FINDING 3: The substantial growth in the
number of physicians in the United States has
not eliminated the problem of geographic
maldistribution; most of this growth is
comprised of specialists who practice in
affluent metropolitan areas, while most of the
underserved population live in rural and
inner-city areas and need enhanced primary
care services.
An oversupply of physicians in the United
States appears to be emerging. Although medical
school class size has been trimmed slightly, and a
greater proportion of graduating students has chosen
primary care fields in the past few years, many
metropolitan areas have a substantial oversupply
of specialty physicians. Unfortunately, this has not
translated into migration of practicing physicians
into underserved areas or primary care specialties.
Geographic maldistribution will persist even as the
physician supply grows.
The recent renaissance of primary care disciplines
has been stimulated by a broad array of federal
and private foundation programs for medical
students and primary care residents, and by changes
in the delivery system that have increased the
market’s demand for generalists. Given the powerful
historical forces that encourage physicians to
specialize—both within the academic community
and in the practice environment—this renaissance
is fragile. Continued support is essential for
programs that identify students likely to serve
underserved communities, encourage them to enter
primary care disciplines, and assist them in establishing
viable practices in underserved communities.
Recommendation 5: Continue to support federal
and state programs such as Title VII of
the PHS Act that have been proven to increase
the number of physicians who choose
generalist careers, practice in rural and inner-
city areas, and serve underserved populations.
FINDING 4: The existing MUA/P and HPSA
criteria no longer do an adequate job of
identifying areas with absolute or relative health
personnel shortages.
Current processes for designation of shortage
areas are flawed. Both measures have become so
malleable that some segment of virtually any geographic
area could obtain designation as a short-age
area under one or both criteria. This partially
reflects the fact that in our current health care system
a substantial proportion of the population is
underserved, either because they are uninsured,
experience cultural, linguistic, and economic barriers
that deny them access to health services that
surround them, or—more rarely—live in places
with very few health care workers.
The principal problem with the current designation
tools is that they have lost credibility (GAO,
1995). This undermines the programs that use them.
Although they have allowed enormous flexibility
in the way in which communities and organizations
use federal programs, some areas officially designated
under these programs may no longer be
underserved. The current revisions of the designation
process being undertaken by BPHC should
maintain some flexibility while ensuring the accuracy
of the designations themselves. Designations
should differentiate provider shortage from economic
disadvantage while being selective enough to effectively
target federal intervention to those most in need.
Recommendation 6: The current MUA/P and
HPSA designations should be replaced by a
uniform, rational, objective, feasible, and periodically
updated measurement of medical
underservice. The current effort of the
HRSA to revise the designation process
should be bolstered and expedited, and
should be based on state-of-the-art research
that incorporates measures of health status,
poverty, cultural disadvantage, the availability
of health insurance coverage, and the effective
supply of health personnel. Designations
should be exclusive enough to promote
the most effective targeting of limited federal
resources.
FINDING 5: The number of physicians in many
rural areas remains inadequate, despite the
rapid expansion in the nation’s physician
supply.
FINDING 6: Expansion of the total physician
supply is an very inefficient way of
addressing the problem of geographic maldistribution
Geographic maldistribution persists, despite the
rapid expansion of the nation’s physician supply
during the past decade. The problem is most marked
for the smallest and most remote communities, but
rural towns in every demographic classification
have fewer physicians of all types, including generalists,
than metropolitan areas.
Increases in the aggregate supply of physicians
have begun to translate into an increased number
of physicians in rural areas, but the response is directly
related to the size of the community and its
proximity to urban areas. The greatest residual problems
are in rural communities of less than 10,000
people that are not adjacent to metropolitan areas:
the physician supply in these areas is only slightly
higher than it was in 1940. While the physician-to-population
ratio in urban areas has more than
doubled since 1960, it has risen by less than 15
percent in the smallest rural communities.
Recommendation 7: The nation should continue
to encourage and support medical education
and health care delivery programs
that increase the flow of physicians to rural
areas, with an emphasis on the smaller and
more remote communities.
FINDING 7: Specialty choice is the most
powerful predictor of rural practice location;
family physicians are much more likely than any
other specialty to settle in rural areas and
comprise almost half of the entire physician
population in rural areas. The relatively small
number of family physicians educated has
contributed to the shortage of rural
physicians.
The supply of rural physicians is largely dependent
on the production of family physicians,
both allopathic and osteopathic physicians. Although
many factors contribute to the choice to
practice in rural areas—rural upbringing, medical
school attended, and special educational service
experiences—the final common pathway for the largest number of rural physicians is a family medicine
residency. Family physicians have the clinical
flexibility to provide care in virtually any rural setting,
and the discipline of family medicine has long
and enduring rural roots.
It is important to recognize that there is a distinction
between enhancing generalist careers because
of society’s need for more primary care physicians
and the importance of training family
physicians specifically because of their predilection
for rural practice. The emphasis on training
more general internists and pediatricians—and the
efforts of the specialty of OB/GYN to define itself
as a generalist discipline—provide an important
source of primary care physicians for the nation
as a whole but have had a relatively minor influence
on ameliorating the problem of rural physician
shortages, especially in the more sparsely
populated rural areas. General surgeons have a potentially
important role to play in rural areas, but
changes in training of general surgeons—and
further specialization within the field of surgery
generally—have led to a decline in the supply of
rural general surgeons.
Recommendation 8: Federal support for undergraduate
and residency training of family
physicians should be sustained. Title VII
support for family medicine programs with
a successful record of placing physicians in
rural and underserved areas should be increased.
Recommendation 9: Encourage the development
of primary care residencies in general
internal medicine and general pediatrics and
residencies in general surgery and OB/GYN
that prepare, deploy, and support graduates
who will have the skills and the desire to
practice in rural areas.
FINDING 8: Women are much less likely than
men to practice in rural areas; the recent
increase in the proportion of women
physicians may affect the future supply of rural
physicians.
The rapid expansion of the number of women
in medicine has potential implications for the future
supply of rural physicians. Women are much
less likely than men to locate in rural areas, and
this phenomenon has the potential to further complicate
the recruitment of rural physicians. This is
an area where additional information and monitoring
of trends are important.
Recommendation 10: Support future research
into the impact of gender on rural
practice location, and consider the establishment
of demonstration programs that lead
to an increase in the number of women practicing
in rural areas.
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