As a Ph.D. student who made very good grades at the bachelor's and master's level, I can tell you that grades have little to do with why I don't live in rural West Virginia where I grew up. I moved away to go to university, then moved further away for my husband to attend graduate school, and then moved out of the country to do a Ph.D. that I hope will allow me in some way to make a contribution to the community where I grew up. I have very strong family ties. I am brokenhearted every time I leave them. But there are many, many more factors at work here than simple "choice." For one, my 18 month old son has severe asthma. The healthcare available in my family's area is frightening (My mother nearly died in the hallway of the emergency room because she was given a medication she was allergic to and then told she just needed to "calm down" when she was having a siezure. That type of oversight is not uncommon at their local hospital.). The jobs market is abysmal - especially for highly-educated people. And the chances of supporting not only my immediate family but my extended family, as well, are exponentially greater if I live in an area where I can be better compensated for my experience/expertise (i.e. not rural WV). It is hurtful that often readers of these statistics assume that people who don't return to the areas where they were raised do so because they would rather not "go back to the sticks." On the contrary, many of us feel we don't have a choice. Here's hoping we can meet halfway somewhere.

Colleges and medical schools tend to select those with top standardized test scores, but a consequence is fewer of the graduates staying in the state to provide health care in the state that invested in them from birth to graduation.

Children that are most urban or highest income or children of professionals including physicians are most likely to have top standardized test scores, are 2 - 10 times more likely to gain medical school admission, and are least likely to remain in states and locations in need of care. This is a group shaped by exclusive neighborhoods, private high schools, high school in exclusive suburbs, and exclusive colleges. Birth to admission uniquely shapes these students away from primary care, rural workforce, and underserved workforce and toward specialty choices in 4% of the land area in top concentrations off physicians. 

One of the reasons that states support their public medical schools so poorly is that the medical school fails to meet state workforce needs. National policies also fail. For example the accelerated family medicine residency program was replicated into a number of states and programs in two states had graduates that were 70% found in rural practices in the state that trained them for medical school and family medicine residency (and usually before). This training model was terminated despite 40% rural location rates (10% for US physicians) and despite 20% underserved location rates (7 - 8% for US physicians) and despite top delivery of primary care in the nation (30 Standard Primary Care years) and the lowest cost of primary care delivery for the cost of all education and training of any primary care source.

States that identify and support children that are bonded to family, community, and other state characteristics are in the best position to incent future workforce in medicine and a number of areas. These are typically lower and middle income children and those first generation to college. By selecting these students to become physicians, the benefits also include more primary care delivery per graduate, more rural workforce, more underserved workforce, more who care for the elderly, and physicians who are more likely to share common ground with their patients - a boost to better care and lower costs.

Before I came to Nebraska this process was set in motion and during my 15 years it continued to grow. It was set in motion by people by people who understood that it would take 40 - 50 years of effort to address needed workforce. It takes 10 years after realizing the process that is needed to get to the needed workforce production and then 35 class years of graduates or a generation of physicians to get to the design level. Nebraska was well on its way until state and federal policies sent workforce other directions, including out of state.  Not surprisingly Nebraska has joined the 25 - 30 states that will have insufficient workforce as graduates that once remained 50% instate now have 30% instate retention. In the urban origin UNMC students in 2009, only 3% chose family medicine in a state with about half of the population dependent upon family medicine.

Robert C. Bowman, M.D.   North American Regional Co-Editor of Rural and Remote Health
www.basichealthaccess.org