Among the most enduring problems

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1 Which Medical Schools Produce Rural Physicians? A 15-Year Update Frederick Chen, MD, MPH, Meredith Fordyce, PhD, Steve Andes, PhD, and L. Gary Hart, PhD Abstract Purpose Despite continued federal and state efforts to increase the number of physicians in rural, disparities between the supply of rural and urban physicians persist. The authors examined the training of the rural physician workforce in the United States. Method Using a national cross-sectional analysis of the 2005 American Medical Association and American Osteopathic Association Masterfile physician data, the authors examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school between 1988 and Results Eleven percent (20,037) of the physician cohort were currently practicing in a rural location in Eighteen percent (2,045) of osteopathic medical school graduates were currently practicing in a rural location. Twenty-three percent (6,282) of family physician graduates practiced in rural. Women continue to be less likely than men to practice in rural, although the gap is narrowing. Rural residency trainees were over three times more likely to practice in rural (RR 3.4, P.001). Conclusions The proportion and number of physicians entering rural practice has remained stable compared with earlier analyses. However, recent trends such as declining primary care interest are not yet reflected in these data and may portend worsening shortages of rural physicians. Acad Med. 2010; 85: Editor s Note: A commentary on this article appears on pages Among the most enduring problems in rural America is the shortage and maldistribution of physicians. 1 3 Despite continued federal and state efforts to increase the number of physicians in rural, disparities between the supply of rural and urban physicians persist. 3 5 The recent Institute of Medicine (IOM) report on rural health quality highlights the critical need for well-trained physicians to deliver high-quality care to Dr. Chen is lecturer, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington. Dr. Fordyce is investigator, WWAMI Rural Health Research Center, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington. Dr. Andes was a research scientist, American Osteopathic Association, Chicago, Illinois, at the time of this study. Dr. Hart was director, WWAMI Rural Health Research Center, and professor, Department of Family Medicine, University of Washington School of Medicine, Seattle, Washington, at the time of this study. Correspondence should be addressed to Dr. Chen, Department of Family Medicine, University of Washington School of Medicine, th Avenue NE, Suite 201, Seattle, WA ; telephone: (206) ; fax: (206) ; fchen@u.washington.edu. rural. 1 Although the report emphasizes that rural physicians must be trained in quality improvement, information technology, and evidencebased medicine, the availability of highquality care in rural depends primarily on an adequate supply of physicians practicing in these. It has been more than 15 years since Rosenblatt et al 6,7 described the MDgranting schools that train rural physicians. In addition, recent literature has not adequately described the contributing role of DO physicians and international medical graduates (IMGs) in the rural physician workforce. This report describes the training of the rural MD and DO physician workforce in the United States and examines the variations in the ways medical schools and residency programs produce rural physicians. In the original study, Rosenblatt et al 6 found that a small subset of the nation s medical schools produce the majority of rural physicians in the United States. We sought to update that finding and expand the analysis to residency training programs, with a specific focus on training programs located in rural. Method In 2006, we performed a national crosssectional analysis of the 2005 American Medical Association (AMA) and American Osteopathic Association (AOA) Masterfile physician data. We examined a 10-year cohort of clinically active MD and DO physicians who graduated from medical school in the years 1988 through 1997 and had completed residency training. This cohort allowed for a reasonable comparison with the 10-year cohort from Rosenblatt and colleagues 6 previous work. In addition, this cohort allows for the most recent graduates (from 1997) to have completed residency training (typically three to five years) and then to have established practice to be captured in the AMA Masterfile. We excluded resident physicians and osteopathic physicians with an unknown professional employment status from the analyses. We determined physicians locations by the reported ZIP code of each physician s primary practice location. When the primary practice location was not available, we used the physician s home address. We mapped the ZIP codes to Rural Urban Commuting Area (RUCA) and county designations. RUCA codes use census tracts rather than counties as a means of identifying degree of rurality or urbanicity. 8,9 A ZIP code approximation version of the census tract-based RUCA codes has been developed ( washington.edu/uwruca/ruca-data.php) 594

2 and was used in this study. Use of these smaller basic building blocks allows for much more precision in defining rural and urban locations than do the largerscale county-level taxonomies. RUCA codes identify as metropolitan (urbanized), micropolitan (large rural), small town (small rural town), or rural (isolated small rural) and are based on both core population size and work commuting flow relationships. Core populations are categorized as metropolitan (continuously built-up of 50,000 or more), micropolitan (10,000 49,999), or small town (2,500 9,999). Work commuting flow accounts for the direction and the extent to which a core population commutes to a city or town of similar or larger size. RUCA version 2.0, used in this study, consists of 10 general settlement types that are themselves further broken down into the 33 subcategories based on work commuting patterns. These 33 subcategories were aggregated to create a four-category classification, which identifies as urban, large rural, small rural, or isolated small rural. We identified the medical school of graduation for each physician. IMGs were defined as physicians who graduated from a non-u.s. or Canadian medical school; graduates from Puerto Rican schools were counted as IMGs. The AMA Masterfile receives these data directly from medical schools. As a result, some but not all medical school campuses are reported separately from their parent institutions. For example, the University of Minnesota Duluth has separate data from the University of Minnesota, whereas University of Illinois Rockford data are included with the University of Illinois data set. We identified the most recent residency program for each physician and identified the location of that residency program as rural or urban on the basis of its ZIP code. Rural residency programs were those located in large rural, small rural, or isolated small rural RUCA categories. The residency analyses focused on family physicians (FPs) because family medicine is the predominant specialty in rural. We aggregated rural physicians to each medical school, and medical schools were compared to show the percentage of the rural physicians produced by each school. A similar analysis was performed for residency training programs. Standard bivariate statistical testing was performed using SPSS (v , Chicago, Illinois). This study was approved for an exemption by the University of Washington institutional review board. Results There were 175,649 clinically active physicians in the cohort of physicians who graduated from medical school in the years 1988 to Of these, 93.6% (164,385) were MD physicians and 6.4% (11,264) were DO physicians. Eleven percent (20,037) of this cohort of physicians were practicing in a rural location in Eighteen percent (2,045) of DO-granting medical school graduates were practicing in a rural location, but only 11% (17,992) of MDgranting medical school graduates were in a rural location (Table 1). Thirteen percent (3,513) of IMGs were practicing in a rural location. The proportion of medical school graduates entering rural practice varied by specialty. Among the specialties, 23% (6,282) of FP graduates practiced in rural. In comparison, 16% (916) of general surgeons, 11% (3,075) of internists, and 9% (1,236) of pediatricians practiced in a rural area (Table 2). During the 10-year study period, there was a stable number and proportion of MD physicians practicing in rural, with a small increase with the most recent graduating cohort in 1997 (10.3% of 1988 graduates versus 11.6% of 1997 graduates). There was a more consistently increasing trend among DO physicians entering rural practice over the decade (18.1% of 1988 graduates versus 19.6% of 1997 graduates) (Figure 1). Rural physician gender Among all the MD physicians in the cohort (rural and urban), 37% (60,912) were female. In the cohort of DO physicians, 31% (3,467) were women. Over the course of the 10-year study period, the percentage of MD and DO female physician graduates increased from 32% in 1988 to 44% in Thirty-one percent (6,211) of rural physicians are women. Women continue to be less likely than men to practice in rural, although the gap is narrowing. There was, however, an increasing proportion of female physicians entering rural practice over the study period (7.8% to 9.8% female MDs, 12.2% to 17.7% female DOs) (Figure 2). This finding represents a significant change from previous analyses of women entering rural practice. 5 Medical schools and residency programs The medical schools that produced the highest percentage of rural physicians placed between 21% and 36% of their graduates in rural (Table 3). There was no substantial change in the list of MD-granting medical schools graduating rural physicians when compared with the earlier study by Rosenblatt et al. 6 However, several DO-granting schools were identified that contributed relatively high percentages of rural physicians. Table 1 Number (%) of all MD, DO, and International Medical Graduate (IMG) Physicians Who Graduated From Medical School From 1988 to 1997 and Were Practicing in Rural Areas* in 2005 Physician type No. (%) in urban No. (%) in large rural No (%) in small rural No. (%) in isolated small rural Total no. (%) in rural MD (n 164,375) 146,383 (89.1) 11,953 (7.3) 4,284 (2.6) 1,755 (1.1) 17,992 (11.0)... DO (n 11,262) 9,217 (81.8) 1,172 (10.4) 594 (5.3) 279 (2.5) 2,045 (18.2)... IMG (n 26,393) 22,880 (86.7) 2,089 (7.9) 984 (3.7) 440 (1.7) 3,513 (13.3) * The urban and rural categories are defined using Rural Urban Commuting Area codes. 595

3 Table 2 Number (%) of MD and DO Physicians of Each Specialty Who Graduated From Medical School From 1988 to 1997 and Were Practicing in Rural Areas* in 2005 Specialty No. (%) in large rural No. (%) in small rural No. (%) in isolated small rural Total no. (%) in rural Family medicine 3,137 (11.3) 2,108 (7.6) 1,037 (3.7) 6,282 (22.6)... Internal medicine 1,925 (7.0) 775 (2.8) 375 (1.4) 3,075 (11.2)... General pediatrics 876 (6.4) 268 (2.0) 92 (0.7) 1,236 (9.1)... General surgery 614 (11.0) 242 (4.3) 60 (1.1) 916 (16.4)... Orthopedics 523 (10.4) 132 (2.6) 28 (0.6) 683 (13.5)... Obstetrics gynecology 870 (8.2) 219 (2.1) 46 (0.4) 1,135 (10.7)... Emergency medicine 592 (6.9) 164 (1.9) 66 (0.8) 822 (9.6)... Psychiatry 520 (6.5) 131 (1.6) 42 (0.5) 693 (8.7)... Medical specialties 1,365 (6.0) 336 (1.5) 141 (0.6) 1,842 (8.1)... Surgical specialties 176 (3.4) 13 (0.3) 11 (0.2) 200 (3.9)... Total 13,124 (7.5) 4,878 (2.8) 2,034 (1.2) 20,036 (11.4) * The urban and rural categories are defined using Rural Urban Commuting Area codes. Rural residencies Only 1.4% (2,247) of MD physicians in the cohort trained in a rural residency location. Among these physicians who trained in rural residencies, 36% (814) were in rural practice at the time of our study. In comparison, 3.6% (343) of DO physicians in the cohort trained in a rural program. Fifty percent of DO graduates (170) who trained in a rural residency were in rural practice according to the 2005 Masterfile. Although we found that rural residency trainees are over three times more likely to practice in rural (RR 3.4, P.001), rural residencies account for only 5% of MD physicians practicing in rural and 10% of DO physicians in rural. Rural family medicine training programs are an important contributor to the rural physician workforce. 10 Sixty percent of rural family medicine residency graduates were in rural practice at the time of this study, and they were three times more likely than graduates of nonrural residency programs to practice in a rural location (RR 2.8, P.001). However, only 9% of all rural FPs in our study cohort trained in a rural residency. Discussion This analysis of national data shows that the proportion and number of physicians entering rural practice has remained stable, compared with Rosenblatt and colleagues results. DO physicians and primary care physicians are more likely to practice in rural. Although the number and percentage of rural physicians produced by medical schools Figure 1 Percentage of MD and DO physicians practicing in a rural area in 2005, by year of graduation. The percentage of international medical graduate (IMG) physicians practicing in rural is also shown. was widely distributed, a small number of medical schools produced high proportions of rural physicians. As seen in Table 3, only 10 medical schools had over 25% of their graduates in rural practice. The study by Rosenblatt et al 6 identified a slight decline in the percentage of physicians entering rural practice over time. The data we studied show that the decline has stabilized, although the overall percentage of graduates practicing in rural has decreased. In 1991, 12.6% of recent medical school graduates entered rural practice. In 2005, that number had slipped to 11% of recent medical school graduates. We believe this difference is primarily due to different definitions of rural practice between the two studies. More important, on the basis of our own anecdotal observations, we suspect that this downward trend has accelerated in recent years, although it is not yet captured in the data. As noted by Rosenblatt et al, 6 the likelihood of a physician entering rural practice is associated with specialty. In this cohort of medical school graduates from 1988 to 1997, primary care physicians continue to be more likely to enter rural practice than are specialty physicians. Again, compared with the earlier study by Rosenblatt and colleagues, the percentage of FPs, general internists, and pediatricians entering rural practice has declined (see Table 2). An exact comparison is difficult because the article by Rosenblatt et al used nonmetropolitan county to define rural practice location, and this study 596

4 graduates increasingly choose MD specialty residency training programs. Figure 2 Percentage of MD and DO rural physicians who are female, by year of graduation. The percentage of female family physicians (FPs) practicing in rural is also shown. uses RUCA coding to identify rural physicians. It is worth noting that the total enrollment in medical schools has increased during the time between these two studies. In this context, the stable percentage of physicians entering rural practice represents an increase in the absolute number of physicians in rural locations. To better understand these findings, it may be useful to consider the overall demographic changes in rural America over the same time period. Since 2000, the rural population has experienced modest growth (0.4%), almost one-third that of the U.S. urban population. 11 Of note, the previously reported gender gap among rural physicians is disappearing. The increasing proportion of female rural physicians (Figure 2) is more likely attributable to the increasing number of female medical school graduates coupled with a decline in the percentage of male physicians entering rural practice. As previously reported, DO physicians are significantly more likely to enter rural practice. The percentage of DO graduates entering rural practice remained stable over the decade, approaching 20%. However, recent studies suggest that this percentage has begun to decline as DO Table 3 MD- and DO-Granting Medical Schools With the Highest Percentages of Graduates ( ) Practicing in Rural Areas in 2005 % Graduates practicing Medical school MD/DO in rural, 2005 West Virginia University DO 41 University of Minnesota Duluth MD 36 University of Mississippi MD 32 University of South Dakota MD 31 Mercer University MD 31 Oklahoma State University DO 30 University of North Dakota MD 28 A.T. Still University Kirksville DO 27 East Carolina University MD 26 University of Kentucky MD 25 University of Nebraska MD 23 East Tennessee State University MD 23 Kansas City University of Medicine and Biosciences DO 21 University of Arkansas MD 21 Ohio University DO 21 University of New England DO 20 These data further support the valuable contribution to the rural physician workforce of rural residency programs. Though few in number, these training programs are successful at producing rural physicians. A previous study showed that these rural residency programs provided 71% of the nation s rural training in family medicine. 10 Unfortunately, rural residency programs, especially in family medicine, face serious financial challenges. In a recent study, 10,12 10% (3) of 33 rural residencies have closed, with an additional 7% at severe risk of closure. This study has several important limitations. As we noted above, we used a different rural definition than the previous study by Rosenblatt et al. Although this limits the ability to compare our findings with those of the earlier study, we feel that the RUCA methodology is a much more robust and accurate estimation of rurality. In addition, there are several wellrecognized limitations to AMA and AOA Masterfile data. The data are often inconsistently updated, so changes in physicians locations may take several years to be captured in the data. The AOA data had a portion of missing data for osteopathic physicians whose professional employment status was unknown, and these physicians were excluded from the analysis. It is unknown how many of these missing physicians graduated during the study period, so it is difficult to estimate bias, but we believe it is minimal. Perhaps the greatest drawback to these data is that they do not capture the most recent decade of physician workforce trends. The mid-1990s were a time when a high number and percentage of U.S. medical students were entering family medicine and, as a result, rural practice. During that time, the prominent role of primary care gatekeepers in the new managed care systems attracted medical students to the primary care specialties. Indeed, the increasing proportion of rural physicians beginning in 1993 that we saw in these data has not continued. The past 10 years have shown a dramatic and precipitous decline in the percentage of U.S. medical school graduates entering family medicine, with over half of current 597

5 family medicine residency positions being filled by IMGs. 12 The declining interest in primary care will have major impacts on rural, whose needs are often met by generalist physicians and which often cannot support any physician practice other than primary care. Conclusions As the IOM report emphasizes, rural health is critically dependent on both the supply and the quality of its rural workforce. Not only do rural require an adequate supply of physicians to ensure access to care, but the training of these physicians in information technology, quality improvement, and new models of care is vital to the future of rural health. Although this study cannot address the adequacy of training in these realms, future research should explore the extent to which rural physicians acquire these skills. Current calls to expand medical school class sizes may help support the pipeline for rural physician training. However, if medical schools expand class sizes without explicitly emphasizing primary care or rural health, these expansions may result in more physicians choosing to practice in urban centers, worsening the rural urban maldistribution. 13 On the other hand, medical schools may choose to implement programs and curricula that have a demonstrated success in training rural physicians. 14 At the same time, there has been little discussion of the role of state legislatures in holding state-supported medical schools accountable for producing a substantial percentage of rural physicians. Federal rural health programs and Title VII-funded programs continue to support primary care and rural health training. 15,16 Whereas these data show little significant change in the rural physician workforce, the effects of these policy changes will need to be closely monitored in coming years. Funding/Support: This study was funded by Health Resources and Services Administration, Office of Rural Health Policy, through HRSA Grant #6 UIC RH Other disclosures: None. Ethical approval: This study was approved for an exemption by the University of Washington institutional review board. Previous presentations: An earlier version of this work was presented at the Academy Health annual research meeting, June References 1 Institute of Medicine. Quality Through Collaboration: The Future of Rural Health. Washington, DC: National Academies Press; Council on Graduate Medical Education. Physician Distribution and Health Care Challenges in Rural and Inner-City Areas. Washington, DC: Council on Graduate Medical Education; Rosenblatt RA. A view from the periphery Health care in rural America. N Engl J Med. 2004;351: Doescher MP, Ellsbury KE, Hart LG. The distribution of rural female generalist physicians in the United States. J Rural Health. March 2000;16: Ellsbury KE, Doescher MP, Hart LG. US medical schools and the rural family physician gender gap. Fam Med. 2000;32: Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. Which medical schools produce rural physicians? JAMA. 1992;268: Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG. The effect of federal grants on medical schools production of primary care physicians. Am J Public Health. 1993;83: Morrill R, Cromartie J, Hart G. Metropolitan, urban, and rural commuting : Toward a better depiction of the U.S. settlement system. Urban Geogr. 1999;20: Hart LG, Larson EH, Lishner DM. Rural definitions for health policy and research. Am J Public Health. 2005;95: Rosenblatt RA, Hagopian A, Andrilla CH, Hart G Jr. Will rural family medicine residency training survive? Fam Med. 2006; 38: Kusmin L, ed. Rural America at a Glance, 2008 Edition. Economic Information Bulletin No. (EIB-40). Washington, DC: U.S. Department of Agriculture, Economic Research Service; October Pugno PA, McGaha AL, Schmittling GT, Fetter GT Jr, Kahn NB Jr. Results of the 2006 National Resident Matching Program: Family medicine. Fam Med. 2006;38: Grumbach K. Fighting hand to hand over physician workforce policy. Health Aff (Millwood). 2002;21: Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: A systematic review and projected impact of widespread replication. Acad Med. 2008;83: Fryer GE Jr, Meyers DS, Krol DM, et al. The association of Title VII funding to departments of family medicine with choice of physician specialty and practice location. Fam Med. 2002;34: Davis AK, Reynolds PP, Kahn NB, et al. Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States. Acad Med. 2008;83: