Robert C. Bowman, M.D.
Newer at Five Periods of Health Policy and Physician Career Choice
Physicians have been effectively distributed by only 2 methods, choice of students likely to choose family medicine/rural locations, and health policy involving state and federal investment in patients in the most need of care. The best method of physician distribution involves both health policy and admissions of the students likely to distribute well as physicians.
Studies of the birth origins of students reveal that some are more likely to choose family medicine, primary care, rural locations, and lower income practice settings. These students are older, more likely to be born in US counties of less than 1 million, rural born, born in the same state as their medical school, instate students compared to out of state, and students having lower parent income origins. These groups are smaller in number compared to the large group of students born or raised in counties of over 1 million people that have the least choice of family medicine, rural practice, and primary care poverty location.
These family medicine likely and unlikely students were impacted differently by health policy favorable to primary care. The nation had a "natural experiment" sudden change in primary care during the managed care era. Students had far different career choices during the 1994 - 1998 graduating classes when compared with the past 25 years.
The family medicine likely students did increase in primary care and family medicine choice, but the dramatic change was students born in the most urban counties, particularly those who were born in the same state as their medical school. These students had 50% or more increase in choice of family medicine. Impacting the largest groups of students in the largest percentage change is a very efficient and effective way to distribute physicians.
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 represent more humble origins.
Primary Care Health Policy Changes and Career Choice Change in Medical Students
|
|
FPGP Choice 1989-1992 |
FPGP Choice 1995-1998 |
Increased Choice |
1995-1998 Numbers |
Office Based Primary Care Poverty |
|
Core Urban |
10.6% |
15.6% |
47.0% |
29300 |
+30 % |
|
Suburban |
14.8% |
20.3% |
36.5% |
14514 |
+21 % |
|
Foreign Born |
8.6% |
11.3% |
31.1% |
10127 |
+30 % |
|
Rural |
20.8% |
26.2% |
25.8% |
6045 |
0 % |
|
Younger |
10.9% |
15.6% |
42.4% |
50056 |
+25 % |
|
Older |
16.9% |
22.6% |
33.9% |
12367 |
+9 % |
|
Instate born |
13.5% |
20.0% |
47.9% |
23734 |
+18 % |
|
Out of State born |
11.4% |
15.2% |
32.9% |
38774 |
+24 % |
|
All |
12.3% |
17.0% |
38.5% |
62423 |
+21 % |
Instate born is different than actual instate as determined by the variety of state and medical school policies, but there is a +0.82 correlation between the two. Instate born likely represents a group with more connections in a state than those students designated instate by admissions policies. Increased primary care health policy may have facilitated more choices of primary care and more into urban poverty locations. The distribution to rural areas was just easier to detect with secondary data.
The impact of the era was to distribute physicians effectively by increased choice of primary care, family medicine, and rural family medicine. This impact was greater on the groups of students who were the most numerous, the most urban, and previously the most unlikely to choose family medicine. Older students, already choosing distributional careers at the highest levels, were more resistant to career change with only 25 % increase in choice of family medicine. This resistance has been noted in previous studies (Xu, Older students) and in family medicine where students have not been impacted as much by student debt burdens (Bland, Rosenthal MP, Xu)
Health Policy Change and Medical School Changes
|
Type of School and Number (n) |
Pre-managed % FPGP 87-93 |
Managed Care % FPGP 94-00 |
Increase FPGP Choice in Per Cent |
Increase in Rural Family Medicine |
|
Allopathic Private Least FP (11) |
2.5% |
3.6% |
42.5% |
28.1% |
|
Allopathic Private Next Least (11) |
4.9% |
7.4% |
51.0% |
24.0% |
|
Allopathic Private Next Most (11) |
9.2% |
12.5% |
35.7% |
12.7% |
|
Allopathic Private Most FP (11) |
14.2% |
19.0% |
33.7% |
17.2% |
|
Allopathic Public Least FP (20) |
8.9% |
12.0% |
34.6% |
28.1% |
|
Allopathic Public Next Least (21) |
13.1% |
17.5% |
33.7% |
22.3% |
|
Allopathic Public Next Most (20) |
17.3% |
21.2% |
22.9% |
20.8% |
|
Allopathic Public Most FP (20) |
22.4% |
28.0% |
24.9% |
11.9% |
Primary Care Health Policy and Rural FP - graphic changes in choice of rural family medicine for all US medical schools for the managed care era.
For documentation that those who changed choice were also the most likely to be retained within 60 miles of their medical school location, see the Managed Care Comparison - compare who increased choice of primary care the most according to FP Likely, MCAT, instate, and age
Urban born students "changed" their usual patterns of career selection during this brief era. Medical schools with mostly urban born students had rapid declines in FP match in 2001 - 2003, again reflecting a return to baseline rural vs urban choice of FP, perhaps with some rebound lower than usual.
The connection between birth origins and physician distribution to poverty locations is high. Rural and lower income students choose poverty locations more often. Federal investments in health care have also increased choice of primary care and physician distribution. See Understanding Poverty and Physician Workforce
Robert C. Bowman, M.D.
10/13/04 - update 6/3/05