Creating Rural Medical Workers

[imgbelt img=big_residency-chart.png]If we want health workers to go to underserved areas, we should quit training so many specialists and concentrate on educating medical generalists.



The Incidental Economist

The U.S. has fewer family practice physicians than other countries. We should support those systems and programs that produce more.

A new study about national distributions of physician workforce appeared in Rural and Remote Health Journal. It is interesting comparing the distributions of physicians to concentrations of people, income, medical schools, and development. 

I was struck by what researchers found in Turkey.

In Turkey, the article tells me, generalist physicians are much more likely to spread out around the country. There is little variation in the distribution of generalists in Turkey. No matter if the community is rural or urban, high income or low income, educated more or less, higher or lower in property value — generalists are found at a relatively constant number compared to the population. 

In the United States, it turns out, the same thing holds. There are about 30 family physicians per 100,000 people across a wide range of communities in most of the nation. 

Generalist medical workers tend to spread out. They go where they are needed, in Turkey and the U.S.

I’m counting family practice employed MDs, osteopaths (Dos), nurse practitioners (NPs), and physician assistants (PAs). This even distribution does not hold true if the MD, DO, NP, or PA is employed in something other than family practice, as is true with 88% of MDs and about 75% of DOs, NPs, and PAs. 

The United States continues to graduate just 3,000 family physicians a year. There have been increases in the number of NPs and PAs. But declines in the proportions of NPs and PAs who go into family practice have negated expansions in the number of graduates. 

Training for family practice medicine works to distribute health care professionals into rural areas — to serve generally the 65 percent of the U.S. population that lives in the 30,000 zip codes where physicians are not concentrated. 

Between 24% and 30% of family practice physicians can be found in rural communities. This compares to 9% to 10% for the physician average. Non-family practice physicians have less than 3% to 8% rural distribution, except for the general types of specialties (general surgery, general Ob-Gyn, general orthopedics). These general specialties have managed 11% to 14% rural distribution, but they are in the process of being minimized, marginalized, or eliminated by designs that shape workforce and reimbursement. 

[imgcontainer left] [img:big_residency-chart.png] [source]Texas Tribune

The number of U.S. medical school graduates filling family medicine residency positions has dropped.

A Failure by Design

Other nations train generalist physicians by design. The U.S. does not. 

The design for medical training forces family physicians to go to specific types of colleges, through the most expensive education and preparation, and to medical schools where fewer than 15% of doctors go into family medicine.

Best would be training for family medicine that would begin directly out of high school. This would require schools devoted to family medicine — a route followed in other nations.

Half of all physician assistants went into family practice decades ago. Now fewer than 25% do. 

Nurse practitioners train 45% in family practice, but only 25% of total NP workforce is employed in family practice, according to surveys. Surveys and studies find that about 30% of the employed family practice NPs and PAs are found in rural locations.

In the U.S. today there are more opportunities for health care workers to specialize. Those who would become generalists are depleted during training, at graduation, and across the years after graduation. Higher pay, more support and greater benefits to employers (more revenue generation, lower personnel costs) are part of an entire system that shapes health care in this country — and diminishes access to general health care. This is especially true in the flexible and versatile NP and PA workforce.

Salary and benefit and support factors all insure that specialists in top concentrations get the most support while generalists in practices outside of concentrations get the least and have the least support for what they do. The same is true for nurses, teachers, public servants, and other front line careers.