Workforce Issues

See Rural Workforce article below links

Ethnicity Gender and Rural Practice Choice
Distribution Theory

Rural Coding

Who Fits the Pattern

Medicine, Education, and Social Status
Admissions Ratios and US Medical Students
Decreasing Rural FP Physicians
Managed Care Comparison Table
Distribution of Physicians
Physicians in the US
Rural Background
Comparing Physician Distribution and the MCAT

MCAT and Family Medicine

Health Careers in the New Millennium

Top Priorities For More Docs

Anticipating Changes for young physician, adapting to rural practice, 

Recruitment early and often and at all levels 

COGME August 2000 workforce report, recent data on rural areas and what is needed to remove shortage designations

Retention

Rural Workforce in the Midwest, Innovations

International Medical Graduates

Rural Physicians Start at the Village Level

Recruitment Fairs - Parties or Courtships?

Dealing with Change in Rural Communities

Ripen, Recruit, and Retain Rural Physicians

Rural Managed Care

Medical Education: Medical Education and Residency Issues AMA source, Workforce http://www.aamc.org/meded/edres/workforc/aamc.htm    It is likely that many traditionally underserved communities will continue to have an inadequate number of physicians, particularly generalist physicians, to meet the needs of the population. Given the existence of physician oversupply, it is clear that this problem will not be solved by increasing the supply of physicians. At present there is no federal program that provides funds explicitly for the purpose of establishing new medical schools or expanding the enrollment of existing schools and no federal program should be established for this purpose. The communities that are traditionally underserved are characterized by location - rural or inner city - or by the race and ethnicity of the population. To increase the likelihood that U.S. medical school graduates will establish practices in these communities, federal funds should be provided to encourage and support medical school efforts to expand the opportunities students have to gain experience in rural and inner city communities so that they will have an appreciation of the needs and challenges of practice in these communities. Historically, minority physicians have been more likely than non-minority physicians to establish practices in communities with minority populations. Given this, medical schools should be supported and encouraged in their efforts to increase the diversity of their student bodies so that they will be able to graduate an increasing number of minority physicians. To complement medical school efforts to increase the number of their graduates who might establish practices in traditionally underserved communities, federal incentives should be provided to encourage students to pursue careers as generalist physicians and to establish practices in these communities.

US Rural Workforce 1997 - 2003 and Beyond

Robert C. Bowman, M.D.

RRH North American Regional Editor 

Previous attempts to examine relationships between medical education, family medicine, and rural workforce have been limited. National studies examine only a few variables such as the type, location, or rural mission of medical schools or residencies [1,2]. More commonly studies involve the outcomes of a few select programs [3]. These are usually programs that are doing well.  Studies of large numbers of individual physicians are rare, but these have been the most valuable in understanding interactions such as rural background and interest in family medicine [4]. Few studies have attempted to compare and contrast birth location, medical school type, residency training, ethnicity, gender, type of practice, and practice location.

A new database of recent family practice residency graduates has been compiled. This database includes secondary data regarding family practice and general practice physicians in the United States that graduated from residency from 1997 - 2003 [5]. The American Medical Association Masterfile information was combined with American Academy of Family Physicians data. The data includes allopathic, osteopathic and international medical school graduates.

The initial results have been shared with state and medical school leaders and those who have assisted in the development of the database, especially those at the Robert Graham Center and at the US Federal Office of Rural Health Policy. Additional information, descriptions, tables, and presentations are listed at the World of Rural Medical Education web site (http://www.unmc.edu/Community/ruralmeded/index.htm) [6].

 The family practice graduate database has been used to examine the effect of various interventions designed to graduate more physicians to underserved areas. The database has been used to compare state approaches. In the graphic below, the new family practice graduates are traced from birth state to medical school to residency to practice state. Consistent gains along this "pipeline" are the result of admissions, adequate class sizes/residency positions, superior recruitment, and state growth rates. North Carolina has a combination of high population growth and heavy investment in recruitment. Wisconsin's pattern is recruitment. Most states have a "hump" pattern similar to West Virginia. Such states basically ‘donate’ graduates, tax dollars, and educational investment to other states.

Some medical schools make obvious attempts to "grow your own" including Louisiana State University in Shreveport where 46 % of graduating students that chose family medicine were born in the state, did residency in the state, and chose Louisiana for a practice location. Other states with greater than 30% "grow your own" include Indiana, LSU New Orleans, Arkansas, Minnesota, Mercer, Southern Illinois, West Virginia University, Alabama, and Nebraska. FP graduates from large states or isolated locations such as Puerto Rico, Texas, Michigan, California, and Ohio have the same pattern but this may result from geography as compared to dedicated efforts involving admissions and a statewide effort.

New Rural Family Physicians in the United States

After many high yield seasons of family practice and rural physicians, there has been a change in the weather. The year 2000 was the peak graduation year for all three types of rural family physicians. The rural total then was a haunting 911.  By 2003 there were 741 total rural graduates [7]. The best year for the most isolated rural practice locations was 1998 with 198 new graduates. Since that time the numbers have slumped to 170 in 2002. Family medicine residencies already depend on international medical school graduates for over 50% of entering residency positions. This number will grow as fewer US medical school students chose family medicine residencies in the "match" in 2004. 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.

There are several reasons for such declines in the numbers of rural physicians, but a growing concern is changes in the composition of current allopathic medical students. The 126 US allopathic medical schools admitted 4000 rural background students in 1980. This decreased steadily to 2000 students a year by 1999 (out of 17 000 matriculants) [8]. The same numbers of rural background students are taking the Medical College Admission Test. They are just not being admitted [9].

Two groups have replaced the rural background students. They include underrepresented minorities (URM) and Asian background students. URM students have chosen family medicine at a slightly lower and decreasing rate over the last 7 years. URM FP/GP residents chose rural practice at rates similar to white graduates. Asian students admitted to medical school grew from 520 in 1983 to 2781 in 1999. During this time there was only a small change in the percentage taking the MCAT from 18 to 22% [10]. Asian students chose family medicine at half the rate of other students. Only 5 % of US citizen Asian background FP/GP residents chose rural practice as compared to 15% of non-citizens [7]. Asian background FP doctors from US and international medical schools have a strong preference for California. About 150 were born there, 273 attended California medical schools, 420 chose FP residencies in the state, and 721 began family practices in California [7]. It is likely that Asian and URM background students have had little previous exposure to rural experiences. Additional regression studies involving a subgroup of the most urban FP residency programs documented an improved rural graduation rate when programs included a rural rotation [2}. These programs tend to have greater concentrations of Asian, Hispanic, and Black trainees.

Osteopathic medical schools have tended to graduate more to primary care, family practice, and rural practice. State support has had influence regarding increased numbers choosing family practice and rural practice. Private osteopathic medical schools vary greatly in these measurements. The last state-supported osteopathic school in West Virginia began in 1972. This school now leads the nation in percentage of FP and GP physicians choosing rural practice.

The last round of federal- and state-supported medical schools generally have had family medicine and rural track records well above average for allopathic schools. East Tennessee State and Mercer hold several top ten rural FP statistics and other 1970's public medical schools have had excellent family medicine graduation rates. The star regarding family medicine and rural top ten stats is the Duluth 2 year school. Between 1978 and 2001 there were no new public allopathic schools. This string was broken by Florida State, who recently added an allopathic school embracing rural, minority, and geriatric emphasis and a community-based approach. Florida State had to overcome opposition from existing state medical schools and the Licensing Committee for Medical Education. The extensive documentation prepared by Florida State remains an excellent resource for medical education embracing the underserved [10].

International medical schools are increasingly a major source of family medicine graduates, involving both US and non-US citizens. Major birth countries for the US FP and GP graduates from 1997 - 2003 that could be identified include India with 367, Vietnam 261, Philippines 205, Korea 147,Taiwan 106, China 91, Pakistan 65, Japan 32, Hong Kong 32, Iran 15, and Canada with 24.

Ross University in Dominica was the number one source of all FP graduates in 2003 with 93 graduates out of a 3500 graduating FP/GP doctors [5]. Second to Ross was American University of the Caribbean with 68, then Des Moines University College of Osteopathic Medicine at 66, followed by Illinois 48, Indiana 45, then the rest at 41 including St. Georges University in Grenada, Kirksville College of Osteopathic Medicine, Philadelphia College of Osteopathic Medicine and the University of Minnesota with 40 (could be number 3 at 67 if including the 27 from the Duluth 2 year school) [5]. Note that some schools have a higher percentage of FP graduates, but smaller class sizes.

Table 1: First Locations of FP and GP Physicians Graduating 1997 - 2003

* Estimate from current residents

Data collection points in September of 2001 and March of 2004

Each of the sources had higher rural graduation rates at the beginning of the data collection except for 2001 for osteopathic private schools. Females have lower rural graduation rates by about 5 - 9 percentage points compared to males in each category. Public medical schools (DO and MD) in the more rural states had much better rural graduation rates. International and osteopathic sources are increasing. Allopathic sources are decreasing, consistent with declines in the white male rural background category which has provided the largest group of rural physicians. International schools in North America tend to have more US citizens and also have a slightly higher rural graduation rate.  

Family medicine distributes physicians to all locations as seen below in Table 2. Other primary care disciplines supply urban and large rural locations, but those choosing isolated rural locations and shortage areas are uniquely family medicine [11] [12]. Interventions that can increase the numbers locating in such areas are important. Rural background admissions have been a key component, but declines in such students force examination of new methods. The key column is the far right that represents those who have chosen the most isolated rural locations. Those graduating over 6.1%, the current US population in such areas, are doing well. Note states vary greatly in the different types of rural practice locations available.  Newer FP graduates did not choose isolated and rural practices at quite the same rate as established FP/GP physicians.

Table 2: Family Practice & General Practice, distribution by intervention

† Estimated by Hart [13] using Rural-Urban Community Area (RUCA) coding [13]

Data from Bowman Recent FP Graduates except as noted [5]

Admissions for rural background, rural interest, and family medicine career choice does result in more FP, rural, and isolated rural physicians. Specific family medicine and rural training can boost the numbers choosing more isolated rural areas, even with urban background students (in accelerated programs). Unfortunately the various track models graduate only dozens of graduates a year instead of the hundreds needed and they face significant obstacles in 2004 regarding accreditation, local support, governmental funding, recruitment, and support from family medicine itself. 

Accelerated FP residency programs involve 3 years of medical school and 3 years of FP residency. Nebraska added rural selections and a rural/procedural fellowship year. Even with urban background graduates and without an additional year, the accelerated model graduates 2 - 3 times the usual rural graduation rate. Graduates also tended toward higher scores and more leadership positions [14]. These accelerated programs have unfortunately been terminated by accrediting bodies in graduate medical education. The last candidates have just been accepted this year. The Nebraska program may be the only one to survive as program developer and director Jim Stageman has converted the program to a track beginning in the senior year of medical school.  

Rural training tracks across the United States have 60 - 90% rural graduation rates and comparable performance on exams with superior preparation in procedures [15]. The final two years of training occur in a rural location. Again the recent news is not good for an excellent training model. At a recent meeting of the Rural Medical Educators Group of the National Rural Health Association, one topic was the concern that up to 30% of Rural Training Tracks could close due to funding, support, and recruitment problems. The impact of RTT programs is also limited by relatively few graduates each year.The lack of enough rural background students may be a key factor in their decline. 

The failure of American medical education to widely adopt successful models that impact rural workforce in a positive way is puzzling. Not only do the programs perform well in location, graduates have stellar academic and leadership credentials.

1. The specialized rural and family medicine admissions of the Duluth 2 year medical school and the Physician Shortage Area Program at Jefferson
2. Long term preceptorship models at the University of Minnesota and other locations
3. Accelerated training programs focusing medical school and residency training on FP
4. Rural Training Tracks or 1-2 programs

Summary 

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. The one ray of hope is that medical schools will take note and replicate the same success that they have had regarding admissions of underrepresented minority candidates. Hopefully the large cadre of FP and GP graduates in recent years will be enough to help rural communities until better admissions and training comes their way.  

The New Shortage Era 

Medical schools and medical associations are beginning to release studies noting the coming shortages of physicians. This data is being used to attempt to increase the class sizes in medical schools and to start new medical schools. In this round of debates so far, there appears to be more discussion regarding specialist physicians. At least part of this is concerns that medical schools may not have enough specialty faculty, a factor more related to gender choices and pay differentials between practice and teaching. International physicians are again a major source of supply for academic medical centers. This is distressing to other nations. Medical school emphasis on specialty care physicians is a major part of the maldistribution problem and it will be difficult to increase emphasis and numbers without reducing those choosing areas of great need, such as primary care, psychiatry, public health, or geriatrics. Such efforts may not be good news for groups and communities that are rural, diverse, indigenous, or poverty-stricken. 

Rural shortages impact on a broad range of efforts such as programs to support rural hospitals, assist in the development of networks, and programs to assist rural communities. Such efforts may not make much sense unless there is a steady supply of rural physicians. Vulnerable populations such as those with mental health issues and geriatrics are dependent upon ready access to physicians. Rural physicians represent more than health care, and leadership, economic development, public health, education, recruitment of jobs, and support of other young professionals are among other areas likely to suffer. 

It is important to discern the reasons behind the new shortage discussions.  

The upcoming shortage in specialists is driven by the American thirst for convenience healthcare. The growth in American physicians is far beyond the growth of the population [7]. Studies by Baicker and Chandra on Medicare patients noted that additional health care expense adds little if any additional quality and may be unhealthy in some areas. The addition of 1 general practice physician per 10000 improved the state's quality ranking by more than 10 places (out of 50 states) and a reduction in spending of $684 per individual. Increasing specialists by 1 per 10000 resulted in a quality drop of 9 places and an additional $526 cost per individual [16].  

The current shortage in rural and family physicians is a major cost to the United States. The decline in rural physicians is a major threat to the rural hospitals, jobs, services, leadership, and the survival and "thrival" of rural communities. Each rural FP is worth over 1 million dollars a year in economic impact. Programs that help rural family physicians locate in small towns return many more dollars in investment compared with other rural interventions, agricultural, developmental, or otherwise [17].  Medical schools that admit rural-background students that have a clear and pressing interest in family medicine are giving small towns a future. 

Without admissions of those likely to choose family medicine and rural practice, and without more specific preparation during medical school and residency, it is unlikely that the nation will get much more than increased numbers of specialty physicians and skyrocketing health care costs.

Robert C. Bowman

RRH North American Regional Editor

References

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

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

3. 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. 

4. 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 

5. Bowman RC  Recent Family Practice Graduates accessed at http://www.unmc.edu/Community/ruralmeded/bowman_fp_grad_2004.htm

6. World of Rural Medical Education accessed at http://www.unmc.edu/Community/ruralmeded/index.htm and links on this main page

7. Data from Bowman studies http://www.unmc.edu/Community/ruralmeded/fpgrad/decreasing_rural_fp.htm

8. Association of American Medical Colleges, Minority Students in Medicine XII, Facts and Figures http://www.aamc.org/publications/factsandfigures.htm  

9. Association of American Medical Colleges, Medical College Admission Test Examinee data 1991-1999 http://www.aamc.org/students/mcat/examineedata/char99.pdf

10. Florida State Resource Document http://med.fsu.edu/pdf/02_train_retain_phys.pdf  

11. Data from COGME and Colwill, http://www.cogme.gov/resource_update.htm 

12. Graham Center Map http://www.annfammed.org/cgi/content/full/2/suppl_1/s3/F1

13. Rural Urban Commuting Areas based on the WWAMI methods, http://www.fammed.washington.edu/wwamirhrc/rucas/descript.html

using Hart's method of dividing into http://www.fammed.washington.edu/wwamirhrc/rucas/00C8994E-005B90E7.-1/use_healthcare.html  

14. Accelerated Family Medicine Residencies http://www.unmc.edu/Community/ruralmeded/accelerated_family_medicine.htm

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

16. 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 

17. By the Numbers, Rural Doctors and Rural Economies  http://www.unmc.edu/Community/ruralmeded/fp_grad_tables.htm