U.S. rural physician workforce and
Medical 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
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
Seattle, Washington
Project Aims
Hypotheses
• Describe current rural physician workforce
• Identify which medical schools,
residencies produce rural physicians
• Compare osteopathic and allopathic
schools
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
Current Study
•
•
•
•
• National, cross-sectional
• 2005 AMA and AOA Masterfiles
• Graduates from 1988-1997
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
– Delay allows for residency training,
established practice
• RUCA codes
• Medical schools and residency
programs, rural locations
1
Methods
Results
• Clinically active, patient care physicians
• Removed residents from analyses
• N=175,649
• 164,385 (94%) MDs
• 11,264 (6%) DOs
• 11% practicing in rural areas
• Geocoded practice ZIP codes to RUCAs
• Selected most recent residency for family
physicians (only for >97%)
– 18% DO
– 11% MDs
Rural Distribution by Physician Type
Percent rural physicians
25
100
20
15
10
80
MDs
DOs
IMGs
60
40
MD
DO
20
IMG
5
0
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
0
Urban
30
25
20
15
10
5
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
0
Family Med
Gen Surg
Gen Int Med
Gen Peds
Specialists
Small
Rural
Small
Isolated
More female rural physicians
45
40
35
30
25
20
15
10
5
0
Rural MDs
Rural DOs
Rural FPs
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
Percent rural physicians by specialty
Large
Rural
2
Percentage MD Graduates by Medical School:
All Rural Areas (2005)
40
Top 10 (21%-36%):
1 NIV OF MN-DULUTH SCH MED, DULUTH MN 55812
2 UNIV OF MS SCH OF MED, JACKSON MS 39216
3 UNIV OF SD SCH OF MED, VERMILLION SD57069
4 MERCER UNIV SCH OF MED, MACON GA 31207
5 UNIV OF ND SCH OF MED, GRAND FORKS ND 58201
6 EAST CAROLINA UNIV SCH OF MED, GREENVILLE NC 27858
7 UNIV OF KY COLL OF MED, LEXINGTON KY 40536
8 UNIV OF NE COLL OF MED, OMAHA NE 69105
9 E TN STATE UNIV J H QUILLEN COLL OF MED, JOHNSON C
10 UNIV OF AR COLL OF MED, LITTLE ROCK AR 72205
35
30
25
Bottom 10 (0%-3%):
20
SUNY-HLTH SCI CTR AT BROOKLYN, COLL OF MED, BROOKL
CORNELL UNIV MED COLL, NEW YORK NY 10021
UNIV OF CHICAGO, PRITZKER SCH OF MED, CHICAGO IL 6
HARVARD MED SCH, BOSTON MA 02115
UNIV OF CA, LOS ANGELES, UCLA SCH OF MED, LOS ANGE
A EINSTEIN COLL OF MED OF YESHIVA UNIV, BRONX NY 1
YALE UNIV SCH OF MED, NEW HAVEN CT 06510
NEW YORK UNIV SCH OF MED, NEW YORK NY 10016
STANFORD UNIV SCH OF MED, STANFORD CA 94305
UNIV OF NORTH TX HLTH SCI CTR, FORT WORTH TX 76107
15
10
5
Top 10 rural medical schools - 1992
•
•
•
•
•
•
•
•
•
•
South Dakota
North Dakota
Mississippi
Arkansas
East Carolina
Southern Illinois
New Mexico
Kentucky
Minnesota
West Virginia
0
Medical School of Graduation (Most Practicing to Least -- Left to Right)
Percentage of Rural Family Physician residency graduates by Residency State
60
50
40
30
20
10
N
D
M
T
W
Y
SD
R
M
S
K
S
IA
W
V
M
E
ID
T
N
N
E
K
Y
A
K
N
R
O
W
I
A
L
SC
C
O
O
M
IN
U
T
0
G
A
A
K
V
T
M
O
West Virginia - 41%
Oklahoma St - 30%
AT Still - Kirksville - 27%
Kansas City - 21%
Ohio University - 21%
Univ of New England - 20%
IL
H
I
T
X
W
A
P
A
O
H
V
A
M
I
N
M
N
C
N
H
LA
•
•
•
•
•
•
70
D
C
M
A
R
I
N
J
C
T
D
E
C
A
A
Z
N
V
M
D
N
Y
FL
Top rural DO schools (n=16)
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
3
Conclusions
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
• 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
Large
Rural
Percent
(n)
Small
Rural
Percent
(n)
Total
Rural
Percent
(n)
7.6
(2108)
Isolated
Small
Rural
Percent
(n)
3.7
(1037)
Family Medicine
11.3
(3137)
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)
Specialty
22.6
(6282)
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