Rural Workforce and Health Policy in the United States

The only thing necessary for evil to triumph is for good men to do nothing. Edmund Burke

* Data for 2000 graduate locations not complete. For those medical students choosing primary care and rural locations, the data is complete.

Rural Workforce Efforts Must Involve Coordination of Education, Medical Education, and Rural Practice

Shortages of physicians in rural areas are a worldwide problem. There are no simple solutions, especially for regions with geographic isolation, poverty, and low education levels. However there are approaches that offer improvement. Successful efforts begin, and end, with education.

· Countries that actively distribute additional education resources to communities and regions with low education levels and greater educational challenges are in a better position to graduate young professionals who will return to such locations. Nations who fund education by income or property tax guarantee poorer education in regions with low income and low property values.

· Nations that provide additional resources for the development of partnerships between rural communities and professional schools will use resources most wisely. Nations that do not provide resources to medical schools are not in a position to influence their own workforce.

· When professional schools emphasise the admission of students most likely to return to underserved areas, these areas have the best opportunity to develop services, health care, jobs, economics, and education. When professional schools take the brightest students regardless of student characteristics, origins, age, and educational background, they are penalising underserved communities, local and state education efforts, and the hopes and dreams of students that have worked much harder than most to knock on the door of opportunity.

· Nations must hold medical schools socially accountable, especially when they do not act in the best interest of the nation and underserved peoples. Nations that allow market forces to control workforce will face widening gaps between rich and poor. They will also be unable to control health care costs, access, or quality of care.

· Nations must periodically review national health and education needs in regard to workforce. Faced with complex and difficult decisions regarding access to care, limitations in care, and how to deal with budgetary decisions involving education, health care and other budgetary items, governments often choose inaction. The long-term efforts in education, medical education, and health that can resolve such situations are beyond the political careers and even the life spans of most legislators.

A representative owes the people not only his industry but his judgment. And he betrays them if he sacrifices it for their opinion. Edmund Burke

Countries such as Australia that coordinate education, medical education and rural practice are in a better position to meet health care needs in rural districts. The Australian effort includes support for rural physicians and a variety of medical school improvements, including major increases in admissions of rural background and aboriginal students, new rural general practice medical schools, and emphasis on rural training locations. General practice is a major part of health care in Australia. Australia respects and appreciates the contributions of general practitioners in a way most foreign to those in the United States.

The maldistribution of physicians begins with poor distribution of education resources in the United States Medicine, Education, and Social Status. Rural and inner city origins are important to the graduation of more family physicians and rural physicians Medical school and student characteristics. The pipeline to US medical schools begins with urban advantages in education, highly qualified science and math teachers in public and private schools, and specific college preparation courses. It continues with the most expensive and prestigious colleges in urban areas and includes ready access to skilled college health advisers for the remaining students without the advantage of professional parents. Standardized tests such as the SAT and ACT clearly show bias in socioeconomic status. Standardized Tests Income Ethnicity

Rural and lower income students compete with urban students who have been developing higher education test-taking skills for many years. Fewer rural males are entering higher education. Access to advisers and parents who are professionals is lower in rural areas. Rural and inner city schools have the highest costs, the greatest challenges, and the most diverse populations. Rural and inner city areas have the lowest property tax values. The policy of utilising property taxes for the funding of local education leaves them with fewer resources compared to other schools. Cuts in federal and state funding place even basic programs in jeopardy. At any given point in time about seven states are facing legal actions by rural and/or urban school districts regarding inequities in funding.

Rural born students have a much lower probability of admission to medical school. Research demonstrates that there are only two known factors contributing to more admissions of students born in rural areas

· State education as measured by the percentage graduating from high school and continuing to college is the major factor.

· Special admission tracks for rural students are a minor but significant factor in the regression.

· The 47 US medical schools professing special rural admissions decisions are not practising this policy. The schools in states with 40 - 50% rural population suffered the most declines. All but 2 US medical schools decreased admissions of rural born students.

Despite the odds and disadvantages, rural students continue to take the medical school admissions test in the same numbers [Association of American Medical Colleges, Medical College Admission Test (MCAT) Examinee data 1991-1999 (pages 26-27) http://www.aamc.org/students/mcat/examineedata/char99.pdf] Rural students, those born in state, and older students offer hope for a future for rural workforce. In studies of US medical schools, there is a 0.84 correlation between admissions of rural born students and graduation of rural family physicians (Bowman Birth Origin). see also MCAT Correlations

Special Admissions Tracks involving students selected on the basis of rural background and interest in family medicine have provided great hope regarding US medical education for the past 30 years. Continued ignorance regarding the success of such programs has been the dark side. Regressions based on rural born students reveal that state education is the key variable. More are admitted when the state has a higher college continuation rate.

Special tracks often admit students right after graduation from rural high school. Such students attend designated partnership colleges and complete a defined 4 year college curricula and then begin medical school. In the first year or two of new rural track programs, there can an adjustment phase as students adapt to the fast-paced demands of urban living and medical school. It also takes 1 - 3 years for some colleges to attract the students who are interested in rural college campuses and also raise the level of academic effort. In regions with lower education levels, it may take more time for adjustment. Where states provide excellent education to a broader range of communities, less adjustment time may be needed. Diffusing the efforts at a number of schools diffuses the concentration of competitiveness that improves academic levels. Selection based solely on higher scores is also not likely to aid rural workforce.

The major impact of bridging programs upon a state may be restoration of rural and community colleges to viability in finances and education. Students who previously had to choose an urban college in order to have a chance for admission, now can choose a rural location, consistent with their lifestyle. The major advice from college health advisers across the nation is to choose a college where you will be more comfortable and do your best. Without a wider selection of colleges with the ability to graduate students into professional schools, rural students are at a great disadvantage.

Keeping rural students for more than 4 years on small college campuses is also a good idea. An additional year or two of medical school at a rural location can reduce the impact of urban adjustment and improve performance. An extra year can increase the probability of a marrying a spouse who is more likely to return with the graduate to a rural location. Unmarried rural students moving to typical urban medical school locations face 7 years of urban training with limited availability of a spouse suitable for rural location. The probability of meeting a similarly educated and professional spouse is high. Potential spouses on smaller college campuses are more likely to pursue professional careers that transfer more easily to rural locations. Marriages between doctors and those who will become teachers and nurses hold great potential for meeting the needs of rural communities, given both careers in need and the probability of a longer stay.

Rural origin students have twice the rate of selection of family medicine and rural practice. Sadly such students are becoming scarce on US medical school campuses.

· Rural background admissions have declined from 27% of US medical students to less than 16% (AAMC GQ 1980 - 1999).

· Medical schools in the US have admitted 47% fewer medical students who were born in rural areas in the past 25 years (Birth Origin).

· Over the same time period 17% fewer students have been admitted who were born in the same state as the medical school. Such instate students choose family medicine at a 50% higher rate compared to students born outside the state (Birth Origin).

· Medical students 5 years older choose family medicine at 33% higher rate. There has been a very slight increase in the older students admitted to medical school and the age of graduates from 26.9% to 28.3 years, but there have not been enough not enough to result in significant increases in family medicine numbers (Birth Origin). Like rural students, older students are admitted in lower ratios. Special programs involving older students have graduated more to rural locations (Accelerated Programs noted below).

· Students admitted to medical school in the past 10 years have had higher Medical College Admission Test (MCAT) scores. Medical schools with higher MCAT scores graduate fewer family physicians. A school with a one point higher MCAT score graduates 3 - 6 fewer family physicians each year in an average medical school class with 131 students. This contribution remains prominent even across the full range of variables - percentage of students born in rural or urban areas, longitude, education opportunity, instate admission, presence of a family practice department, and controlling for rurality (Bowman FP Choice).

· Rural background admissions returned to 21% = 5% x 16000 x 22% = 168 more family physicians

· Increase admissions of instate medical students by 10 per school = 150 x 10 x 7% = 105 more FP

· Admit 3 more older medical students per medical school = 500 x 30% = 150 more FP

· Decrease average MCAT score at 80 medical schools by .5 points = 80 x 131 x 1.5% = 160 more FP

· An additional 600 FP doctors from this group would mean 200 more rural physicians each year, with half of this group staying more years, effectively adding rural workforce in the future above new graduates

· 80 - 100 additional rural family physicians by improvements in the selection of National Health Service Corps and military family physicians.

The United States has never graduated much more than 800 rural family physicians a year from allopathic family medicine residency programs. With changes in admissions in current students alone, 1000 is an achievable goal. With changes in federal scholarship programs (NHSC and military), 1100 is a reasonable expectation. With replications of special admissions tracks an additional 100 rural family physicians could be expected for each 300 new medical school positions.

Each additional 100 rural family physicians results in 100 million dollars in economic impact in rural America each year. An additional 400 million a year would allow rural communities to increase efforts in other areas, such as education. The physicians graduated by "Grow Your Own" methods live in rural communities and their income and investments stay locally. This impact is magnified by the increased retention of such graduates. Most Physician Shortage Area Program graduates are still in their initial practice locations. These 400 graduates since 1971 have become 21 % of the rural family physicians in the state. The Pennsylvania's other 40,000 medical school graduates over the past 30 years supply the remaining 79% of rural family physicians from Pennsylvania sources.

Short term rural physicians are costly in terms of orientation and the resources expended to recruit replacements ($200,000 Bookbinder). Communities using higher percentages of such replacement physicians suffer from high turnover rates. They also lose local market share to nearby locations with more stable practice environments. Obligated physicians are less efficient with rates of half to one-third the patient volumes seen as compared to private practice physicians. A 3 year stay for such physicians results in far less than 3 million dollar in economic impact. In addition many obligated physicians are less involved in rural communities, preferring to live in a larger location while commuting part time to underserved locations. This limits effectiveness and acceptance. The quality of a newly graduated rural physician is low compared to one who stays the average 6 years, or even more time when students have more compatible characteristics. Finally federal policies have never worked out the co-existence of federal clinics and private clinics in a way that addresses the needs of more permanent physicians, the community, and local hospitals, especially in more sparsely populated rural areas.

Improvements in education, further admissions decision changes, and special admissions tracks would greatly increase the numbers choosing rural practice. The improvements in education also would boost levels of other professionals from rural origins, particularly teaching professionals.

The trends away from family medicine are consistent over the years. The contributions of rural, older, instate, and MCAT score are known. The following is an estimation of the decline in family physicians from US medical school sources each year. It is important to not that expansions of medical schools and class sizes did not impact these variables. In fact, the probability of rural born admissions decreased during medical school expansion.

· Rural background admissions worsen by .8% a year or 32 fewer FP docs per year

· Increased average MCAT score by 0.1 points per year in all schools = .1 x 3 ppt/1pt x 16000 = 48 fewer family physicians per year

Continuing such a course leaves rural areas in shortage, expecting continued declines in health care access, services, jobs, economics, and population. This course will require additional state and federal funds to address shortage area needs. It will also involve increasing numbers of physicians from international sources. This is penalises local education, outsources jobs to other nations, and depletes other nations of valuable resources. The physicians forced to underserved rural locations will not be the ones likely to stay, so the process will be repeated each 3 years or sooner.

The task of admission is more than just rural origin however. Clearly some rural origin students are not likely to choose rural practice or family medicine. Again limited education opportunity offers an explanation. Rural and underserved origin students with greater intellect can still manage the grades and scores needed to gain admission, even with great disadvantages in educational background. The intellectual emphasis that serves them so well may also lead them to choose careers in urban, subspecialty, and research areas. In some states, medical schools admit all of the rural background students that they feel can pass USMLE 1 testing and become physicians. It takes better state education to provide a larger pool of students. Then admissions committees can find the students who can survive academics, who prefer rural and family medicine, and who can communicate and related effectively.

Admissions emphasis on speeded intellect testing only makes selections of students more ineffective regarding real workforce needs.

Higher MCAT test scores from applicants of a state are correlated with higher median income in the state (0.7 correlation) and a more urban population (0.3 correlation).

· Higher amounts of National Institutes of Health Research dollars (0.68 correlation),

The task for admissions is to select students with broader characteristics. Admissions of rural, older, and slightly lower scoring students is evidence of broader admissions, emphasis on character instead of scores, and admissions of students who will be the best physicians, and usually, but not always the brightest. Medicine, Education, and Social Status

Those components that follow depend upon admissions of enough students who will choose family medicine and rural practice. This is supported by published research without contradiction and by established rural medical education models with over 30 years of experience.

Family medicine is the major source of rural physicians in the US, particularly for medium and isolated rural locations and shortage areas. Without family physicians many rural health systems and hospitals would close, access to public health and prenatal services would vanish, and rural communities would lose up to 10 - 25 % of services, jobs, and economic activity. Somehow federal support for family medicine has been cut, even though states with more general and family practice physicians have the highest quality of health care, the lowest costs, and the best access to health services [Baicker and Chandra, Phillips and Starfield] When there are greater numbers of family physicians, there is better distribution of physicians to underserved areas in the nation, particularly the smaller rural locations.

Important and successful rural medical education models have been published in the finest medical journals. The decentralized efforts in the Pacific Northwest (WWAMI), those in Minnesota (Duluth and the Rural Physician Associate Program), and the Physician Shortage Area Program directed by Rabinowitz are well known. States with such successful medical education efforts serving rural communities include Minnesota, Arkansas, Nebraska, and Pennsylvania. However it would be a mistake to assume that such efforts have been replicated in more than a handful of 150 US medical schools. Widespread replication of any of the above programs would have resulted in 100 - 200 additional rural physicians each year.

Many medical education leaders have given up on serving the underserved because they do not understand the primary importance of admissions. Although appropriate admissions is enough in itself, admissions plus specific training can enhance numbers and increase the probability of a practice in a smaller, more needy area. The higher rates of retention of such graduates would have further reduced the demand for rural physicians.

Federal support for family medicine graduate training remains in the hands of urban hospitals, whose interests do not often include rural practice. Family medicine training programs with clear advantages in rural location, training, and outcomes are being closed, partly through neglect and partly at the hands of national workforce leaders. These include the rural training tracks that graduate over 70% to rural areas and accelerated family medicine programs graduating 50% into practices. The accelerated programs managed to accomplish a feat no medical education program has ever yet accomplished. The success of previous rural location programs has often been attributed to selection of candidates biased toward rural practice or involving training programs in rural locations. Accelerated graduates were not selected on the basis of rural background or rural practice interest. They spent 6 years training in urban locations. Females graduating from accelerated programs had the same rural distributions as males

The termination of accelerated programs resulted from the direct actions of US workforce leaders and accrediting bodies and lack of a coordinated effort on the part of family medicine.

Rural physicians are not getting the support that they need in the US. The costs of overhead, particularly liability insurance costs, have grown far beyond reimbursement and support. Such costs have driven rural physicians out of practice. The costs have impacted others serving in rural areas. Some small rural hospitals, physician groups, and clinics have had to dip into scarce resources to support rural physicians, just to maintain access to primary care and prenatal/obstetrical services.

The costs of medical education are increasing at double-digit rates. Those facing the prospect of lower incomes as family or primary care physicians must pay attention to such considerations. Fewer scholarships are available for students. There is a mismatch in scholarship programs that impacts rural workforce. Those selected for the National Health Service Corps have characteristics most compatible with urban underserved locations (over 90% urban origin and 80% Hispanic or Black). This virtually guarantees a shorter stay in rural areas in those obligated.

Medical students with characteristics that would predict rural practice location and retention (White, osteopathic, interest in family medicine, married, rural origin, lower income, service-orientation) tend to opt for military scholarships and support programs. Nearly 200 potential rural family physicians enter military family medicine each year.

· Military scholarships are the number one source of tuition support for osteopathic medical students.

· The private osteopathic medical schools that have some of the highest tuition costs in the nation are the largest sources of military physicians.

· Students in the few state-supported osteopathic public medical schools have the highest family medicine and rural location rates in the nation.

· More attention to student choices and student characteristics could lead to an additional 50 - 100 more rural family physicians and would not impact military needs.

The military can use family physicians from a variety of origins. Taking those most likely to go and stay in rural areas is not good for the country. This would also reduce US dependence upon physicians from other countries.

The remaining medical students are less rural, they are less connected to state and local areas, and they are far more intellectual in orientation. Such students are suitable for the urban, subspecialty, emergency room, and research careers that continue to gain in popularity; but not rural, primary care, or service careers. In addition medical students are increasingly aware of the less than supportive treatment of family medicine by government, insurance companies, subspecialist physicians, emergency physicians, accrediting bodies, medical leadership, and medical schools.

Academic family medicine is squeezed between the decreases in state and federal funding, the rapid increases in overhead, and the need to invest more faculty time in clinical work and medical school environments. There seems to be little time and energy left for important efforts such as improving admissions or specific training programs involving rural medical education.

The end result of the above influences has been a 30 year decline in interest in family medicine on the part of US medical students. Over half of family medicine residency positions are now occupied by medical students who were trained in other countries. This should be a major concern for other nations hoping to retain their physicians and education investments.

The current US medical students will not necessarily make bad physicians, but they will not be choosing rural family medicine. Nor are they likely to serve in a number of disciplines and locations in most need in the US. A strong and diverse physician workforce requires a diverse range of students. Older students provide maturity. Students who have overcome obstacles of income and education are more likely to appreciate their accomplishments and serve the nation accordingly. Those of different cultures or backgrounds are more likely to serve underserved areas. Even without the need for family medicine and rural practice, the US has workforce needs that cannot be met by a steady stream of urban students from similar schools, backgrounds, colleges, and families.

More complete osteopathic data would reflect higher numbers for osteopathic graduates

Part III Connections: Education, Medical Education, Family Medicine, and Rural Practice

The connection between education and the production of more professionals who will return to underserved areas is important to understand. Without constant attention to all levels of education and professional education, it is unlikely that a region, state, province, or nation will be able to address workforce shortages and maldistribution of professionals.

Studies note that medical schools in states with better education opportunity graduate more family physicians. The percentage of students graduating from high school and continuing in college was the most important education variable in this regression study (Bowman FP Choice). Studies focusing more closely on the determinants of admission of students from rural areas (the ones most likely to return) noted that this graduation percentage explained 44% of the variance in the admissions of rural born students in the past 10 years. States with higher 8^th grade achievement test scores, states that spend more on education and higher education, and states with higher median income also graduate more family physicians, although graduation/continuation rates are the best predictors. The only other factor contributing to rural born admissions was special admissions tracks involving rural students.

Rural students resemble inner city minority students in their lack of preparation and "polish." Both face education obstacles and income barriers. Both rural and inner city students also tend to choose family medicine. The similarities are not universal. Over half of inner city students access special preprofessional "fellowships" at little or no cost. Minority students also tend to support those at earlier points in the pipeline to medical school. Rural students would do well to emulate these efforts. In a highly competitive medical school admissions environment, it does not take much to fall short.

When maldistribution of physicians and other professionals is combined with low income and maldistribution of education resources and teaching professionals, the result is disastrous. Communities sink slowly into poverty and paralysis. Fewer aspire to careers involving higher education, resulting in even fewer returning to serve as teachers and other types of professionals. This results in fewer services and jobs and lower population levels and even greater challenges for rural education and economics. This is a vicious and accelerating cycle of events that must be constantly addressed at local, state, and national levels.

The US does not anticipate major interventions in education or family physicians. US physicians other than family physicians are expected to grow at more significant rates.

Schoolteachers have the same if not worse maldistribution with fewer minority schoolteachers and great challenges serving rural and inner city areas. Growing metro areas area constantly recruiting teachers away from other states.

The total physician number is the most subject to increase beyond current estimates, given increasing efforts to import physicians and new proposals to expand medical school positions. The new international physicians are less and less likely to be family physicians. Academic medical centers are one of the reasons that international specialists are in great demand. Medical schools have found it more and more difficult to recruit the faculty needed for teaching, research, and service, even those they have trained. US medical graduates can make more in private practice situations. Other academic faculty are setting up their own surgical centers. When medical schools are in or near shortages areas in the US, they can even get the US government to sponsor their recruitment of international faculty.

Maldistribution of resources has always been a difficult problem for individual nations to address in the past. Fortunately physicians were not always as portable. Now physicians are more willing to migrate all over the world. The lure of more resources, more colleagues, more income, and fewer demands upon time is strong. It is indeed a challenge to practice medicine in areas with poor education, limited public health, and fewer members on the health team. When larger and more resource-intensive nations do not address workforce needs in rural health, primary care, and public health; attention turns to international sources. Nations with fewer resources stand to lose the most. This makes little sense in the world today. Health and education emphasis can prevent the spread of hopelessness and poverty, "immunizing" nations from the disease known currently by the name terrorism.

The US did attempt to address workforce needs in the past. Steep declines in general practice physicians in the US during the 1950s and 1960s resulted in a series of national reports and eventually the creation of formal Family Medicine training. Family physicians in the US have 4 years of college, 4 years of medical school, and 3 years of graduate medical education residency training. Family medicine numbers rose rapidly for 6 years. Initially rural location rates were high, an indicator of great need and graduation of a physician well-suited to rural areas. Family medicine enjoyed the support of most states, specific federal funding for medical education and graduate training, and was tolerated by medical schools. Eventually a few medical schools were created that emphasised family medicine, although they were limited in focus and in class size. The initially and dramatic rise of family medicine has been followed by 30 years of decline. Attempts to improve the environment of medical education and reimbursement has not improved the lot of family physicians. There was an interesting interruption in this decline that should have taught the US some important lessons.

The ultimate environmental stimulus in favour of family medicine impacted the graduating medical school classes from 1994 to 1998. This was the managed care era brought on by a coalition of government and business interests. For a brief moment US leaders realized that the nation could not afford the massive increases in health care costs brought about by undisciplined "market forces." Medical students graduating in these “managed care” years faced a much different scenario. Under the managed care umbrella, there were limited jobs for highly paid specialists and guaranteed jobs for family and primary care physicians. There was indeed a temporary increase in interest in family medicine resulting in 600 more US senior medical students (20 – 30% more) choosing family medicine each year. The impact upon the distribution of physicians was important. The US had the best access to health care in underserved and rural areas in decades. However this era soon passed, with US medical students choosing FP and primary care specialties in even lower numbers.

The gap between rural and urban is widening in the US. From 1982 - 1992, 20 new medical schools opened their doors. Many were created to help improve the numbers of family physicians. An increase in medical student positions should have increased the potential for admission to medical school. It was a great opportunity to admit more from rural and inner city areas. This opportunity was lost. Students from rural areas declined in actual numbers. Perhaps more important was a decline in the probability of admission to medical school during this time of expansion. In the past decade there has been an improvement in rural probability of admission, but now more rapid expansions are planned again.

For many years the Council on Graduate Medical Education, foundations, and medical education leaders emphasized primary care, family medicine, and other disciplines in shortage in the nation. Even the Association of American Medical Colleges tolerated such rhetoric and added their own support for more diverse admissions.

Now US medical education leaders are asking for the nation to make “market forces” the predominant national health policy regarding physician workforce. Market forces may work well when resources and people are evenly distributed, but this is not the case in the US or other nations. There are large discrepancies between pay for physicians that serve people and those that subspecialize and do procedures and hospital work. There are tremendous variations in the distribution of resources. Locations with more resources can invest more in recruitment.

Towns and regions with the least resources tend to lose out without constant vigilance on the part of government and national health leaders. Since US physicians are trained exclusively in medical schools and hospitals that are resource-intensive, physician graduates often prefer locations with more resources and personnel. They also tend to prefer locations similar to the ones where they received their final training. Over 97% of US residency training is in urban locations, often the most urban locations in the world.

The combination of declining primary care numbers, fewer family practice graduates, the closure of rural training programs, and declines in the admissions of rural background students is likely to result in a significant and steady decline in the supply of rural physicians in the United States for the next 7 years, if not longer. Peak rural graduation numbers were in 2000, with slow declines since that time. Peak rural graduates coincides with all time high graduations of FP and primary care graduates. This "Perfect Storm" was driven by managed care efforts. It was brief and is unlikely to be replicated by the US.

As bad as it is for US family medicine and primary care, it is getting worse for small towns. Since 2002 there have been fewer family medicine graduates choosing rural locations.

Without admissions of rural background students and specific rural training, US medical education will not be able to meet current and future shortages. Closures of rural-oriented medical school and graduate training programs will not help restore rural physicians. The rural numbers would also be far worse without expensive recruitment packages such as loan repayment and scholarship programs for US citizens and special programs to recruit international graduates.

More complete osteopathic data would reflect higher numbers for osteopathic graduates.

Reversing the many factors involved in rural shortages will take major changes in education, admissions, education, and health policy over many years. Most of all it will take leadership willing to study, review past successes, and change. The US seems to be ignoring the past lessons of expansion and managed care. Expansion without accountability led to worsening distribution of resources. Accountability in the form of the managed care "natural experiment," with somewhat restricted choice of physician career, led to the best distribution of resources. Admissions of students with higher probability of family medicine would provide the best opportunity for best access, cost, and quality. This will take a coordinated effort between education and medical education.

It is entirely possible that increasing health care costs at the state level are beginning to erode revenues that were once available to education. At a time when there are less resources available to education, the areas with the highest costs of education tend to suffer and rural and inner city locations do have the highest costs and the least resources. Family medicine represents a solution. Family medicine has been a good investment for the US. Studies indicate that increased numbers of family practice and generalist physicians are associated with better quality care and less cost [Baicker and Chandra]. In addition to saving health care dollars, family physicians represent better access to care.

Without an admission process that is different, and that admits students who are different, and without evidence of a more responsible and accountable medical education system, other nations can expect the United States to be looking for family physicians and rural physicians from international sources.

Rosenblatt, RA, Whitcomb, ME, Cullen, TJ, Lishner, DM, & Hart, LG. (1992). Which medical schools produce rural physicians? JAMA, 268(12), 1559-1565.

Bowman, RC, & Penrod, JD. (1998). Family practice residency programs and the graduation of rural family physicians. Family Medicine, 30(4), 288-292.

Coombs, John; Geyman, John; Hart, Gary; Lishner, Denise; and Thomas Norris. Physician Education and Rural Location: A Critical Review. Working Paper of WWAMI Rural Health Research Center, University of Washington School of Medicine, 1999.

Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP, Critical factors for designing programs to increase the supply and retention of rural primary care physicians, JAMA 2001; 286: 1041-1048

Rosenthal T Outcomes of Rural Training Tracks: A Review--Tom Rosenthal, M.D. The Journal of Rural Health Volume 16, No.3, Summer 2000

Locations of Recent Med School Graduates of ---	1994	1995	1996	1997	1998	1999	2000 *
Urban	15605	15775	15364	15398	15549	15997	16381
Large Rural	1180	1236	1151	1124	879	726	440
Medium Rural	354	362	364	325	317	235	148
Isolated Rural	272	256	275	256	225	191	128

Medical school source	1998-2000	2001-2003	2004-2006*
International	1397	2168	3240
Osteopathic Public	308	340	510
Osteopathic Private	979	1062	1230
Allopathic Private	2026	1656	1200
Allopathic Public	6107	5625	4140

Type of School	Rural FP Graduates since 1997	1997 Graduates Choosing Rural Practice %	2002 Graduates Choosing Rural Practice %
International		16	16
Osteopathic Public	197	33.3	28.7
Osteopathic Private	495	19.9	24.1
Allopathic Private	626	20.4	14.2
Allopathic Public	3145	26.7	23.9