Best Beginnings for Health Access Clinicians

Highest income, most urban, children of professionals are not the best beginnings for health access workforce. Geographic origins, specialized life orientation, choice of prestigious colleges and medical schools, deficits of family medicine choice (2 - 4%), and lowest distribution levels all limit health access recovery. As American medical students increase in exclusivity, it is not a surprise that they decrease in health access workforce result. Earlier life influences shape the next steps via experiential place - resulting in failures in health access.

Medical School Admission and Origin

Greatest probability of higher education is seen in those highest in income. The top 146 colleges are considered the most prestigious and are the most likely starting point for careers in medicine and other professions. Carnevale and Rose documented 74% of such university students arising from the top income quartile (3 to 1 higher ratio) with only 3% arising from the bottom income quartile (1 out of 8). To gain higher education, higher education tracks are required plus high school graduation. In second grade children take tests that funnel them to tracks leading to higher education, or not. Substantial advantages in language and other areas are seen in children of most exclusive origins. Lack of early childhood intervention assures little opportunity for those behind from birth.

Before birth, children in America have much higher and much lower 
opportunity for higher education and advanced degrees. 

Previous birth origin studies have documented highest ratios of admission by geographic origin, race, ethnicity, and gender.

Mexican American populations and geographic locations such as counties with lower to lowest income have 3 to 5 times lower probability of medical school admission. Asian populations and populations connected with highest income, most urban, and most educated origins have 3 to 1 greater probability of admissions or higher, reaching 7 times in Asian Indian populations - the highest income US population with one of the most concentrated most urban origins.

County birth origins of physicians indicate highest or lowest probability of admission from birth. Birth in Los Alamos NM or Schenectady NY or Bartlesville OK or Huntsville AL is birth more likely to involve concentrations of PhD parents - research and development for the federal government or corporations. Counties that have benefited from highest income suburbs are also tops in birth origin. Collin County TX is associated with academic outcomes, schoolboy football prowess, and top ratios of medical school admission.

Asian populations concentrate in highest income, highest property value, most urban locations and had 3 to 1 admissions or 15% of medical students despite about 5% of the US population. These ratios are even higher in some medical schools that have reached 40% Asian - in medical schools associated with highest Asian population concentrations. Asian Indian populations are less than 1% in the US yet are over 7% of medical students in the US.

Highest income, most urban, highest property value aids in school district funding, college focused tracks during school, and other advantages dating back to birth and before. Advantage and disadvantage matters. This was true for 1990s graduates and further divisions between US populations will divide admission origins further.

1994 - 2000 Allopathic Graduates Medical Students 1994-2000 % of
Medical Students
Ratio Compared to Allopathic Medical Students US Population Number
Age 18 - 24
Medical Students 1994-2000 (AAMC)
US All Student Total 125,549 100.00% 201.7 25327972 125549
Asian Indian 8,136 6.50% 22.6 183600 8136
Chinese 4,882 3.90% 59.7 291600 4882
All Asian Students 20,340 16.20% 63.2 1285073 20340
Vietnamese 1,424 1.10% 83.6 118988 1424
Foreign Born (Since 2000) 16.00% 120.6
All Urban Born 109,228 87.00% 138.6 15142695 109228
US All Student Total 125,549 100.00% 201.7 25327972 125549
White 81,973 65.30% 214.1 17551232 81973
All Foreign Born 7,533 6.00% 279.8 2107550 7533
Only Native American 871 0.70% 314.7 274116 871
All Rural Born 16,321 13.00% 356.9 5825433 16321
Black 8,880 7.10% 422.4 3751202 8880
Any Native American  871 0.70% 501.3 436646 871
Low Income Rural 3,690 2.90% 677.6 2500356 3690
All Hispanic 5,975 4.80% 756.3 4519145 5975
Mexican American 2,887 2.30% 915.1 2642011 2887

Income Quintile and Estimated % of Medical Students Admitted By Income Group

TopQuintile Income





2ndQuintile Income 25,110 20.00% 201.7 5065594 25110
3rd Quintile Income 15,066 12.00% 373.6 5628438 15066
4th Quintile Income 10,044 8.00% 616.4 6191282 10044
5th Quintile Income 2,511 2.00% 2689.8 6754126 2511

Admissions Ratio By Birth Origins

As county income levels increase, family medicine choice decreases as does rural practice location and location where workforce is needed.

In addition, family medicine choice since 2000 has decreased across all populations compared to the above. Students of privilege have different state origins, different county origins, different origins within counties, attend different medical schools, and have lowest choice of health access careers. From Admissions Ratio By Birth Origins  and Rural Medical Education site

Since 2001, greater gaps have been seen between those admitted and those not admitted - a likely function of fewer Americans doing well and most Americans falling behind.

As probability of admission decreases, choice of family medicine increases. Across the locations and populations associated with lower concentrations of income, education, and clinicians, family medicine clinicians are more likely to be seen. Generalists and general lifestyle dominates where care is needed. Primary care, family practice, and practice where needed follows origin factors.

A steady movement away from admission of the students most likely to choose family medicine has been a factor freezing family medicine at 3000 annual graduates per class year since 1980 - a factor in preventing recovery of health access workforce. This may not be as powerful a factor in preventing primary care recovery as compared to poor primary care payment support, but admissions, medical school training, and policy designs all conspire to keep most Americans limited in access - and not just in family medicine result.

The Family Medicine Multiplier

As in the recent blog, family medicine is more important than ever. FM graduates deliver multiple times more primary care over a career than the other 5 sources. FM graduates have the multiple times greater distribution because of family practice over an entire career. The medical education barriers that prevent family medicine should be bypassed. Preparation and early training must be made specific to family practice. Our nation should stop bypassing its best health access solutions.

Also for each birth origin and across each medical school, family medicine choice multiplies distribution to locations and populations in need by 2 to 3 times. No matter what the birth origin, the family medicine multiplier is needed. Birth origin changes are failing for the purpose of health access recovery, but family medicine multiplies health access result regardless of birth origin.

With the decline of birth origins associated with distribution, family medicine choice is even more important. The lesson of changes in birth origins and poor choice of family medicine in medical school

- is the need for family medicine medical school - to bypass origin and medical school barriers.

When specific focus is brought to bear upon health access recovery, the requirements for health access recovery can be better understood - Instate, Primary Care, Where Needed
  • Instate origins, preparation, and training with all possible connections to the state in need of workforce for optimal result
  • Permanent 90% or greater primary care result over a career  
  • Distribution where workforce is most needed - as is seen only in family practice position result over a career
Maximal instate, maximal primary care, and maximal distribution where needed is the result of a design for training clinicians in family practice with 90% family practice position result. This is the current result of family medicine training and other clinician sources would need to have 90% family practice position result to contribute best to health access.

States that truly intend instate health access recovery and the economic recovery associated with such services, would do well to invest specifically rather than in workforce that moves readily to states, to non-primary care, and to locations with concentrations of physicians - the usual directions as guided by policy and training.

Recent Works

Family Medicine Needs a New Beginning

Hotspotting Has Many Spots To Consider

Retail Clinic Recoil

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice

Domino Decline By Design

Declines in Health Care Delivery Despite Increases in Health Spending

Perverse Health Payment Dividing US

How To Resolve Health Access for 40 States Behind By Design

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.


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