A bit long, perhaps more easily read and linked to documentation and extra
perks at http://www.unmc.edu/Community/ruralmeded/failure_to_launch.htm
I have tried to find pieces of the nation that are not able to birth
physicians. Using mostly county level analysis, I have combined the
poorest, the most rural, and the most socially different. But there
were still 4 - 6 physicians arising out of 100,000 population per year
I will attempt to use the known distributions of physicians and their
origins to combine it with what we know about certain areas of the nation,
such as Florida.
I used Ghelfi and Parker's various categorization systems developed in the
1990s and I could get some below 4 admits per 100,000 , but not many In the
following table the national averages are demonstrated. There is also a
great division between counties with a medical school (also contiguous
counties if in the same city) and counties that did not have a medical
school. Finally the lowest rates of admission are listed for various types
of areas, states, and counties.
Lowest Admissions Per 100,000 for the 1987 – 1996 Class Years, All Medical
School Sources (admits * 100,000 / pop of county groups / 10 class years
grads) over 90% of birth origins can be matched to a county for this group,
over 95% for US MD Grads, 80% for osteopathic, variable for international,
this does not include those born outside the United States, which increases
admissions ratios from 7 to 9 per 100,000.
Total Total Admits FPGP Under-serve Rural
Counties Admits Found in d
per FPGP per
100,000 100,000
National Average for US Born 3138 7.05 1.07 15.2% 5.6% 12.8%
County/City with Medical 196 9.52 1.23 13.0% 4.7% 10.1%
School
Counties without Medical 2942 4.57 0.90 19.8% 7.3% 18.5%
School
Lowest Admissions Found By
County or County Group Birth
Origins
Commuting Counties 381 1.47 0.37 25.1% 10.6% 22.7%
Counties Adjacent < 10,000 123 2.00 0.43 21.4% 9.4% 23.9%
(Urb 4)
Adjacent Small Metro < 10000 626 2.41 0.59 24.5% 8.5% 23.0%
(Urb 6)
Whole County PC Shortage 784 2.42 0.56 23.3% 14.1% 24.4%
Not Adjacent Less Than 2500 514 2.44 0.73 29.8% 11.6% 33.4%
(Urb 9)
Retirement Counties 190 2.63 0.52 19.8% 8.0% 22.9%
Over 20% Over Age 65 388 3.16 0.75 23.6% 7.4% 23.3%
Poverty Counties 535 3.18 0.76 23.9% 16.4% 26.9%
Manufacturing County 506 3.31 0.76 23.1% 8.6% 25.4%
Predominantly Black Rural 88 3.35 0.66 17.4% 17.4% 24.6%
Farming Dependent County 556 3.52 0.99 28.0% 8.5% 26.6%
NH 10 3.66 0.60 15.6% 5.2% 16.3%
8 Not Adjacent 2500 – 10000 554 3.66 1.02 27.8% 10.5% 29%
FL 67 4.11 0.59 11.5% 6.2% 10.0%
ME 16 4.16 0.73 17.7% 6.3% 17.9%
The above represent the lowest probability of admission in the nation and
many of these represent the highest probability of distribution.
No public medical school - Maine and New Hampshire could improve the
potential for admissions with a public medical school or at least the
addition of more funded positions working with existing medical schools.
Some of these arrangements have already been made. It may take time for
those born in counties to experience the increase in opportunity.
Foreign born populations - states such as California with 25% foreign born
will have slightly lower rates of US born admissions, especially if the
foreign born populations have high levels of education and professional
degree. This is more common in Asian populations or all outside of Central
American origin, given US immigration policy and immigration trends. Those
from contiguous nations are different than those from more distant origins,
who usually have same or better status compared to whites. Changes over the
past 2 decades for US Born medical students do show declines in admissions
from certain types of US counties. These are counties that also have the
highest levels of Asian population and Hispanic population. Florida has 13%
foreign born. Miami-Dade County is the only US county that is predominantly
foreign born. Since the most populous counties admit the most, this could
suppress US born admissions for the state.
Fewer Young People - Counties with older populations are also seen.
Although there are certainly direct reasons why such counties would not be
admitting medical students (unless we admitted up to age 75), there may be
even more to consider. Do certain populations shape counties in ways that
make it difficult for education, income distribution, and opportunity? Do
counties that have lost their professionals just become older and older
over time? Many in some parts of rural America once hoped to turn
leadership roles over to younger people, only to find none to assume these
positions. Federal and state policies also do not reward the distribution
of resources and education and health care. Given education and health care
as the most important components of the economies of many of these
counties, decisions made by a wide range of leaders and professionals can
be crucial, or they may not be made because the people are unaware and
unwilling to explore.
Dependent Counties - There are a number of county types that rely upon
outside influences such as governments, trade agreements, and changes in
economies. Nations do a poor job of anticipating problems when economies
change. Without addressing declines in the early stages, the nation ends up
adding another population in chronic poverty instead of addressing those
already left behind. Rapidly increasing rates of child poverty in the
Midwest in working parents with a high school education is a sign of adding
to the burdens rather than addressing them. Much of this midwest change
involves economies left behind and also leaders that did not diversify when
they were on top (auto, steel, coal, manufacturing, mining).
Commuting Counties - losing market share to more urban locations in all
areas of economics makes it difficult to support local services, schools,
and more. Wahoo ("home" of David Letterman) Nebraska is sandwiched between
the Omaha and Lincoln metro areas. It is perennially on the health
professions shortage lists. Has good schools through lots of local effort,
but large segments of the population head east to Omaha or south to Lincoln
for work, drive by malls and shopping centers on the way to work, take
their health services from or near work, and stop at the malls on the way
home. Most rural communities, made fully aware of this to the point of
action, change their own courses dramatically, but this usually is more
successful for the more distant locations.
When I revised the birth origin figures to include all physicians such as
osteopathic and international (schools in Caribbean, Mexico) who were born
in the United States beyond just the US MD grads, Florida escaped being
less than 4 per year, but barely. Of course every one else improved too, so
the state's counties were still at the bottom. Even though Florida does
have a mix of all of the above types of areas, the state still does poorly,
basically at the bottom in medical school admissions for children in states
that have a chance by having a public medical school available. Florida was
also at the bottom of rural born admissions. From other studies, I can tell
you that Florida is likely to be at the bottom for black male admissions.
When states have difficulties with rural male or black male or any lower
income origin male medical school admission, they also have a much higher
rate of prison, social expenditure, to go with lower education and higher
education outcomes. The Hispanic populations in Florida are a mix. Some do
well, however overall across the nation Hispanics share the same lower
admission rate with lowest income rural areas. Also lower income Hispanics
such as from Mexico and Central America tend to choose family medicine and
distribute to underserved areas, not so with Hispanics from higher income
origins. Cuban populations represent many displaced professional families.
Exploring zip codes across the nation also were interesting for Florida.
Mostly I just zoomed through states as there were usually steady gradients
by income and poverty stats or by moving geographically across the nation
with adjacent zip codes by latitude and longitude. Florida was different.
Few states have the income and poverty contrasts between adjacent zip codes
as found in Florida.
Even if more detailed analysis revealed that Florida was a concentration of
those left behind, it might at least raise awareness that groups are being
left behind and are being concentrated together by geographic location.
Florida may be one of the states that makes the best case for major early,
often, and extensive childhood and early education interventions.
The story of Florida State medical school is also remarkable. The geriatric
director for the state approached the state's medical schools once to give
them money to train for geriatrics, they said yes and agreed on a figure,
but their lobbyists killed the measure. She came back again to the medical
schools and asked what went wrong. They did not give much answer but did
agree that more money might be needed. They killed the bill again. This
resulted in the most detailed studies ever done for the preparation of an
allopathic medical school and the design to address geriatrics, rural
peoples, and the needs of minority populations in Florida. A new model
involving community based training was involved that modified or violated
(take your pick) the Flexner centralized major medical center plan for
medical education. The medical schools at Florida were not happy about
competition and claimed there was no need, that there were not enough
qualified students, or that FSU could not do the job. Of course the states
needs were growing at rapid rates, the state's medical schools were more
than willing to take students from the state and other locations, and FSU
had long had admissions and a first year medical school class so it clearly
had much of the expertise, structure, and initial personnel. The existing
schools may have even influenced LCME, the accrediting body, although LCME
focused mostly on the difficulties of the new model.
The key to the model was having personnel with a track record for working
with medical students in their community practices. FSU had already hired
the best in the state (Ocie Harris) who had decades of such experience.
During the consultant work arranged by the skilled
geriatric/political/marketer ML Dugger, FSU had also marketed itself such
that it attracted some of the top medical educators in the nation. Finally
the FSU president had enough. Assuming his other role as a trial lawyer, he
told LCME in no uncertain terms to approve them or they would meet in
court. LCME had little choice. FSU had more than done their homework.
But......The school is still vulnerable for 3 reasons as noted in all of
the above - specifically the poor state investment in children, the poor
processing in needed state areas, and a very expensive medical education
model of about $25 million. This model depends upon continued good favor
with the legislature and also the practice outcomes of the graduates who
are emerging in greater numbers, in other words it depends upon the people
of the state of Florida. If the school does well and if it documents its
graduates flowing to every legislative district to serve, it will likely
survive - a tall order given other difficulties in the state. Their
outcomes will also be limited by the general lack of social support, which
makes the lives of all service oriented types from teachers to nurses to
family physicians in the state.
It is doubtful that the legislature or the state or the other medical
schools will give allowances for the background contribution of the state.
For example, the other county groups in the table above have higher rates
of Family Medicine and either rural or underserved locations or both. The
fact that Florida born medical students have some of the lowest rates of
all three does not make the task easy for FSU. Then there is the liability
and massive increased cost of health care and cost of living. In my
studies, these are factors that drive family physicians away from a state,
the ones most likely to remain in primary care and to distribute to rural
and to underserved areas. It is my personal feeling that family physicians
value people, and have a difficult time with any location that does not
value people, families, or children.
Florida has become a concentration of future, current, and past
professionals. Professionals do structure environments and they have
structured Florida. One of the major questions regarding states such as
California, New York, Texas, and Florida, who have the means to make
changes yet do not, is what the nation will do to address member states who
do not contribute teachers, nurses, family physicians, and public servants,
who hire private security yet do not support public safety and police. What
will the nation do now that millions of people are put in harm's way in
territory regularly claimed by hurricanes and due again for floods and
earthquakes. More people in these locations is a very bad idea. More people
plus great divisions compacted together is a very, very bad idea. Then
there is the basic problem of water.
The contrasts are remarkable in other ways. The lesson of Katrina was seen
and Texans evacuated from Rita, but the same was not true for Florida, few
even stored up provisions for a few days as asked by the governor. The
Mayor of Houston asked for and received $1 million each from 5 major oil
companies and used it to turn Houston apartments into housing for Katrina
victims, many of whom remain. The State of Texas requires millions in
reserve of school districts for emergencies, these huge reserves were
tested to the limit, and only provided the first 6 months for Houston ISD
to take care of tens of thousands of new children, but 6 months was more
than enough time to make these adjustments.
The bottom line is that the state is a very inefficient place to live,
especially for the lower and middle income types. It is a state for higher
income types who are retired, professionals, and others who can afford to
live in the state.
Florida might consider fixing the front end at age 0 – 6, education, and
pre-admissions. This might be more cost effective that adding at the tail
end with more total admissions, especially from the newer medical schools
that have not worked for years to plan, prepare, and implement plans
specific to the state’s great and growing needs.
There is one clear location defined by the current physicians born in
Florida that graduated from medical school from 1987 - 1996. Over 72% were
found in major medical center locations. This is nearly the same rate as
those born in cities and counties with medical schools across the nation,
the ones most likely to be children of professionals. Expansions of medical
school positions in Florida could easily add many more children of
professionals to the ranks of physicians, with little or no improvement in
physician distribution. The example of Mississippi and South Dakota is
similar. When you admit more medical students than the state has capacity
to prepare students, you end up with more urban and higher income origin
types and greater ratios of these students. You can do the same thing with
a sudden expansion. When there is a sudden opportunity with a rapid
expansion of medical school positions, then the only ones around to take
advantage of this are the highest income types. They can convert to
medicine and still finish college on time. Lower income, minority, and
rural types respond to new opportunity more slowly and depending on the
education, higher education, and career orientation efforts. This can take
years or decades to respond to new opportunity unless education efforts
have preceded, as in the fortuitous Sputnik impacts on the 1960s and 1970s
(top education and higher ed emphasis) before the med school expansion of
1970 - 1980. As for Florida or other areas, whether those admitted exceed
the state's capacity for caring, dedicated, empathetic physicians is as yet
to be studied. This will be left to another time when physicians are first
considered because of who they are, rather than who their parents are.
Many of the categories are derived from work from USDA, Urban Influence
codes, and types of counties by Parker and Ghelfi. Other constant sources
have been Tom Ricketts (UNC) and Gary Hart (WWAMI). These folks not only
helped categorize the nation, they have also helped people to understand
what is happening in the nation and in the world.
Most importantly were the living experiences extending from my own birth to
professional parents in engineering and nursing, my teachers and school
teacher wife, my children who have overcome the barriers placed in their
way by education systems, my patients who encounter these and other
barriers daily, and the environments provided to me by those who have paid
enormous sums to educate me and train me to become a professional, one who
helps shape societies.
Robert C. Bowman, M.D.
[log in to unmask]
www.ruralmedicaleducation.org
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