A183A9B-3048-651A-FE048E671102A334
National Rural Health Association National Rural Task Force Conference Call April 8, 2008 Recruiting the Right Students to the Health Professions - Dr. Robert C. Bowman, A.T. Still University
School of Social Medicine Genogram - A T Still School of Osteopathic Medicine Arizona arises from two different family lines of Montefiore mentors http://www.socialmedicine.org/2008/05/10/
Last Year
Graham Center One-Pager Medical School Expansion: An Immediate Opportunity to Meet Rural Health Care Needs http://www.aafp.org/afp/20070715/graham2.html
Health Care Workforce Tools Developed
The Health Access Medical School Vehicle for Health Access Recovery
United We Stand - Uniting primary care is less important than helping the United States understand Primary Care
Primary Care Workforce Years, Short Review - The nation would need to graduate 2 to 5 times as many graduates of any form of primary care to deliver the equivalent workforce of one family physician over 30 years of physician services. Even the best category of international medical internal medicine graduate delivers is estimated to deliver less than 20% of a shortened medical career in primary care.
Distribution: Index Concentrations of Physician Distribution - For the 1987 - 1999 class years, rural born family physicians and internal medicine IMG physicians are each about 2% of the US workforce. These rural born family physicians are 9% of the rural underserved workforce and IMG internal medicine physicians are 5%. Both are important contributors at greater than average levels. Compare and contrast the various types that distribute to rural underserved and urban underserved locations. How do international medical graduate internal medicine physicians compare to family physicians? What does birth origin and medical school type have to do with practice location?
VISA Programs: Do They Help In Primary Care and Rural Areas? - international medical graduate office internal medicine, the best representative of underserved IMG distribution, is compared to various forms of family medicine. Data and links from GAO and other sources is also listed
Family Medicine Choice: Initial Class Years of New Medical Schools - New osteopathic public schools start out with lower FP choice and build to top levels. Osteopathic private schools start out with high levels of FPGP choice. Comparisons of school type, school, and starting averages to national averages.
Rural Recruitment and Retention Factoids - the latest changes in admissions, career choice, policies, and politics make it more difficult than ever to meet rural workforce needs.
Changing Primary Care Contributions 1970 - 2015 - what has been, is now, and will be regarding primary care contributions for FM, IM, Peds, NP, and PA - Most will be steady or declining, while family medicine contributions increase
What Could Have Been: Maximal Primary Care Training Capacity - why are we less than 80% when we should be near 100%, with a rosy future for lower and middle income patients?
Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location - PA advantages a few years back included isolated rural areas but FPs led in large rural and small rural locations, state variations are seen, reviewing these variations and the deteriorations in PA rural levels should be important considerations to workforce planners.
Who Fits the Pattern? Check out your medical school DNA income distribution on the rating scale. Does student birth income distributions match to rural careers, family medicine, or a subspecialist category. Birth county incomes compared to MCAT and careers.
Community Medical Outreach Model Why wait, develop the physician servant leaders that we most need even before they reach medical school
Failure To Launch - Counties with the lowest probability of admission, some reasons, and discussions of why Florida ranks among these counties.
Divisions in Physician Career and Location Choice Related to Age at Graduation - Changes in the United States mean that physicians layer out by socioeconomics, age, and scores into three different career types: those that emphasis people, direct patient care, and generalist focus; those that those that distribute and those that do not.
Distribution of Physicians: Medical Schools Listed with Distribution, MCAT scores, Instate Retention, and More
Current Active Health Care Policy Decisions - Increasing GME positions generically is a very bad idea. Specific changes and their likely result, based on the decisions of the latest 40% of physicians.
Family Medicine Standards and Constants - There are reasons for optimal distribution and primary care delivery. In fact it is very hard to keep a family physician from becoming a family physician. Research demonstrates a 25% maximum and a 6% minimum FP choice. Those graduating more than 25% or less than 6%, are working hard to do it.
Recent Black Family Physicians - US Born, Foreign Born, Higher income or lower, is there at difference in physician distribution to rural, underserved, academic, or military careers for US MD Grad Black Family Physicians? The early returns are in for 1997 - 2003 FP Grads. The real overall difference may well be choice of FP.
Admissions: To Do No Harm - Access to medical school faces a new barrier. Just registering for the MCAT is a challenge. One more barrier in a whole series that shapes future physicians. Time for changes!
Medical School Type and Distribution: Initial Database Description and Rural Application Graphics - new definitions of medical school type are needed based more on their admissions policies, also new database definitions are provided, with application to rural distribution
Medical School Type and Distribution - some schools distribute, others do not - comparisons by rural, underserved, office based, major medical center, and other factors
Multiplier Impacts Involving Birth Origins, Age, Choice of Family Medicine - why admitting more urban, foreign born, Asian, and highest income medical students will not distribute physicians outside of major medical centers
Family Medicine The Distributional Specialty - data on family medicine, the chief component of physician distribution
Rural Interested Senior Medical Students - are compared to the literature, to survey findings on 1995 seniors, and to actual outcomes regarding medical student choices. The analysis integrates birth origin, Community Health Center, and primary care career choice studies.
Choice of Family Medicine Regression - Schools admitting the most exclusive students and states that fail to present a broad range of students to medical school admissions committees will not be graduating family physicians. Newer medical schools and those in more western locations graduate more family physicians and distribute physicians more equitably.
Distribution of Physicians - Table listing medical schools and their physician distribution levels, also MCAT, early research graduation rates, and graduate retention instate. Those that do well should expand. Those that are not doing well in distribution should consider special programs to admit more distributional types of students, or not expand.
Family Medicine Contributes More - the significant contributions of family medicine are too often ignored, studies comparing physicians over longer time periods reveal the advantages of a specialty that goes and stays and stays in family medicine
Matters of Perspective - why medical education leaders are missing the point about distribution
Birth Origins and Distribution Tables - updated tables on the student characteristics involved in distribution
Ethnicity Gender Admissions and Distribution - tables comparing admissions, choice of family medicine, distribution, rural, underserved, military, teaching, major medical center location
Medical School Admissions By Income - changes in the income origins of US physicians predict lower choice of family medicine and lower physician distribution. This pipeline table compares the highest, middle, and lowest income students from high school to college to medical school to choice of family medicine. Not good stats to view for a holiday.
Multidimensional Choice of Rural Practice Compare by Birth Origins, Age, School Type, Region of the Nation
Distribution of Physicians includes info on rural choices, family medicine, MCAT scores, office poverty, by school, age of the class, and other factors important in distribution
Medical School Type and Distribution - comparison of various medical school types and subtypes by distribution
Geriatrics Distribution in the United States - sources and distribution levels for the 1987 - 1999 medical school grads
Physician Workforce Research Studies
COGME Links at http://www.cogme.gov/pubs.htm Rural, Minorities in Medicine, International Medical Graduates, Physician Education, Improving Access to Health Care, Physician Workforce Reform, Women and Medicine, Physician Workforce Funding Recommendations, COGME Recommendations, Changing the Governance of Graduate Medical Education to Achieve Physician Workforce Objectives Physician Distribution and Health Care Challenges in Rural and Inner-City Areas, GME Payment Reform, Proceedings of the GME Financing Stakeholders Meeting, Collaborative Education to Ensure Patient Safety, Process by which International Medical Graduates are Licensed to Practice in the United States, Preparing Learners for Practice in a Managed Care Environment, The Effects of the Balanced Budget Act of 1997 on Graduate Medical Education
Those who wish to consider the impact of neglected infrastructure or how colleges gatekeep admissions by income levels may do well to review Winner Take All Economics by Robert H. Frank or others. The studies apply to higher education and make sense for medical education and medicine where 1 or 2 medical centers dominate a market or a few insurance companies dominate a state market or as the nation reduces down to 2 pharmacy chains. One size attempting to fit all is problematic for physicians, health policies, and other areas. New NY Times article in the Real World of Wages, Trickle Down
Try www.cultureaccessandhealth.org for a cultural approach to health access and more economists. It is interesting that US businesses have learned to be culturally competent as a matter of survival, but health care?
The studies track the most recent graduates in their current locations. The studies involve equilibrium conditions, not just first practice outcomes. These studies involve the AMA Masterfile with locations using OfficeMax software. The major contribution involves extensive coding of the birth origins of the physicians with 97% of this data available for allopathic graduates from US schools. There are new frames of reference that assist with health policy evaluation such as Comparing Medical Students By Class Year and categorizations of major medical centers, rural, urban, and underserved locations.
For more on the interaction of education, admissions, and distribution see Growing Up America
The growth of the US population (63 % from 1970 - 2020) is outdistancing
- the growth of family physicians (56 % anticipated 1970 - 2020 or lower)
- the growth of black and Hispanic physicians (lower than population growth of each group)
Increased numbers of primary care and family physicians are also important regarding health care quality and cost issues. Baicker and Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries Quality of Care, Health Affairs April 2004 http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf
or Starfield's efforts with Phillips http://www.aafp.org/afp/20040801/editorials.html
or Starfield, Barbara. Primary Care: Concept, Evaluation, and Policy. New York, Oxford University Press, 1992.
Health Affairs has new articles by Starfield, Hsu, Xu and others. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.97
or Phillips, Dodoo, and Green at http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.111/DC1
However the major flaw of most economic works is failure to consider distributions, child development, and early education. The nations that have more primary care, generalists, and family physicians also invest more in children, which make all facets of a nation more efficient including health care, education, economics, and more. Top health and education outcomes have only been reached by nations that invest the most in children.
There are also concerns as to whether the increasing numbers of urban and foreign born medical students can effectively serve a more and more diverse population involving a wider and wider range of income levels, cultures, and geographic areas.
[email protected]
www.basichealthaccess.org
www.ruralmedicaleducation.org
