We want to highlight three regional findings. The UP campus focuses on educating physicians who will serve rural Michigan. Our results indicate that, consistent with this mission, 45% of UP graduates (76 of 168) practiced in rural communities, compared with 16% of all MSU-CHM graduates (488 of 3,107; P < .01). Our results show that UP graduates were also more likely to choose primary care (52% [88 of 168] vs. 44% [1,363 of 3,107], P = .03) and high-need specialties (65% [109 of 168] vs. 57% [1,781 of 3,107], P = .045). The results of our logistic regression analysis confirm this last finding: UP graduates remained significantly more likely to practice in high-need specialties (P = .04). UP graduates have had the strongest geographic effect on the UP.
According to our results, Grand Rapids graduates are least likely to practice primary care (39% [327 of 848] vs. 44% [1,363 of 3,107], P ≤ .01) or to choose high-need specialties (52% [437 of 848] vs. 57% [1,781 of 3,107], P < .01). They are less likely to choose rural practice than other graduates (13% [110 of 848] vs. 16% [488 of 3,107], P = .01) but more likely to practice in HPSAs (46% [392 of 848] vs. 44% [1,374 of 3,107], P < .01). Although, according to our logistic regression analysis results, the differences in likelihood of practicing in HPSAs and primary care do not remain significant, the rural practice and high-need specialty choice differences do persist. Grand Rapids graduates are also most likely to practice within 50 miles of their community (27% [227 of 848], compared with all graduates (20% [635 of 3,107]).
Our results show that Flint graduates are the least likely to practice in rural communities, compared with graduates from other campus communities (11% [59 of 539] vs. 16% [488 of 3,107], P = .01), and this difference persists in logistic regression analysis. Both Flint and Saginaw graduates have a regional effect on Wayne County, which includes Detroit. In contrast, Kalamazoo graduates concentrate more in counties with midsized urban communities, including Kalamazoo, Grand Rapids, Lansing, and Southeast Michigan.
Overall, 43% (1,328 of 3,107) of MSU-CHM graduates from the years studied were actively practicing in Michigan in 2011. Kalamazoo and Saginaw students were less likely to stay in Michigan than all other graduates (respectively, 38% [208 of 554] and 36% [157 of 436], P = .01 and P < .01). These differences persisted in multivariate analysis. Figure 2 illustrates all graduates’ distribution through the state as a whole. Taken together, the proportions of MSU-CHM graduates in each Michigan county grossly reflect the state’s population.
Notably, our results indicate that graduates of every campus are more likely to practice in HPSAs than other physicians. Med School Mapper indicates that 25.5% of Midwest physicians practice in HPSAs,32 whereas, according to our results, 44% of all MSU-CHM graduates studied (1,374 of 3,107) practiced in HPSAs in 2011. Our results indicate that, overall, 44% of MSU-CHM graduates (1,363 of 3,107) practice primary care.
Nationally, in 2016, 22 MD-granting U.S. medical schools had established regional campuses (present for more than a decade); 89 did not. Those with regional campuses had a larger geographic footprint within their state or region (mean 31 counties vs. 21 counties; P < .01).
This study adds to current knowledge about medical education by demonstrating that a community-based, longitudinal distributed model can benefit the regional and statewide physician workforce. Perhaps most important, every MSU-CHM campus had a clear effect on its regional physician workforce. Although MSU-CHM is only one medical school, our analysis of other institutions suggests that our findings are generalizable: medical schools with regional campuses have broader, long-term, positive geographic effects compared with single-campus institutions.
The findings are important for communities because access to local physicians, especially in primary care, is essential for public health. Physicians also make significant contributions to local economies, particularly in underserved communities, by staffing hospitals and outpatient care facilities, generating local employment.33–36 The study demonstrates that regional campuses not only support primary care3,5,16 but also support local and regional physician retention. The time and funds that a community spends on teaching medical students are a good investment; both help to build the community’s future.
The results of our study are also important for medical schools. Community-based regional campuses require enormous institutional will and investment to create and maintain.5 Institutional leaders may find these results useful for demonstrating the value of regional campuses to community partners, funding organizations, private donors, and states.
Many MSU-CHM campuses are in high-need areas of the state, and these communities face significant challenges. MSU-CHM has invested in these communities, and in turn, the communities have invested in the growth of the college. For example, the entire UP constitutes a rural, underserved region. Flint, Michigan, which has recently emerged from a financial crisis, is consistently ranked among the most dangerous U.S. cities and is in the midst of a public health crisis resulting from lead contamination of the city water supply.37 The number of students completing their UME at both campuses has increased over time, and the two regional campuses are now central locations for unique student programs.11,38 Immersion of students in underserved communities such as these likely contributes to the high proportion of MSU-CHM graduates who now practice in HPSAs and practice primary care.
Some major findings are consistent with the distinct local cultures and geographic features of each campus. Here we discuss the most important campus characteristics in relation to our results and consider their implications.
The UP campus has been successful in its mission of educating rural physicians who will choose high-need specialties and serve Michigan. We have previously published a comprehensive evaluation of the geographic effect of UP campus graduates,11 which, along with the results of this current study, adds to previous literature demonstrating that students educated in rural communities are more likely to practice rurally, practice primary care, and remain in the local community.10,15,39–41
Flint is geographically close to Detroit and shares many characteristics of this urban core. Both are large cities that grew during the prosperous years of the automobile industry and now face significant economic hardship. Saginaw, a smaller city, also shares a common history of economic development based on automobile manufacturing, followed by economic decline. Interestingly, our results show that Flint and Saginaw graduates are as likely to practice in Wayne County, which includes Detroit, as they are to practice in Genesee and Saginaw Counties (which include, respectively, Flint and Saginaw). We believe this finding is due to the similar urban, underserved characteristics of these three cities.
Grand Rapids is Michigan’s second largest city, and home to MSU-CHM’s largest clinical campus. It is the only campus with a tertiary referral center, which includes a children’s hospital, a cardiovascular subspecialty hospital, a cancer center, and a research institute. This medical complex has grown substantially in the last two decades, offering many opportunities for physician employment. The high local retention of MSU-CHM graduates in Grand Rapids aligns with this growth. The campus graduates’ lower rates of rural practice and high-need specialty practice reflect its subspecialty orientation.
Interestingly, the communities with enhanced graduate retention are also the communities that have expanded over time. Like Grand Rapids, the Flint campus has retained more MSU-CHM graduates within its 50-mile radius than average. Further, MSU-CHM has substantially increased its clinical, educational, and research presence at the campuses in both of these communities in the last decade. In contrast, both the Kalamazoo and Saginaw campuses have fewer practicing graduates than the MSU-CHM average. In the last decade, both of these campuses have ended their relationship with MSU-CHM. These campus–community relationships might have survived if local graduates had had a more visible effect. We believe that the presence of alumni may be important for both sustaining this community-based clinical model and facilitating growth. Although we did not measure whether our graduates serve as faculty at any campus, we believe many do, and that their work in these roles strengthens MSU-CHM’s presence in and relationships with communities.
Finally, there is a need for medical schools to strengthen the community-based model by further developing the scholarship of community-engaged medical education.5 A recent Best Evidence Medical and Health Professional Education synthesis describes the literature on community–medical school relationships as “heterogenous and largely idiographic,” characterized primarily by descriptive studies.3 Our study contributes to this scholarship by examining specific workforce outcomes, but is limited by the inclusion of only a few variables. Likely, many unexamined factors, including location of residency training,12 have contributed to our successes (and failures). Still, we know that MSU-CHM students have lived, studied, cared for patients, and volunteered in communities for decades. In the years ahead, it will be useful for medical educators to continue to measure and evaluate the best ways to learn from, respond to, and collaborate with communities where students become physicians.
Because we performed many statistical comparisons, we suggest caution to avoid overinterpreting results. Our study analyzes a single medical school, which limits generalizability; however, we addressed this by adding a small national evaluation. Our analysis used self-reported AMA Masterfile data, which could raise concerns regarding validity. To minimize errors, we confirmed practice locations of recent graduates.
We defined a practice as a HPSA practice if any portion of the practice ZIP Code included a Primary Care HPSA. This definition may be less stringent than other measures of underserved practice, limiting comparability.
For our study, we used a more stringent definition of primary care than some others have used. Specifically, we excluded graduates who began their careers in a primary care residency, but then later completed a subspecialty fellowship. We believe our narrower definition more accurately reflects the physician workforce,42 but it may limit comparability to other published outcomes. Our definition also included hospitalists, who constitute an increasing proportion of general internal medicine physicians.43
Although the study demonstrates a relationship between students’ medical school campus and eventual practice location, we cannot infer causality. As discussed above, MSU-CHM students indicate their preferred clinical community. We have not assessed students’ communities of origin, and many may have returned to practice in places where they grew up. Residency location is strongly associated with eventual practice location,12 but we did not assess or control for this factor in this descriptive study.
Consistent with other research, this study demonstrates that students’ long-term practice choices—that is, their specialties and practice locations—reflect their educational communities. Thus, establishing new medical schools—or expanding existing ones—in dispersed communities may have significant long-term implications for the local physician workforce. Community-based medical education may help increase the proportion of graduates who practice primary care, practice other high-need specialties, and serve urban and rural underserved populations. Thus, further developing community-based and community-engaged medical schools can help advance the social mission of medical education.44,45
The authors wish to thank the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and Dr. Aron Sousa.
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© 2018 by the Association of American Medical Colleges
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