No abstract

In the early 1970s, affirmative-action programs were introduced to accomplish a number of social goals, including increasing the supply of minority physicians and improving the health care of the poor. To assess the success of such programs, we analyzed data on people who graduated from U.S. medical schools in 1975 to determine how specialty choice, practice locations, patient populations served, and board-certification rates differ between minority and nonminority graduates. A larger proportion of minority graduates (55 per cent vs. 41 per cent, P less than 0.001) chose the primary-care specialties of family practice, general internal medicine, general pediatrics, and obstetrics-gynecology. Significantly more minority physicians (12 per cent vs. 6 per cent, P less than 0.01) practiced in locations designated as health-manpower shortage areas by the federal government and had more Medicaid recipients in their patient populations (31 per cent for blacks, 24 per cent for Hispanics, 14 per cent for whites; P less than 0.001). Physicians from each racial or ethnic group served disproportionately more patients of their own racial or ethnic group (P less than 0.001), but minority physicians did not serve significantly more persons from other racial or ethnic minority groups than did nonminority physicians. Many minority physicians served patient populations much like those of their nonminority colleagues, which indicates that substantial integration of the medical marketplace has taken place. Significantly fewer minority graduates had become board-certified by 1984 (48 per cent vs. 80 per cent, P less than 0.001), and most of this disparity was associated with differences in premedical-school characteristics and in the patient populations they served. Our analysis shows that minority graduates of the medical school class of 1975 are fulfilling many of the objectives of affirmative-action programs.

To estimate the number of full-time-equivalent (FTE) physicians and geriatricians needed to provide medical care in the years 2000 to 2030, we developed utilization-based models of need for non-surgical physicians and need for geriatricians. Based on projected utilization, the number of FTE physicians required to care for the elderly will increase two- or threefold over the next 40 years. Alternate economic scenarios have very little effect on estimates of FTE physicians needed but exert large effects on the projected number of FTE geriatricians needed. We conclude that during the years 2000 to 2030, population growth will be the major factor determining the number of physicians needed to provide medicare care; economic forces will have a greater influence on the number of geriatricians needed.

We studied the recent distribution of board-certified specialists among cities and towns of different sizes. Between 1960 and 1977, diplomates of the eight specialty boards that we studied appeared for the first time in many small nonmetropolitan towns. The percentage increase in numbers of specialists in small towns significantly exceeded that in cities, but the absolute increase in specialists per 100,000 persons was greater in metropolitan areas. Our findings suggest that the increased supply of specialists activated market forces that caused the observed changes in distribution. It is also possible that a new preference for small-town living has contributed to this evolving pattern. If an increase in physician supply has been the major force responsible for the movement into nonmetropolitan areas, this trend implies that smaller and smaller towns will acquire board-certified specialists as the number of physicians increases.

We used detailed information from 16 states to determine the distance that residents of outlying areas (or of towns of less than 25,000, outside metropolitan areas) must travel to receive various types of medical care. For both 1970 and 1979, we found that approximately 80 per cent of such residents lived within 10 miles' driving distance of some physician and 98 per cent lived within 25 miles. Most of the remaining 2 per cent lived in areas so sparsely settled that physicians will not find them economically attractive as practice locations. During the 1970s, the distance of members of the studied population from medical and surgical specialists was substantially reduced. The greatest improvement occurred for the specialties that had the largest percentage increase in their numbers. As the physician pool expands further during the 1980s, geographic access to specialty care for rural and small-town residents should show a further notable improvement. However, this improvement may not suffice to meet what some consider the "medical need" of those who are geographically isolated or economically deprived.