Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices? Funded by the Josiah Macy, Jr. Foundation Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student and Resident Choices? The Robert Graham Center: Policy Studies in Family Medicine and Primary Care Robert L. Phillips, Jr., MD MSPH Martey S. Dodoo, PhD Stephen Petterson, PhD Imam Xierali, PhD Andrew Bazemore, MD MPH Bridget Teevan, MS Keisa Bennett, MD Cindy Legagneur, BS JoAnn Rudd, MA and Julie Phillips, MD MPH Michigan State University College of Human Medicine March 2, 2009 Copyright 2009 Josiah Macy, Jr. Foundation Grant B07-09 Approved by the Georgetown University IRB Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices? The Robert Graham Center Washington, DC With Support From: The Josiah Macy, Jr. Foundation ii Collaborators Advisory Board Candice Chen, MD MPH George Washington University Medical Education Futures Study George E. Fryer, Jr., PhD University of Arkansas for Medical Sciences Diane R. Rittenhouse, MD MPH University of California San Francisco Scott Shipman, MD MPH Dartmouth Medical College iii Acknowledgements We thank the following for their generous help with Study Data and Recommendations: David C. Goodman, MD MS Dartmouth Medical College Sarah Brotherton, PhD American Medical Association Bob Edsall American Academy of Family Physicians iv Table of Contents About The Robert Graham Center……………………………………….......…….……..….....................vi Executive Summary…………………………………………………….………………………..….............vii Foreword………………………………………………………………...............………………...................xi Message from the Josiah Macy, Jr. Foundation…………………………….........................................xiii Figures...........………………………………………………………………...............…….…....................xv Chapter One What We Know About Factors Affecting Medical Student & Resident Career Decisions...........1 Chapter Two Study Aims, Questions, Methods, Limitations.............................................................................8 Chapter Three Outcomes of Current Physician Training..................................................................................13 Chapter Four Debt...........................................................................................................................................16 Chapter Five Title VII Effect, Personal Interests, and Experiences in Medical School...................................33 Chapter Six Return on Investment……………………………………………………...........……………………40 Chapter Seven Conclusions and Recommendations…...........…..…………………………………………………45 Appendices……………………………………......…………………….…………………....………………53 References…...……………………………......……………….……….……………………....……………75 v About The Robert Graham Center The Robert Graham Center: Policy Studies in Family Medicine and Primary Care The Robert Graham Center is a research center that exists to improve individual and population health by enhancing the delivery of primary care. The Center aims to achieve this mission through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations from the local to international levels. It is a functioning division of the American Academy of Family Physicians that operates with editorial independence. This project was completed with the support of the Josiah Macy, Jr. Foundation. The information and opinions contained in research from the Graham Center do not necessarily reflect the views or policy of the AAFP. vi Executive Summary Unlike many Western nations, the United States does not manage or actively regulate the number, type, or geographic distribution of its physician workforce. As a result, medical trainees choose how and where to work. As with most free markets, equitable distribution is at risk without well-informed, evidence-based policies and incentives capable of promoting equitable access to appropriate care. This study contributes to understanding of important policy options and incentives by identifying factors that influence medical student and resident choices about medical specialties and location of practice. Specifically, it identifies factors that are associated with choice of primary care specialties, particularly family medicine, and with caring for rural and underserved populations. Prior studies of the impact of debt on student specialty choice have revealed mixed effects. Recent studies suggest that physician payment disparities and the medical school learning environment are potent factors for specialty choice, and that exposure to Federal Title VII grant-funded programs during medical school and residency is associated with higher likelihood of students choosing primary care specialties and practice in underserved settings. Most studies of specialty choice or practice location focus on the decisions students make at graduation or immediately thereafter. This study is perhaps the most comprehensive to date, as it examines multiple factors along the training path and how they relate to the end result, which is specialty of physician practice and where they practice. This study incorporates nearly 20 years worth of survey data from graduating medical students about their experiences, their debt, their beliefs, and their intentions. It includes historical files over the same period of exposure to Title VII funds during training, and of participation in National Health Service Corps (NHSC). It includes cross-sectional data about physicians' current specialties and practice locations, and a five-year cross-section of service in Rural and Federally Qualified Health Centers. All of these data about individual physicians were brought together to test for associations between student characteristics and training influences that may have policy relevance for a more purposefully produced health care workforce. Findings: The income gap between primary care and subspecialists has an impressively negative impact on choice of primary care specialties and of practicing in rural or underserved settings. At the high end of the range, radiologist and orthopedic surgeon incomes are nearly three times that of a primary care physician. Over vii a 35-40 year career, this payment disparity produces a $3.5 million gap in return on investment between primary care physicians and the midpoint of income for subspecialist physicians. There are measurable student characteristics, intentions, and training experiences that are significant predictors of our study outcomes. Rural birth, interest in serving underserved or minority populations, exposure to Title VII in medical school, and rural or inner-city training experiences all significantly increased the likelihood of students choosing primary care, rural and underserved careers. Being married increased the likelihood of choosing family medicine. Attending a public medical school significantly increased the probability of choosing a primary care specialty and practicing in a rural, shortage or underserved area, compared with private medical schools. Title VII exposure in residency increased the likelihood of serving in the National Health Service Corps and physician shortage areas but not primary care or rural practice. Other student characteristics reduced the likelihood of study outcomes. Women are much less likely to choose rural practice, and men are less likely to choose primary care. The outcomes associated with debt were complex. Students with no debt and no obligating scholarships (NHSC or Armed Forces) were the least likely to later practice in primary care, in a rural area or in a health center. Debt above $250,000 also reduced these outcomes compared to other levels of debt. Students who took scholarships and reduced debt were much more likely to have careers in all three. There is a group of students sensitive to debt or agreeable to trading debt for service that chooses NHSC and, possibly, other loan repayment programs. The NHSC is currently only available to 3-4% of physicians despite a much larger applicant pool. Conclusions: The outcomes we studied -- practicing in primary care, practicing in family medicine, practicing in a rural community, practicing in a health center, practicing in an underserved area, ever having served in the NHSC-- are important if we hope to secure access to primary care for all people in the United States. Within the last decade, US medical student interest in and choice of these important outcomes fell well below the thresholds necessary to maintain the physician workforce in primary care and underserved settings, threatening to enhance an existing workforce maldistribution. The complex relationship between debt and career outcomes likely has several explanations. Medical students increasingly come from affluent families who may influence career specialty and income expectations, and limited exposure to rural or underserved populations. Alternatively, debt-averse students may not apply to medical school due to fear of debt or may choose less expensive public schools. Both suggest a selection bias against our study outcomes--schools may select students less likely to choose these careers, or students more likely to make these choices are not applying. Students willing to accept obligating debt reduction (NHSC, military), are much more likely to later practice and viii