U.S. rural physician workforce andMedical education

Frederick M. Chen, M.D., M.P.H.Meredith Fordyce, Ph.D.

Gary Hart, Ph.D.

WWAMI Rural Health Research Center

University of Washington

Seattle, Washington

Purpose of Project

• 2005 IOM report on rural health quality– Health IT systems– Appropriate financing– Rural health workforce

• Continuing need for physicians in rural areas

Project Aims

• Describe current rural physician workforce

• Identify which medical schools, residencies produce rural physicians

• Compare osteopathic and allopathic schools

Hypotheses

1. Majority of rural physicians are produced by a small subset of medical schools.

2. Physicians trained in osteopathic medical schools are more likely to locate in rural areas

3. Type and location of residency programs are an influence on production of rural physicians

1992 Study

• 1991 AMA Masterfile

• Graduates from 1976-1985

• MD physicians only

• No RUCA codes, used metro/non-metro areas at county level

• Examined medical schools, characteristics

Current Study

• National, cross-sectional

• 2005 AMA and AOA Masterfiles

• Graduates from 1988-1997– Delay allows for residency training,

established practice

• RUCA codes

• Medical schools and residency programs, rural locations

Methods

• Clinically active, patient care physicians

• Removed residents from analyses

• N=175,649

• Geocoded practice ZIP codes to RUCAs

• Selected most recent residency for family physicians (only for >97%)

Results

• 164,385 (94%) MDs• 11,264 (6%) DOs

• 11% practicing in rural areas– 18% DO– 11% MDs

Percent rural physicians

0

5

10

15

20

25

1988198919901991199219931994199519961997

MDsDOsIMGs

0

20

40

60

80

100

Urban LargeRural

SmallRural

SmallIsolated

MD

DO

IMG

Rural Distribution by Physician Type

Percent rural physicians by specialty

0

5

10

15

20

25

30

1988198919901991199219931994199519961997

Family MedGen SurgGen Int MedGen PedsSpecialists

More female rural physicians

0

5

1015

20

25

3035

40

45

1988198919901991199219931994199519961997

Rural MDsRural DOsRural FPs

0

5

10

15

20

25

30

35

40

0

5

10

15

20

25

30

35

40

Percentage MD Graduates by Medical School:All Rural Areas (2005)

Medical School of Graduation (Most Practicing to Least -- Left to Right)

1 NIV OF MN-DULUTH SCH MED, DULUTH MN 558122 UNIV OF MS SCH OF MED, JACKSON MS 392163 UNIV OF SD SCH OF MED, VERMILLION SD570694 MERCER UNIV SCH OF MED, MACON GA 312075 UNIV OF ND SCH OF MED, GRAND FORKS ND 582016 EAST CAROLINA UNIV SCH OF MED, GREENVILLE NC 278587 UNIV OF KY COLL OF MED, LEXINGTON KY 405368 UNIV OF NE COLL OF MED, OMAHA NE 691059 E TN STATE UNIV J H QUILLEN COLL OF MED, JOHNSON C10 UNIV OF AR COLL OF MED, LITTLE ROCK AR 72205

Top 10 (21%-36%):

SUNY-HLTH SCI CTR AT BROOKLYN, COLL OF MED, BROOKLCORNELL UNIV MED COLL, NEW YORK NY 10021UNIV OF CHICAGO, PRITZKER SCH OF MED, CHICAGO IL 6HARVARD MED SCH, BOSTON MA 02115UNIV OF CA, LOS ANGELES, UCLA SCH OF MED, LOS ANGEA EINSTEIN COLL OF MED OF YESHIVA UNIV, BRONX NY 1YALE UNIV SCH OF MED, NEW HAVEN CT 06510NEW YORK UNIV SCH OF MED, NEW YORK NY 10016STANFORD UNIV SCH OF MED, STANFORD CA 94305UNIV OF NORTH TX HLTH SCI CTR, FORT WORTH TX 76107

Bottom 10 (0%-3%):

Top 10 rural medical schools - 1992

• South Dakota• North Dakota• Mississippi • Arkansas• East Carolina• Southern Illinois• New Mexico• Kentucky• Minnesota• West Virginia

Top rural DO schools (n=16)

• West Virginia - 41%• Oklahoma St - 30%• AT Still - Kirksville - 27%• Kansas City - 21%• Ohio University - 21%• Univ of New England - 20%

0

10

20

30

40

50

60

70

DC MA RI NJ CT DE CA AZ NV MD NY FL IL HI TX WA PA OH VA MI NM NC NH LA GA AK VT MO IN UT OR OK MN CO WI AL SC TN NE KY AR MS KS IA WV ME ID ND MT WY SD

Percentage of Rural Family Physician residency graduates by Residency State

Rural residency training

• 36% of MD graduates from rural residencies are in rural practice

• 50% of DO graduates from rural residencies are in rural practice

• Rural residency graduates 3 times more likely to practice in rural area

• RR=3.4, p<.001

Conclusions

• Rural physician production appeared stable

• Family physicians, osteopaths more likely to practice in rural

• Stable group of medical schools produce most rural physicians

• Rural residency programs more likely to produce rural physicians

Conclusions

• Doesn’t reflect the most recent trends and changes

• How will it be affected by medical school expansion?

Percent physicians in rural areas, by RUCA and specialty Specialty

Large Rural Percent (n)

Small Rural Percent (n)

Isolated Small Rural Percent (n)

Total Rural Percent (n)

Family Medicine

11.3 (3137)

7.6 (2108)

3.7 (1037)

22.6 (6282)

Internal Medicine

7.0 (1925)

2.8 (775)

1.4 (375)

11.2 (3075)

General Pediatrics

6.4 (876)

2.0 (268)

.7 (92)

9.1 (1236)

General Surgery

11.0 (614)

4.3 (242)

1.1 (60)

16.4 (916)

Medical Specialties

6.0 (1365)

1.5 (336)

.6 (141)

8.1 (1842)

Surgical Specialties

7.7 (2268)

1.6 (481)

.4 (112)

9.7 (2861)

Total

7.5 (13124)

2.8 (4878)

1.2 (2034)

11 (20037)

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