"Not everyone working in primary care has the same likelihood of working in rural or inner-city practices," said Kevin Grumbach, MD, UCSF professor and chair of family and community medicine and director of UCSF's Center for California Health Workforce Studies. "We found that physician assistants, family physicians, nurse practitioners and nurse midwives are more likely to work in needy communities than are general internists, pediatricians, and obstetricians."
According to Grumbach, physician assistants, nurses and family physicians have a history of having an explicit mission of service to the underserved as part of their professions. State and federal funds have been used in the past to increase the number of people practicing in these areas of the health care profession based on the assumption that many of these people would then practice in needy communities. "That's exactly what has happened," Grumbach said. "Those investments have paid off," he added.
However, training programs for physician assistants, nurses and family physicians are in danger of being drastically diminished or cut entirely because of state- and federal-level cutbacks, Grumbach said. "Cuts in primary care training programs exert a toll on patients living in needy communities. Every time a family practice or physician assistant program closes due to loss of funding, the health care system turns off another pipeline supplying the future primary care clinicians who serve needy communities."
The study, which appears July 29 in the July/August issue of the Annals of Family Medicine, reveals that physician assistants were most likely to work in underserved areas, such as federally designated "Primary Care Health Professions Shortage Areas," followed closely by family physicians, nurse practitioners and nurse midwives. Primary care physicians practicing general internal medicine, general pediatrics or obstetrics/gynecology were less likely to practice in rural and urban shortage areas.
Grumbach and his colleagues examined data collected in 1998 by the American Medical Association and the states of California and Washington. They found that 22 percent of physician assistants in California and 28 percent of physician assistants in Washington were located in rural areas. These percentages compared to 13 percent of California's population and 24 percent of Washington's population residing in these areas in that year. In California, family physicians were twice as likely as other primary care doctors to practice in rural areas.
The results were similar for needy urban regions in California, with 28 percent of urban physician assistants, 33 percent of urban nurse midwives and 21 percent of urban family physicians working in shortage areas, compared with only 15 to 17 percent of urban physicians in the other primary care disciplines working in Shortage Areas.
The results of the current study should help policymakers to set priorities when working to both increase access to health care and balance budgets, Grumbach said. "If the goal in health care is to prioritize resources for patients most in need, then we should be investing in the training programs that produce primary care clinicians who are likely to work in needy communities," he said.
Additional authors included Elizabeth Mertz, MPA, research associate and Janet Coffman, MPP, former manager of the UCSF Center for California Health Workforce Studies; and L. Gary Hart, PhD, and Lorella Palazzo, MA, of the University of Washington.