Health Professions By Michelle M. Washko, John E. Snyder, and George Zangaro 10.1377/hlthaff.2014.1356 HEALTH AFFAIRS 34, NO. 5 (2015): 852–856 ©2015 Project HOPE— The People-to-People Health Foundation, Inc.
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DATAWATC H
Where Do Physicians Train? Investigating Public And Private Institutional Pipelines Where a physician is educated—in a public or a private institution—affects his or her practice choices, including the likelihood of choosing a career in primary care. It is important to monitor the educational pipeline for physicians to ensure that a robust cadre of professionals is entering the health care workforce from public-sector institutions to meet the growing demand for primary care providers.
Michelle M. Washko ([email protected]) is deputy director of the National Center for Health Workforce Analysis at the Health Resources and Services Administration (HRSA), in Rockville, Maryland. John E. Snyder is the senior medical officer in the Office of Planning, Analysis, and Evaluation at HRSA. George Zangaro is director of the National Center for Health Workforce Analysis at HRSA.
U
nderstanding educational pathways for health occupations in the United States is important for strategizing how to reduce workforce shortages, since the number of graduating professionals ultimately influences workforce capacity and, hence, access to care. State-supported universities and colleges play an important role in training the nation’s health care workforce. These public institutions have a history of providing access to education for people who might not otherwise be able to afford it. The institutions increase opportunities for economically disadvantaged people to attend medical school in their home states by charging
lower tuition costs for in-state residents.1,2 This makes medical school more affordable and ultimately increases a person’s career opportunities in the long run.3 Studies show that physicians who attended private-sector institutions or have greater educational debt are less likely to choose to practice in critically needed primary care specialties.4 In contrast, public medical schools with primary care missions tend to produce more generalist physicians and people who ultimately practice in underserved communities.5 As Exhibit 1 illustrates, the nation faces current and future shortfalls in the number of primary care physicians needed to meet future de-
Exhibit 1 Meeting Primary Care Demands: Public And Private Medical Schools
SOURCE Authors’ analysis of data from the following sources: (1) 2010 Integrated Postsecondary Education Data Systems Completions Survey; (2) Association of American Medical Colleges, Results of the 2013 Medical School Enrollment Survey (see Note 13 in text); (3) Jeffe DB, et al. Primary care specialty choices of United States medical graduates (see Note 9 in text); (4) Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners through 2020 (see Note 5 in text). aFor medical students who completed both the Matriculating Student Questionnaire and Medical School Graduation Questionnaire, administered by the Association of American Medical Colleges.
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mand. Compared to private institutions, public institutions graduate slightly more physicians who pursue primary care specialties, having had a lower cost of attendance and having less educational debt than physicians who attended private institutions. Thus, site of education is a key consideration when developing strategies to meet national health workforce needs.6–9 This article describes the contributions of public and private postsecondary institutions to the education of physicians.
Study Data And Methods The Integrated Postsecondary Education Data System (IPEDS) is a set of mandatory surveys administered by the National Center for Education Statistics at the US Department of Education. The center conducts these mandatory surveys of institutions that participate in or apply to participate in federal student financial aid programs. We used data from the 2010 Completions Survey, which contains information on each degree or certificate earned from IPEDS institutions during the 2009–10 academic year. Additionally, two federal taxonomies, the Classification of Instructional Programs and the Standard Occupational Classification system, were used to define a more specific educational pathway for each health occupation. The former taxonomy classifies academic disciplines at institutions of higher education, and the latter classifies all occupations in the US economy. A crosswalk between the codes in the two taxonomies was created and used to generate a cohort of graduates who were adequately prepared for independent practice, based on the required levels of education for the various occupations (for example, people in the physician pipeline were classified as having to earn at least a doctoral degree, and people in the clinical psychology pipeline as needing to obtain at least a master’s degree). Additionally, our comparison of IPEDS data to data from non–federal government sources (such as accrediting bodies and professional associations) suggests that IPEDS accurately reflects the current educational pipeline. Institutions are classified as public or private in the IPEDS Institutional Characteristics Survey. Public institutions are defined as those operated by publicly elected or appointed officials and supported primarily by public funds. Private institutions are defined as those controlled by private individuals or organizations and supported primarily through private funding. Private not-for-profit institutions are defined as those whose controlling organization accrues no profit, other than income to pay wages, rent, or other
expenses. Private for-profit institutions are those whose controlling organization does receive additional types of income, and their goal is to generate a profit for their shareholders or owners. There are limitations to analyzing data from IPEDS. First, the data indicate each educational award—that is, each degree or certificate earned at reporting institutions—during the academic year examined. People who earn dual degrees are counted twice, which could skew the contributions of an institutional type. Second, institutions that do not participate in federal financial aid programs may report to IPEDS, but they are not legally required to. Therefore, our analysis may underestimate the impact of the private sector. Lastly, completion of a degree does not necessarily translate into the presence of an additional full-time-equivalent person in the workforce. Some graduates might not work full time or might not even work at all.
Study Results To better understand the context of physician educational pipelines, this analysis begins with a look at the broader health occupation landscape. Exhibit 2 presents twenty health occupations by type of educational institution. These twenty were selected because they are among the largest US health occupations, they have well-established educational paths that include formal postsecondary education,10 and there are adequate data on them available in public sources. For the twenty health occupations overall, 63.1 percent of degrees and certificates granted to graduates were awarded by public institutions (Exhibit 2). The majority of the remainder were awarded by private not-for-profit institutions. When we took the type of degree required for a profession—such as a master’s degree or a doctoral degree—into consideration, we found that the proportion of graduates from the private notfor-profit sector increased as the level of education increased. There were two exceptions: More doctoral-level degrees for physicians and pharmacists were conferred by public institutions than by private not-for-profit ones. Physicians play an important role in meeting the growing health care needs of the nation. Thus, understanding their educational pipeline is particularly important. There are two different pathways one can follow to become a physician: the allopathic pathway leads to a Doctor of Medicine (MD) degree, and the osteopathic one leads to a Doctor of Osteopathy (DO) degree. There are 129 allopathMay 2 015
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Health Professions Exhibit 2 Graduates In Twenty Health Occupations, By Type Of Educational Institution, 2010 Institution type (%) Profession Dental hygienistsa,b Dietitians and nutritionistsc Clinical laboratory technologistsa,b,c Physical therapist assistantsa Speech-language pathologistsd Licensed practical and vocational nursesb Social workersc,d Registered nursesb,c Dentistse Pharmacistse All physicianse Allopathic (MDs)e Osteopathic (DOs)e Occupational therapistsd Chiropractorse Physician assistantsb,c,d Clinical psychologistsd,e Optometristse Physical therapistse Counselorsd Medical and health services managersc Medical records and health information techniciansa,b All of the above
Number of graduates 7,278 2,601 5,687 4,650 14,161 52,211 35,955 161,705 5,087 11,873
Public 86.4 85.3 84.1 79.5 78.5 71.8 70.2 68.2 59.2 55.6
Private not-for-profit 8.1 12.8 8.8 10.2 21.4 5.4 29.7 24.4 40.8 43.7
Private for-profit 5.5 1.9 7.1 10.3 0.1 22.8 0.0 7.4 0.0 0.7
20,537 16,647 3,890
53.3 60.9 21.0
46.7 39.1 79.0
0.0 0.0 0.0
4,983 2,601
51.9 0.0
47.2 100.0
0.9 0.0
5,338 16,873
32.0 27.9
66.1 64.1
2.0 8.0
1,364 8,948
37.2 44.4
62.8 51.9
0.0 3.7
6,641 13,660
30.3 35.5
41.4 36.3
28.4 28.3
7,028 391,659
42.8 63.1
4.3 27.2
52.9 9.3
SOURCE Authors’ analysis of data from the 2010 Integrated Postsecondary Education Data Systems Completions Survey. NOTES Professions are listed in order of highest percentage to lowest percentage public institution until occupational therapists. After that, beginning with chiropractors, they are listed in order of highest percentage to lowest percentage private not-for-profit institution. Physician assistants are almost exclusively educated at the bachelor’s and master’s degree levels. However, there are still a small number of accredited associate degree programs that are converting to bachelor’s or master’s degree programs. a Degrees for more than one but less than two years of study. bAssociate’s degrees. cBachelor’s degrees. dMaster’s degrees. e Doctoral degrees.
Exhibit 3 Educational Institutions Where Physicians Are Trained, By Census Region, 2010
SOURCE Authors’ analysis of data from the 2010 Integrated Postsecondary Education Data Systems (IPEDS) Completions Survey. NOTES The only medical schools in US nonstate areas—Insular Areas (Territories and Commonwealths), freely associated states, and Outlying Areas—and for which there are IPEDS data are all in Puerto Rico. Graduates from medical schools in Puerto Rico make up only 1.42 percent of US medical school graduates annually and hence are not included in the exhibit. Of the graduates from Puerto Rican schools, 31.69 percent are from public and 68.31 percent are from private institutions. West region: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY. South region: AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV. Midwest region: IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI. Northeast region: CT, ME, MA, NH, NJ, NY, PA, RI, VT.
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ic medical schools 11 and 30 osteopathic schools12 in the United States. Of the allopathic schools, 78 (60.5 percent) are public and 51 (39.5 percent) are private; of the osteopathic schools, 6 are public (20.0 percent) and 24 (80.0 percent) are private. Medical school enrollment has increased over the past several years, with 4,861 first-year positions projected to be added in the period 2002– 18—a 30 percent increase.13 One cause of the new positions is the opening of sixteen new medical schools during this period.13,14 The majority of this growth in the number of medical schools has occurred in the public sector (62 percent); regionally, the largest share of it has occurred in the South (44 percent).13 In 2010 a slight majority of US medical school graduates were trained in public schools. As Exhibit 3 shows, there are notable regional differences. The majority of medical school graduates
Exhibit 4 Population Density And Percentage Of Physicians Trained In Public Institutions, By Census Division
SOURCE Authors’ analysis of data from the following sources: (1) 2010 Integrated Postsecondary Education Data Systems Completions Survey; (2) Census Bureau. Resident population data (text version) [Internet]. Washington (DC): Census Bureau; [cited 2015 Mar 19]. Available from: http://www.census.gov/2010census/data/apportionment-dens-text.php.
in the Northeast were trained at private not-forprofit institutions. However, public institutions graduated the largest proportion of new physicians in the nation’s other regions. Consistent with the location and type of new medical schools, 66.4 percent of medical school graduates in the South were from public institutions. Exhibit 4 shows that the West South Central states primarily train physicians in public institutions, whereas states in New England train a higher percentage of physicians in private institutions than any other census division does. Even more compelling is the fact that the fourteen most rural states train 75 percent of their physicians in public institutions, whereas the split between public and private institution training is more even in the other states (data not shown).15
Conclusion These data show that the majority of health occupation degrees and certificates were earned in public-sector institutions, making this type of institution the primary pipeline for educating the nation’s US-trained health workforce. This
is true also for physicians specifically. However, there is some geographical variation across the country in terms of which regions graduate more physicians from public medical schools. In the Northeast, particularly in New England, more physicians graduate from private institutions than from public ones. In the South public institutions have a slight edge on producing physician graduates. It is also worth noting that of the sixteen new medical schools established in the United States since 2002, seven are in the South.14 The analysis also confirms that more physicians graduate from public institutions than from private ones in rural areas, especially in the most rural states. This is a particularly important point to note because previous research16 has shown that where physicians train can help determine not only where they practice, but also their future specialty. Physicians trained in rural areas tend to practice in rural areas.16 In addition, physicians trained in public institutions choose primary care specialties more often than their counterparts who are educated at private institutions. This may be partly due to the lower educational costs of public medical schools, May 2 015
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Health Professions which in turn provide graduates with the opportunity to pursue a career with a lower salary. Public institutions receive considerable state funding to serve their communities. Thus, states The authors thank Edward Salsberg, Margaret Glos, and Shafali Srivastava for the initial conceptualization of and special efforts that led to this analysis. The authors also acknowledge the thorough input of the anonymous
have a significant interest in ensuring that these academic institutions practice social accountability and provide a return on the states’ investment. ▪
reviewers and Donald Metz of Health Affairs, which helped improve the usefulness of this article. The views expressed in the article are solely the opinions of the authors and do not necessarily reflect the official policies
of the Department of Health and Human Services (HHS) or the Health Resources and Service Administration (HRSA), nor does mention of the names of HHS or HRSA imply endorsement by the US government.
NOTES 1 Youngclaus J, Fresne J. Trends in cost and debt at U.S. medical schools using a new measure of medical school cost of attendance [Internet]. Washington (DC): Association of American Medical Colleges; 2012 Jul [cited 2015 Mar 19]. (Analysis in Brief). Available from: https://www .aamc.org/download/296002/data/ aibvol12_no2.pdf 2 Association of American Medical Colleges. How do I…pay for medical school? [Internet]. Washington (DC): AAMC; [cited 2015 Mar 19]. Available from: https://www.aamc .org/students/aspiring/paying/ 283080/pay-med-school.html 3 Nemec MR. Ivory towers and nationalist minds: universities, leadership, and the development of the American state [Internet]. Ann Arbor (MI): University of Michigan Press; 2006 [cited 2014 Oct 9]. Available from: http://www.press .umich.edu/pdf/0472099124-ch3 .pdf 4 Palmeri M, Pipas C, Wadsworth E, Zubkoff M. Economic impact of a primary care career: a harsh reality for medical students and the nation. Acad Med. 2010;85(11):1692–7. 5 Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners through 2020 [Internet]. Rockville (MD): HRSA; 2013 Nov [cited 2015 Mar 19]. Available from: http://bhpr.hrsa.gov/healthwork force/supplydemand/usworkforce/ primarycare/projectingprimarycare
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.pdf 6 Phillips RL Jr, Dodoo MS, Petterson S, Xierali I, Bazemore A, Teevan B, et al. Specialty and geographic distribution of the physician workforce: what influences medical student and resident choices? [Internet]. Washington (DC): Robert Graham Center; 2009 Mar 2 [cited 2015 Mar 19]. 102 p. Available from: http://www .graham-center.org/online/etc/ medialib/graham/documents/ publications/mongraphs-books/ 2009/rgcmo-specialty-geographic .Par.0001.File.tmp/Specialtygeography-compressed.pdf 7 Senf JH, Campos-Outcalt D, Kutob R. Factors related to the choice of family medicine: a reassessment and literature review. J Am Board Fam Pract. 2003;16(6):502–12. 8 Block SD, Clark-Chiarelli N, Singer JD. Mixed messages about primary care in the culture of U.S. medical schools. Acad Med. 1998;73(10): 1087–94. 9 Jeffe DB, Whelan AJ, Andriole DA. Primary care specialty choices of United States medical graduates, 1997–2006. Acad Med. 2010; 85(6):947–58. 10 Education either is required for licensure or is listed in Bureau of Labor Statistics. Occupational outlook handbook [Internet]. Washington (DC): Bureau of Labor Statistics; 2014 Jan 8 [cited 2015 Mar 19]. Available from: http://www.bls .gov/ooh/ 11 Association of American Medical
12
13
14
15
16
Colleges. Tables and graphs for fiscal year 2013 [Internet]. Washington (DC): AAMC; [cited 2015 Mar 19]. Available from: https://www.aamc .org/data/finance/2013tables/ American Association of Colleges of Osteopathic Medicine. U.S. colleges of osteopathic medicine [Internet]. Chevy Chase (MD): AACOM; c 2015 [cited 2015 Mar 19]. Available from: http://www.aacom.org/about/ colleges/Pages/default.aspx Association of American Medical Colleges. Results of the 2013 Medical School Enrollment Survey [Internet]. Washington (DC): AAMC; 2014 Mar [cited 2015 Mar 17]. Available from: https://members.aamc.org/ eweb/upload/13-239%20 Enrollment%20Survey%20201310 .pdf Liaison Committee on Medical Education. Medical school directory [Internet]. Washington (DC): LCME; c 2015 [cited 2015 Mar 27]. Available from: http://www.lcme.org/ directory.htm Of the ten most rural states, four (Alaska, Idaho, Montana, and Wyoming) do not have medical schools. To have a list of ten rural states with medical schools, we added to the group the next four most rural states. Chen F, Fordyce M, Andes S, Hart LG. Which medical schools produce rural physicians? A 15-year update. Acad Med. 2010;85(4):594–8.
doi:
DATAWATC H
Where Do Physicians Train? Investigating Public And Private Institutional Pipelines Where a physician is educated—in a public or a private institution—affects his or her practice choices, including the likelihood of choosing a career in primary care. It is important to monitor the educational pipeline for physicians to ensure that a robust cadre of professionals is entering the health care workforce from public-sector institutions to meet the growing demand for primary care providers.
Michelle M. Washko ([email protected]) is deputy director of the National Center for Health Workforce Analysis at the Health Resources and Services Administration (HRSA), in Rockville, Maryland. John E. Snyder is the senior medical officer in the Office of Planning, Analysis, and Evaluation at HRSA. George Zangaro is director of the National Center for Health Workforce Analysis at HRSA.
U
nderstanding educational pathways for health occupations in the United States is important for strategizing how to reduce workforce shortages, since the number of graduating professionals ultimately influences workforce capacity and, hence, access to care. State-supported universities and colleges play an important role in training the nation’s health care workforce. These public institutions have a history of providing access to education for people who might not otherwise be able to afford it. The institutions increase opportunities for economically disadvantaged people to attend medical school in their home states by charging
lower tuition costs for in-state residents.1,2 This makes medical school more affordable and ultimately increases a person’s career opportunities in the long run.3 Studies show that physicians who attended private-sector institutions or have greater educational debt are less likely to choose to practice in critically needed primary care specialties.4 In contrast, public medical schools with primary care missions tend to produce more generalist physicians and people who ultimately practice in underserved communities.5 As Exhibit 1 illustrates, the nation faces current and future shortfalls in the number of primary care physicians needed to meet future de-
Exhibit 1 Meeting Primary Care Demands: Public And Private Medical Schools
SOURCE Authors’ analysis of data from the following sources: (1) 2010 Integrated Postsecondary Education Data Systems Completions Survey; (2) Association of American Medical Colleges, Results of the 2013 Medical School Enrollment Survey (see Note 13 in text); (3) Jeffe DB, et al. Primary care specialty choices of United States medical graduates (see Note 9 in text); (4) Health Resources and Services Administration. Projecting the supply and demand for primary care practitioners through 2020 (see Note 5 in text). aFor medical students who completed both the Matriculating Student Questionnaire and Medical School Graduation Questionnaire, administered by the Association of American Medical Colleges.
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mand. Compared to private institutions, public institutions graduate slightly more physicians who pursue primary care specialties, having had a lower cost of attendance and having less educational debt than physicians who attended private institutions. Thus, site of education is a key consideration when developing strategies to meet national health workforce needs.6–9 This article describes the contributions of public and private postsecondary institutions to the education of physicians.
Study Data And Methods The Integrated Postsecondary Education Data System (IPEDS) is a set of mandatory surveys administered by the National Center for Education Statistics at the US Department of Education. The center conducts these mandatory surveys of institutions that participate in or apply to participate in federal student financial aid programs. We used data from the 2010 Completions Survey, which contains information on each degree or certificate earned from IPEDS institutions during the 2009–10 academic year. Additionally, two federal taxonomies, the Classification of Instructional Programs and the Standard Occupational Classification system, were used to define a more specific educational pathway for each health occupation. The former taxonomy classifies academic disciplines at institutions of higher education, and the latter classifies all occupations in the US economy. A crosswalk between the codes in the two taxonomies was created and used to generate a cohort of graduates who were adequately prepared for independent practice, based on the required levels of education for the various occupations (for example, people in the physician pipeline were classified as having to earn at least a doctoral degree, and people in the clinical psychology pipeline as needing to obtain at least a master’s degree). Additionally, our comparison of IPEDS data to data from non–federal government sources (such as accrediting bodies and professional associations) suggests that IPEDS accurately reflects the current educational pipeline. Institutions are classified as public or private in the IPEDS Institutional Characteristics Survey. Public institutions are defined as those operated by publicly elected or appointed officials and supported primarily by public funds. Private institutions are defined as those controlled by private individuals or organizations and supported primarily through private funding. Private not-for-profit institutions are defined as those whose controlling organization accrues no profit, other than income to pay wages, rent, or other
expenses. Private for-profit institutions are those whose controlling organization does receive additional types of income, and their goal is to generate a profit for their shareholders or owners. There are limitations to analyzing data from IPEDS. First, the data indicate each educational award—that is, each degree or certificate earned at reporting institutions—during the academic year examined. People who earn dual degrees are counted twice, which could skew the contributions of an institutional type. Second, institutions that do not participate in federal financial aid programs may report to IPEDS, but they are not legally required to. Therefore, our analysis may underestimate the impact of the private sector. Lastly, completion of a degree does not necessarily translate into the presence of an additional full-time-equivalent person in the workforce. Some graduates might not work full time or might not even work at all.
Study Results To better understand the context of physician educational pipelines, this analysis begins with a look at the broader health occupation landscape. Exhibit 2 presents twenty health occupations by type of educational institution. These twenty were selected because they are among the largest US health occupations, they have well-established educational paths that include formal postsecondary education,10 and there are adequate data on them available in public sources. For the twenty health occupations overall, 63.1 percent of degrees and certificates granted to graduates were awarded by public institutions (Exhibit 2). The majority of the remainder were awarded by private not-for-profit institutions. When we took the type of degree required for a profession—such as a master’s degree or a doctoral degree—into consideration, we found that the proportion of graduates from the private notfor-profit sector increased as the level of education increased. There were two exceptions: More doctoral-level degrees for physicians and pharmacists were conferred by public institutions than by private not-for-profit ones. Physicians play an important role in meeting the growing health care needs of the nation. Thus, understanding their educational pipeline is particularly important. There are two different pathways one can follow to become a physician: the allopathic pathway leads to a Doctor of Medicine (MD) degree, and the osteopathic one leads to a Doctor of Osteopathy (DO) degree. There are 129 allopathMay 2 015
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Health Professions Exhibit 2 Graduates In Twenty Health Occupations, By Type Of Educational Institution, 2010 Institution type (%) Profession Dental hygienistsa,b Dietitians and nutritionistsc Clinical laboratory technologistsa,b,c Physical therapist assistantsa Speech-language pathologistsd Licensed practical and vocational nursesb Social workersc,d Registered nursesb,c Dentistse Pharmacistse All physicianse Allopathic (MDs)e Osteopathic (DOs)e Occupational therapistsd Chiropractorse Physician assistantsb,c,d Clinical psychologistsd,e Optometristse Physical therapistse Counselorsd Medical and health services managersc Medical records and health information techniciansa,b All of the above
Number of graduates 7,278 2,601 5,687 4,650 14,161 52,211 35,955 161,705 5,087 11,873
Public 86.4 85.3 84.1 79.5 78.5 71.8 70.2 68.2 59.2 55.6
Private not-for-profit 8.1 12.8 8.8 10.2 21.4 5.4 29.7 24.4 40.8 43.7
Private for-profit 5.5 1.9 7.1 10.3 0.1 22.8 0.0 7.4 0.0 0.7
20,537 16,647 3,890
53.3 60.9 21.0
46.7 39.1 79.0
0.0 0.0 0.0
4,983 2,601
51.9 0.0
47.2 100.0
0.9 0.0
5,338 16,873
32.0 27.9
66.1 64.1
2.0 8.0
1,364 8,948
37.2 44.4
62.8 51.9
0.0 3.7
6,641 13,660
30.3 35.5
41.4 36.3
28.4 28.3
7,028 391,659
42.8 63.1
4.3 27.2
52.9 9.3
SOURCE Authors’ analysis of data from the 2010 Integrated Postsecondary Education Data Systems Completions Survey. NOTES Professions are listed in order of highest percentage to lowest percentage public institution until occupational therapists. After that, beginning with chiropractors, they are listed in order of highest percentage to lowest percentage private not-for-profit institution. Physician assistants are almost exclusively educated at the bachelor’s and master’s degree levels. However, there are still a small number of accredited associate degree programs that are converting to bachelor’s or master’s degree programs. a Degrees for more than one but less than two years of study. bAssociate’s degrees. cBachelor’s degrees. dMaster’s degrees. e Doctoral degrees.
Exhibit 3 Educational Institutions Where Physicians Are Trained, By Census Region, 2010
SOURCE Authors’ analysis of data from the 2010 Integrated Postsecondary Education Data Systems (IPEDS) Completions Survey. NOTES The only medical schools in US nonstate areas—Insular Areas (Territories and Commonwealths), freely associated states, and Outlying Areas—and for which there are IPEDS data are all in Puerto Rico. Graduates from medical schools in Puerto Rico make up only 1.42 percent of US medical school graduates annually and hence are not included in the exhibit. Of the graduates from Puerto Rican schools, 31.69 percent are from public and 68.31 percent are from private institutions. West region: AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR, UT, WA, WY. South region: AL, AR, DE, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV. Midwest region: IL, IN, IA, KS, MI, MN, MO, NE, ND, OH, SD, WI. Northeast region: CT, ME, MA, NH, NJ, NY, PA, RI, VT.
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ic medical schools 11 and 30 osteopathic schools12 in the United States. Of the allopathic schools, 78 (60.5 percent) are public and 51 (39.5 percent) are private; of the osteopathic schools, 6 are public (20.0 percent) and 24 (80.0 percent) are private. Medical school enrollment has increased over the past several years, with 4,861 first-year positions projected to be added in the period 2002– 18—a 30 percent increase.13 One cause of the new positions is the opening of sixteen new medical schools during this period.13,14 The majority of this growth in the number of medical schools has occurred in the public sector (62 percent); regionally, the largest share of it has occurred in the South (44 percent).13 In 2010 a slight majority of US medical school graduates were trained in public schools. As Exhibit 3 shows, there are notable regional differences. The majority of medical school graduates
Exhibit 4 Population Density And Percentage Of Physicians Trained In Public Institutions, By Census Division
SOURCE Authors’ analysis of data from the following sources: (1) 2010 Integrated Postsecondary Education Data Systems Completions Survey; (2) Census Bureau. Resident population data (text version) [Internet]. Washington (DC): Census Bureau; [cited 2015 Mar 19]. Available from: http://www.census.gov/2010census/data/apportionment-dens-text.php.
in the Northeast were trained at private not-forprofit institutions. However, public institutions graduated the largest proportion of new physicians in the nation’s other regions. Consistent with the location and type of new medical schools, 66.4 percent of medical school graduates in the South were from public institutions. Exhibit 4 shows that the West South Central states primarily train physicians in public institutions, whereas states in New England train a higher percentage of physicians in private institutions than any other census division does. Even more compelling is the fact that the fourteen most rural states train 75 percent of their physicians in public institutions, whereas the split between public and private institution training is more even in the other states (data not shown).15
Conclusion These data show that the majority of health occupation degrees and certificates were earned in public-sector institutions, making this type of institution the primary pipeline for educating the nation’s US-trained health workforce. This
is true also for physicians specifically. However, there is some geographical variation across the country in terms of which regions graduate more physicians from public medical schools. In the Northeast, particularly in New England, more physicians graduate from private institutions than from public ones. In the South public institutions have a slight edge on producing physician graduates. It is also worth noting that of the sixteen new medical schools established in the United States since 2002, seven are in the South.14 The analysis also confirms that more physicians graduate from public institutions than from private ones in rural areas, especially in the most rural states. This is a particularly important point to note because previous research16 has shown that where physicians train can help determine not only where they practice, but also their future specialty. Physicians trained in rural areas tend to practice in rural areas.16 In addition, physicians trained in public institutions choose primary care specialties more often than their counterparts who are educated at private institutions. This may be partly due to the lower educational costs of public medical schools, May 2 015
34:5
Health A ffairs
855
Health Professions which in turn provide graduates with the opportunity to pursue a career with a lower salary. Public institutions receive considerable state funding to serve their communities. Thus, states The authors thank Edward Salsberg, Margaret Glos, and Shafali Srivastava for the initial conceptualization of and special efforts that led to this analysis. The authors also acknowledge the thorough input of the anonymous
have a significant interest in ensuring that these academic institutions practice social accountability and provide a return on the states’ investment. ▪
reviewers and Donald Metz of Health Affairs, which helped improve the usefulness of this article. The views expressed in the article are solely the opinions of the authors and do not necessarily reflect the official policies
of the Department of Health and Human Services (HHS) or the Health Resources and Service Administration (HRSA), nor does mention of the names of HHS or HRSA imply endorsement by the US government.
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