Special Article
The Changing Geographic Distribution of Board-Certified Physicians
N Engl J Med 1980; 303:1032-1038October 30, 1980DOI: 10.1056/NEJM198010303031803
- Abstract
- Abstract
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. (N Engl J Med. 1980; 303:1032–8.)
Media in This Article
Table 1
Percentage of Communities with Board-Certified Specialists in 1960, 1970, and 1977.*Table 2
Percentage of Communities in Which the Five Largest Specialties Are All Represented.*Article Activity
- Article
THE geographic distribution of physicians continues to be a major concern of public policy. The high degree of specialization among recent graduates has accentuated the fear that areas outside urban centers will remain underserved despite the large increase in the number of physicians.1 2 3 It is said that specialists prefer the metropolis and can locate there in excessive numbers because they are less subject to economic competition than are providers of other types of goods and services.4 5 6 7 8 9 10
We undertook this study to record the distribution of board-certified specialists in recent years and to learn what forces have influenced their choice of location. We have looked only at board-certified specialists because an overwhelming percentage of graduates are now obtaining certification.11
We have attempted to answer several questions. First of all, as their numbers have increased, how have board-certified physicians distributed themselves among cities and towns of various sizes? Secondly, how has the distribution of specialists between metropolitan and nonmetropolitan areas been changing? Thirdly, what accounts for the pattern of specialists' locations? Finally, on the basis of past experience, what can we predict for the future location of specialists?
Methods
Selection of Samples
To analyze the location patterns of specialists, we selected the years to be studied, a sample of specialists, and a sample of states. Within these states, we ascertained the population of each community and determined which of the communities had board-certified specialists in residence.
We obtained information for three index years (1960, 1970, and 1977), and we chose to study eight specialties and family practice. The specialties included the five with the largest membership (internal medicine, surgery, pediatrics, obstetrics/gynecology, and radiology) and three smaller specialties. Urology was selected as a representative surgical specialty. Neurosurgery and dermatology were chosen as examples of surgical and medical specialties that treat a relatively narrow range of clinical problems. In addition, family practice was selected because its practitioners treat the broadest range of clinical problems and serve as the only board-certified physicians in many small towns. Our analysis of family practice will be limited to the year 1977 because certification in this field did not begin until 1970.
We studied 23 states that together contained 43 per cent of the country's nonmetropolitan population in 1976.12 "Nonmetropolitan population" refers to persons residing outside Standard Metropolitan Statistical Areas (SMSA's): counties that contain cities with populations of 50,000 or more). The states were chosen in clusters from four regions so that we could assess geographic variation in specialist distribution. The Central region comprised Iowa, Kansas, Minnesota, Missouri, Nebraska, Oklahoma, and Wisconsin. Northern New England included Maine, New Hampshire, and Vermont. The Rocky Mountain and Northern Great Plains region consisted of Colorado, Idaho, Montana, North Dakota, South Dakota, Utah and Wyoming. The Southern region was defined as Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee.
Population of Communities
The population of each city or town in the 23 states in 1960 and 1970 was obtained from the United States Census.13 We estimated the amount of increase in each community's population between 1970 and 1977 by multiplying the 1970 census figures by state-specific estimates of the growth rates of metropolitan and nonmetropolitan populations.
Towns with populations of less than 2500 were deleted from our sample because virtually no board-certified physicians other than family physicians are located in such small towns. For the purpose of our analysis we considered an SMSA to be a single city; in other words, towns within a metropolitan area were not treated as separate entities. The land area comprising the SMSA in 1970 was used in each year to define the metropolitan area.
Location of Specialists
The cities and towns in which specialists practiced were determined from the Directory of Medical Specialists.14 Doctors who listed two offices were assumed to practice half the time in each location. This method of allocation did not appreciably affect our estimates of the availability of specialists, because only about 2 per cent of the physicians indicated that they practiced in more than one community. About 5 per cent of the physicians listed were certified by more that one board; the rules used to assign them to specialties are available from the National Auxiliary Publications Service (NAPS).*
Distribution of Specialists
Percentage of Towns with a Given Type of Specialist
The percentage of smaller cities and towns with at least one board-certified specialist of each type has grown, in many cases remarkably, since 1960 (Table 1Table 1
Percentage of Communities with Board-Certified Specialists in 1960, 1970, and 1977.*). Even by 1960, the five largest specialties (the first five listed in Table 1) were fairly well represented in communities with at least 20,000 inhabitants, and in cities larger than 30,000 coverage was nearly complete. Most towns with populations of less than 20,000, however, did not have even one internist, pediatrician, or obstetrician/gynecologist practicing within the town limits, although about 60 per cent of the towns between 10,000 and 20,000 population had a surgeon and nearly half had a radiologist.Subsequently, the situation improved dramatically; for each of the five largest specialties, at least 80 per cent of towns with populations between 20,000 and 30,000 had acquired a resident diplomate by 1977. Indeed, many towns as small as 10,000 acquired specialists. Besides family practitioners, surgeons and radiologists had entered the smallest communities; two thirds of the towns between 10,000 and 20,000 had one or both, and nearly two fifths of the towns between 5000 and 10,000 had a surgeon.
The outward movement of the five largest specialties as a group is a particularly striking phenomenon. By 1977, more than 70 per cent of communities with 20,000 to 30,000 inhabitants had a full complement of the five specialties (internist, surgeon, pediatrician, obstetrician/gynecologist, and radiologist); 17 years earlier, less than a third of these communities had all five (Table 2Table 2
Percentage of Communities in Which the Five Largest Specialties Are All Represented.*). In the next larger group of towns (30,000 to 50,000), the proportion rose from about half to 95 per cent.Specialties providing secondary and tertiary care have also appeared increasingly in small communities. For example, among towns with 30,000 to 50,000 inhabitants, by 1977 nearly all had a urologist, three quarters a dermatologist, and one quarter a neurosurgeon, whereas in 1960 the proportions were three fifths, one third, and one twelfth, respectively.
Family physicians were present by 1977 in three eighths of towns as small as 2500 to 5000 and in more than half of towns between 5000 and 10,000. Small towns were thus more likely to have a family physician than any other board-certified physician.National Health Service Corps personnel have not appreciably influenced these results. A list of all board-certified physicians in the Corps as of December 1978 indicated that only 10 (five family physicians, four internists, and one surgeon) were counted in the nonmetropolitan area of our sample.
*For more detailed information order NAPS Document 03740 from ASIS/NAPS c/o Microfiche Publications, P.O. Box 3513, Grand Central Station, New York, NY 10017. Remit, in advance, $3 for each microfiche-copy reproduction or $5 for each photocopy. Outside the United States and Canada, postage is S3 for a photocopy or $1 for a microfiche. Make checks payable to Microfiche Publications.
Coverage of Basic Services
Residents of communities that have an internist, a surgeon, a pediatrician, and an obstetrician/gynecologist in residence can obtain a wide range of high-quality basic medical services, but only a few towns with populations of less than 20,000, as shown in Table 3Table 3
Percentage of Communities with Coverage of Basic Services across Community Sizes in 1977.*, can boast that all four of these specialties are represented. On the other hand, as shown in the first part of Table 3, the majority of towns with populations of 5000 to 20,000 have coverage of basic medical services either from a cluster of specialists or from a certified family physician.The second part of Table 3 deals with the narrower question of the number of communities in a given size range with local access to individual basic services (e.g., surgical or pediatric) from either a board-certified specialist or a family physician. The data show that small towns are less dependent on family physicians for basic surgical services than for the services of any other specialty.
Regional and State Differences
Logistic-regression analysis shows that differences in the distribution of specialists across the four geographic regions are significant (P<0.01). However, they are small and do not have obvious implications for policy. In general, the data show that specialists in northern New England have entered smaller towns than have specialists in other regions. Differences among states are small and are statistically significant in only a few instances. (The detailed data and the methods used have been filed with NAPS [Document 03740].)
Analysis of the Patterns of Distribution
To provide a framework for assessment of factors responsible for the distribution of specialists, we assume that the specialist chooses a practice location in a manner that best satisfies personal preferences for income on the one hand and for professional and environmental attributes on the other. To achieve a high income, physicians choose to practice in communities where the demand for their services is relatively high. If all communities were equally attractive, the workload of all physicians would approximately balance out. However, because physicians will accept a smaller workload and a resulting reduction in income in order to live in especially attractive areas, such areas will always be somewhat better served.
This model, which is derived from standard location theory, 15 16 17 18 can serve as a framework for analysis of the locations of physicians at any given time and for predictions of changes in location patterns over time as various factors influence income and the attractiveness of different communities. The key variables that merit consideration are the number of physicians, the professional and environmental attributes of the communities of different sizes, and the geographic distribution of the demand for care.
Factors Accounting for the Changes Over Time
Change in the Number of Physicians
Consider the circumstance in which physicians increase in number but the other relevant variables are unchanged, that is, the profile of physician's location preferences remain constant and the changes in demand for services are the same everywhere (e.g., demand per person and population in each town-size range are both constant). Under these conditions the market area for each physician will shrink, and all town-size ranges in which each town originally had a specialist will gain such specialists at a similar proportional rate.
But in smaller town-size ranges (e.g., towns of 5000 to 10,000 inhabitants) not all towns have a given type of specialist present. If the number of specialists in the country doubles, the number of such specialists in these ranges should more than double. As market areas shrink, some unserved small towns will become attractive as focuses of new market areas, and doctors entering such towns will provide an extra increment in the supply of physicians.
Table 4Table 4
Ratio of Specialists per Person in 1977 to Specialists per Person in 1960.* presents the actual ratios of specialists per person in 1977 to specialists per person in 1960 for the six specialties that were well represented over the full spectrum of community sizes and could therefore be analyzed meaningfully. Values have been deflated by population to adjust for changes in demand in each range that stemmed from changes in population alone. Analysis indicates that the proportional increase in the total number of specialists per person was significantly greater (P<0.01) when there was a greater percentage of unserved towns in a given town-size range in 1960, as the previous paragraph predicted.In the context of the model of location choice described above, the figures in Table 4 imply that the increase in the number of physicians can account for the observed changes in physician-location patterns. Moreover, our data show that as the overall numbers of specialists increased, physicians did not simply distribute themselves everywhere in equal proportions. If the number of specialists had increased in the same proportions everywhere (assuming that the location preferences of each cohort of specialists remained constant over time), that would imply that specialists could locate wherever they wished without reference to the demand for their services; in other words, they would have enough control over the demand for care that they could subvert market forces in selecting a location. That specialists can completely determine the demand for their services appears unreasonable, and moreover, inconsistent with the data in Table 4.
Some may argue that the higher proportional growth rate of specialists in smaller towns merely reflects the replacement of retiring general practitioners or noncertified specialists, but this argument is specious. First of all, such specialists as radiologists, urologists, and gynecologists provide many services that general practitioners do not provide. Secondly, even if one regarded noncertified specialists as equivalent to certified specialists on the average, the replacement argument does not hold. The percentage of increase in the number of specialists (certified and noncertified) in nonmetropolitan areas (excluding counties considered potential SMSA's) between 1970 and 1977 was substantially greater than that in metropolitan areas (40 per cent vs. 20 per cent).4 , 19 This finding, as in the case of board-certified specialists alone (Table 4), implies that many unserved towns in nonmetropolitan areas were acquiring doctors as market areas throughout the country were shrinking.
Metropolitan and Nonmetropolitan Distribution
Metropolitan communities had many more specialists per person in 1960 than did nonmetropolitan areas (Table 5Table 5
Number of Board-Certified Specialists per 100,000 Persons in Metropolitan and Nonmetropolitan Areas, 1960 and 1977.*). Because the proportional increases in numbers of specialists in metropolitan and nonmetropolitan areas were only moderately different between 1960 and 1977, it therefore follows that the absolute differences in the numbers of specialists per person must have widened. Table 5 also shows the magnitude of these increased discrepancies. However, the data do not explain what factors are responsible for the greater clustering of specialists in metropolitan areas.One factor may well be that most specialists prefer to live in large communities that provide an inviting cultural and professional environment not available elsewhere. Evidence in support of this thesis, based on differences in income in large and small communities, is presented below.
Another factor, probably of considerable importance, is the phenomenon of "border crossing." Some nonmetropolitan residents seek routine care in a neighboring metropolitan area because it is the closest or most convenient source. Others go to nonmetropolitan physicians for routine services but travel to the city for highly specialized care, such as open-heart surgery. The amount of border crossing is not trivial. For example, Fuchs estimates that in the early 1970's nonmetropolitan residents underwent about 30 per cent of their operations in metropolitan areas.20 Thus, a substantial fraction of the demand of nonmetropolitan residents is satisfied by metropolitan physicians.
Because of border crossing, even when location preferences are left aside, one would expect metropolitan areas to hold a considerable advantage in numbers of specialists per resident. Should such a discrepancy be of concern? Perhaps so, but more information is needed before any conclusion can be reached. From a policy perspective the appropriate size of the discrepancy depends on the particular type of service and the distance people must travel to obtain it. In secondary and tertiary care, a considerable amount of border crossing is highly desirable. Clearly, every small town cannot and should not acquire every type of specialist. Indeed, some recent data on the regionalization of medical services suggest that the quality of care would be improved by increased border crossing to large medical centers.21
Border crossing for primary care is sometimes to be expected. Some nonmetropolitan residents live only a few miles from a metropolitan area and may go there for primary care with little inconvenience. The discrepancy in the number of physicians per person that is due to this type of border crossing will probably persist indefinitely and should not be a matter of concern. People in sparsely settled areas, such as farmers or ranchers, will also contribute to border crossing indefinitely if the nearest community is a metropolitan area. This too seems to be a matter of little concern.
The degree to which such situations account for the discrepancy in the number of physicians per person and the implications of border crossing for policy can only be assessed by analysis of the distances traveled for various types of care and of the resulting burden per physician.
Change in the Attributes of Various Locations
If the attributes of towns themselves changed over time, what effect on the distribution of physicians might we expect? If metropolitan locations became relatively less desirable as places to live and other factors in the choice of a location did not change, a greater fraction of physicians entering practice could be expected to locate in small towns. (A similar result would obviously be obtained if the value that physicians attached to attributes of nonmetropolitan towns — e.g., proximity to hunting and fishing — increased.) There is little evidence on which to judge whether nonmetropolitan areas have become relatively more attractive over time, but the evidence that we have found gives no indication that physicians' preferences for rural living have changed.22
Change in the Geographic Distribution of Demand
If the demand per person increased at different rates in various town-size ranges, the patterns of physicians' locations could be explained even if both the number of physicians and the attributes of various locations were unchanged. For example, if the demand for care rose more in nonmetropolitan areas than in metropolitan areas, smaller towns would yield a higher financial return than they previously yielded and would become more attractive. In fact, examination of such major determinants of demand as age, sex, and insurance status does not suggest any appreciable change in the geographic distribution of demand per person during the period of our study.23 24 25
Distribution of Specialists at Each Given Time
Our model of location choice implies not only how physicians will distribute themselves over time but at each given time. For each year of study, one would expect that because the demand for any particular type of medical care increases with the size of the town, the likelihood that a specialist of a given type will be present will increase with the size of the town. Our data show that for each specialty in each year, such is the case (Table 1).
The model also implies that the greater the demand for services of a particular type of specialist, the smaller the size of town that will be likely to have such a specialist. The data again conform to this prediction. Neurosurgeons and dermatologists, who are in least demand per person of the specialty groups that we studied, serve larger towns than do internists, surgeons, and pediatricians (Table 1). Family physicians, who provide the widest range of services and are in greatest demand, serve the smallest towns of all.
Finally, the model implies that if a disproportionate fraction of physicians prefer to live in large cities, they will earn less money (in real terms) than do their colleagues in nonmetropolitan areas. The data are consistent with this prediction. Physicians practicing in metropolitan areas with populations of 1 million or more earn about 13 per cent less in real terms than do their colleagues but work only about 7 to 9 per cent fewer hours (P<0.01). (The derivation of these figures is explained in an appendix filed with NAPS [Document 03740].)
Discussion
Between 1960 and 1977, the number of board-certified specialists in the United States nearly tripled. As a point of departure, we therefore chose to determine whether an increased supply of physicians, through a resulting activation of market forces, could itself account for the observed patterns of specialist location. The finding that the percentage increase in the number of specialists per person in small towns was greater than that in large towns and the pattern of distribution across town-size ranges at each studied time are both consonant with a market-forces hypothesis.
Our results do not exclude the possibility that a change in preference for small towns may have played a part in shaping decisions about location. As we have pointed out, however, we have no evidence of a substantial shift in preferences and no need to consider attitudinal changes important in the patterns that we have observed.
Could the demand for health care have increased more in nonmetropolitan than in metropolitan communities, thus contributing to the observed shift in the pattern of location? Again, we have no evidence that substantial shifts of this sort have taken place, and there is no reason to consider them as an explanatory factor.
Finally, let us consider the possibility that physicians, in responding to competitive forces, have been willing and able to induce some unwarranted demands for their services. If such a phenomenon occurred, and if it took place to a greater degree in metropolitan areas, movement into nonmetropolitan areas would have been retarded. It is not possible for us to determine whether these events took place.
Implications for the Future
Our analysis has important implications for the future if it is assumed that market forces have played the dominant part in determining physician distribution and will continue to do so. The period from 1977 to 1985 will see a 30 per cent increase in the number of physicians, nearly all of whom will be certified.26 According to our analysis, this increase, all other things being equal, will add substantially to the ranks of specialists in both nonmetropolitan and metropolitan communities, with the percentage in nonmetropolitan areas exceeding the percentage increase in each specialty nationally. For example, the Bureau of Health Manpower projects that the number of pediatricians will increase 55 per cent between 1977 and 198526; on the basis of this value we predict that the number practicing in nonmetropolitan areas will increase more than 55 per cent. At the same time, the absolute increase in the number of physicians per person in metropolitan areas should exceed that in nonmetropolitan areas.
The location of hospital facilities should not constrain this movement into smaller towns. Approximately 80 per cent of the communities in the 5000 to 10,000 range and 60 per cent of the communities in the 2500 to 5000 range had hospitals in 197027; these values considerably exceed the proportion of communities that now have certified specialists.
Another factor favoring the diffusion of physicians into small towns during the 1980's is the composition of current cohorts of medical-school graduates by specialty as compared with the composition of the classes of the past few decades. During the period after World War II and until the past few years, there was a progressive shift toward specialization among medical-school graduates. Because specialists other than family physicians have a strong tendency to locate in larger towns than those in which general practitioners locate, relatively small fractions of these graduates located in nonmetropolitan areas. Given the current trend toward family practice, the future will look quite different. From 1970 to 1977, the number of general and family practitioners fell by 15 per cent, but between 1977 and 1985 the number is projected to increase by 22 per cent.26 This shift toward the production of more physicians for whom small towns can effectively compete should have a notable effect on the provision of care in such towns.
Finally, our data pertain to physicians who entered medical school in the 1950's and 1960's. To the degree to which medical schools have altered their admission policies in the 1970's to favor students from nonmetropolitan towns, the proportion of physicians practicing in such towns may increase still further.28 , 29
Policy initiatives under consideration are likely to enhance these trends. A national health-insurance program would probably cause the demand for care to increase in nonmetropolitan areas at a rate slightly higher than that in metropolitan areas because a somewhat larger proportion of nonmetropolitan residents have no hospital or surgical insurance.25 Small towns would then become more attractive sites for practice. This tendency would be reinforced if the plan narrowed differences in physicians' fees between metropolitan and nonmetropolitan areas.30 , 31 Finally, continuation or expansion of the National Health Services Corps will most certainly increase the number of physicians in nonmetropolitan areas that otherwise would not attract a physician.
Supported in part by a grant to Dr. Schwartz from the Robert Wood Johnson Foundation, Princeton, N.J., by the Health Insurance Study grant from the Department of Health, Education, and Welfare to the Rand Corporation, by a grant (1 R03 HS03808-l)from the National Center for Health Services Research to the Rand Corporation, by a biomedical-research support grant (5 S07 RR05710–08) from the National Institutes of Health to the Rand Corporation, and by the Rand Corporation.
The opinions and conclusions expressed herein are solely those of the authors and should not be construed as representing the opinions or policy of the Robert Wood Johnson Foundation or any agency of the United States Government or the Rand Corporation.
Source Information
From the Rand Corporation, Santa Monica, Calif., and the Department of Medicine, Tufts University (address reprint requests to Dr. Schwartz at Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111).
- References
References
1
Davis K, Marshall R. New developments in the market for rural health care. In: Scheffler RM, ed. Research in health economics. Greenwich, Conn.: JAI Press, 1979:72, 83.
2
Lee PR. Testimony, Health Manpower Programs. Hearings before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce, United States House of Representatives (serial 94–3). Washington, D.C.: Government Printing Office, 1975:382, 398.
3
National Commission on the Cost of Medical Care. Report, Vol. 1. Chicago: American Medical Association, 1978:87.
4
American Medical Association. Physician distribution and medical licensure in the US, 1977. Chicago: American Medical Association, 1979.
5
Cooper T. Testimony, Health Manpower Legislation, 1975. Hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, September 16 and 26, 1975. Washington, D.C.: Government Printing Office, 1976:992–3.
6
Detsky AS. The economic foundations of national health policy. Cambridge, Mass.: Ballinger, 1978.
7
Fein R. Meeting the needs of rural people for health and medical care, Health Manpower Legislation, 1975. Joint Hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare and the Subcommittee on Rural Development of the Committee on Agriculture, United States Senate, July 31, 1975. Washington, D.C.: Government Printing Office, 1976:855–68.
8
Kennedy EM. Opening statement, Health Manpower Legislation, 1975. Hearings before the Subcommittee on Health of the Committee on Labor and Public Welfare, United States Senate, September 16 and 26, 1975. Washington, D.C.: Government Printing Office, 1976:924.
9
Scheffler
Medline10
Weinberger CW. Testimony, Health Manpower Programs. Hearings before the Subcommittee on Health and the Environment of the Committee on Interstate and Foreign Commerce, United States House of Representatives (serial 94–3). Washington, D.C.: Government Printing Office, 1975:317.
11
American Medical Association
CrossRef | Web of Science12
United States Department of Commerce, Bureau of the Census. Statistical abstract of the United States, 1978. Washington, D.C.: Government Printing Office, 1978.
13
Idem. 1970 census of population. Vol. 1. Washington, D.C.: Government Printing Office, 1973.
14
Directory of medical specialists. Chicago: Marquis Who's Who, 1961, 1971, 1978.
15
Beckmann M. Location theory. New York: Random House, 1968.
16
Greenhut ML, Ohta H. Theory of spatial prices and market areas. Raleigh, N.C.: Duke University Press, 1975.
17
Richardson HW. Regional economics. New York: Prager Publishers, 1969.
18
Newhouse JP, Williams AP, Schwartz WB, Bennett BW. The geographic distribution of physicians: Is the conventional wisdom correct? Presented at the annual American Economic Association meetings, Atlanta, Georgia, December 28, 1979.
19
American Medical Association. Distribution of physicians in the United States, 1970. Chicago: American Medical Association, 1971.
20
Fuchs
CrossRef | Web of Science | Medline21
Luft
Full Text | Web of Science | Medline22
United States General Accounting Office. Progress and problems in improving the availability of primary care providers in underserved areas. Washington, D.C.: Government Printing Office, 1978. (publication no. [HRD]77–135).
23
United States Department of Commerce, Bureau of the Census. County and city data book. Washington, D.C.: Government Printing Office, 1972.
24
Idem. County and city data book. Washington, D.C.: Government Printing Office, 1967.
25
United States National Center for Health Statistics. Vital and Health Statistics. Series 10, no. 117. Hospital and surgical insurance coverage. Washington, D.C.: Government Printing Office, 1977. (DHEW publication no. [HRA]77–1545).
26
Health Resources Administration, Bureau of Health Manpower. A Report to the President and Congress on the status of health professions personnel in the United States. Washington, D.C.: Government Printing Office, 1978. (DHEW publication no. [HRA]78–93).
27
American Hospital Association 28
Cooper
Medline29
Steinwald
CrossRef | Web of Science | Medline30
Burney
CrossRef | Web of Science | Medline31
Institute of Medicine. Medicare-Medicaid reimbursement policies: social security studies final report. Washington, D.C.: National Academy of Sciences, 1976.
- Citing Articles (52)
Citing Articles
1
Shinichi Tanihara, Yasuki Kobayashi, Hiroshi Une, Ichiro Kawachi. (2011) Urbanization and physician maldistribution: a longitudinal study in Japan. BMC Health Services Research 11:1, 260
2
Paul A. Jargowsky, Jeongdai Kim. The information theory of segregation: uniting segregation and inequality in a common framework. Emerald Group Publishing, 2009:3-31.
3
Jeongdai Kim, Paul A. Jargowsky. The GINI coefficient and segregation on a continuous variable. Emerald Group Publishing, 2009:57-70.
4
Martin J. Mistretta. (2007) Differential Effects of Economic Factors on Specialist and Family Physician Distribution in Illinois: A County-Level Analysis. The Journal of Rural Health 23:3, 215-221
5
David A. Matsa. (2007) Does Malpractice Liability Keep the Doctor Away? Evidence from Tort Reform Damage Caps. The Journal of Legal Studies 36:S2, S143-S182
6
Richard A. Cooper, Thomas E. Getzen, Prakash Laud. (2003) Economic Expansion Is a Major Determinant of Physician Supply and Utilization. Health Services Research 38:2, 675-696
7
Michael G. Madianos, Costas Zacharakis, Chryssa Tsitsa, Costas Stefanis. (1999) The mental health care delivery system in greece: regional variation and socioeconomic correlates. The Journal of Mental Health Policy and Economics 2:4, 169-176
8
Judith D. Singer, Stephen M. Davidson, Suzanne Graham, Harriet S. Davidson. (1998) Physician Retention in Community and Migrant Health Centers. Medical Care 36:8, 1198-1213
9
Fredrick K. Orkin. (1998) Rural Realities. Anesthesiology 88:3, 568-571
10
Ge Lin, Thomas C. Rosenthal, Mary Horwitz. (1997) Physician location survey: Self-reported and census-defined rural/urban locations. Social Science & Medicine 44:11, 1761-1766
11
Rune Sørensen, Gunnar Rongen, Jostein Grytten. (1997) Local Government Decision-Making and Access to Primary Physician Services in Norway. International Journal of Health Services 27:4, 697-720
12
Tung-liang Chiang. (1995) Deviation from the carrying capacity for physicians and growth rate of physician supply: The Taiwan case. Social Science & Medicine 40:3, 371-377
13
Malcolm C. Brown. (1994) Using gini-style indices to evaluate the spatial patterns of health practitioners: Theoretical considerations and an application based on Alberta data. Social Science & Medicine 38:9, 1243-1256
14
Nancy S. Jecker, Alfred O. Berg. (1992) Allocating medical resources in rural America: Alternative perceptions of justice. Social Science & Medicine 34:5, 467-474
15
Colwill , Jack M. , . (1992) Where Have All the Primary Care Applicants Gone?. New England Journal of Medicine 326:6, 387-393
Free Full Text16
Stuart A. Foster. (1991) THE EXPANSION METHOD: IMPLICATIONS FOR GEOGRAPHIC RESEARCH
. The Professional Geographer 43:2, 131-14217
J.Ross Barnett. (1991) Geographical implications of restricting foreign medical immigration: A New Zealand case study, 1976–1987. Social Science & Medicine 33:4, 459-470
18
Michael E Gallery, E Jackson Allison, Joyce M Mitchell, Robert Williams. (1990) Manpower needs in academic emergency medicine. Annals of Emergency Medicine 19:7, 797-801
19
H Davis. (1988) The accuracy of industry data from death certificates for workplace homicide victims.. American Journal of Public Health 78:12, 1579-1581
20
T Dennis. (1988) Changes in the distribution of physicians in rural areas of Minnesota, 1965-85.. American Journal of Public Health 78:12, 1577-1579
21
Rabinowitz , Howard K. , . (1988) Evaluation of a Selective Medical School Admissions Policy to Increase the Number of Family Physicians in Rural and Underserved Areas. New England Journal of Medicine 319:8, 480-486
Full Text22
Schwartz , William B. , Sloan , Frank A. , Mendelson , Daniel N. , . (1988) Why There Will Be Little or No Physician Surplus between Now and the Year 2000. New England Journal of Medicine 318:14, 892-897
Full Text23
Steven A. Schroeder, Thomas Mitchell. (1988) Employment choices in conditions of physician oversupply. Journal of General Internal Medicine 3:1, 25-31
24
C E McConnel, L A Tobias. (1986) Distributional change in physician manpower, United States, 1963-80.. American Journal of Public Health 76:6, 638-642
25
Jonathan D. Mayer. (1986) International perspectives on the health care crisis in the United States. Social Science & Medicine 23:10, 1059-1065
26
Marc Galanter. (1985) Postgraduate Certification in Alcohol and Drug Dependence. Alcoholism: Clinical and Experimental Research 9:5, 387-389
27
P P Budetti. (1984) The 'trickle-down' theory--is that any way to make policy?. American Journal of Public Health 74:12, 1303-1304
28
H. H. Tilson. (1984) Notes from a Fertile Field: A New Forum. American Journal of Public Health 74:12, 1304-1304
29
Byron Cone Pevehouse. (1984) Residency training in neurological surgery, 1934–1984: evolution over 50 years of trial and tribulation. Journal of Neurosurgery 61:6, 999-1004
30
(1984) How Many Miles to the Doctor?. New England Journal of Medicine 311:12, 802-802
Full Text31
Barbara H. Kehrer, Frank A. Sloan, Judith Wooldridge. (1984) Changes in primary medical care delivery, 1975–1979: Findings from the physician capacity utilization surveys. Social Science & Medicine 18:8, 653-660
32
Williams , Albert P. , Schwartz , William B. , Newhouse , Joseph P. , Bennett , Bruce W. , . (1983) How Many Miles to the Doctor?. New England Journal of Medicine 309:16, 958-963
Full Text33
James K. Cooper, Timothy P. Johnson. (1983) Physician distribution—Will it get worse instead of better?. The American Journal of Medicine 75:1, 4-6
34
Menken , Matthew , . (1983) Consequences of an Oversupply of Medical Specialists: The Case of Neurology. New England Journal of Medicine 308:20, 1224-1226
Full Text35
Stephen E. Peterson, Alvin E. Rodin. (1983) GMENAC report on U.S. physician manpower policies: Recommendations and reactions. Health Policy and Education 3:4, 337-349
36
G Wilensky. (1983) Economic advantages of board certification. Journal of Health Economics 2:1, 87-94
37
O L Peterson, B S Bloom. (1983) Regionalization of surgical services.. American Journal of Public Health 73:2, 179-183
38
Brian Schrag. (1983) Justice and the justification of a social policy: The distribution of primary care physicians. Social Science & Medicine 17:15, 1061-1074
39
I S Moscovice, R A Rosenblatt. (1982) Rural health care delivery amidst federal retrenchment: lessons from the Robert Wood Johnson Foundation's Rural Practice Project.. American Journal of Public Health 72:12, 1380-1385
40
(1982) Geographic Distribution of Specialists. New England Journal of Medicine 306:6, 369-369
Full Text41
Ottensmeyer , David J. , Smith , Howard L. , . (1982) Rural Health Care. New England Journal of Medicine 306:2, 74-78
Full Text42
Steinwachs , Donald M. , Levine , David M. , Elzinga , D. Jack , Salkever , David S. , Parker , Rodger D. , Weisman , Carol S. , . (1982) Changing Patterns of Graduate Medical Education. New England Journal of Medicine 306:1, 10-14
Full Text43
Newhouse , Joseph P. , Manning , Willard G. , Morris , Carl N. , Orr , Larry L. , Duan , Naihua , Keeler , Emmett B. , Leibowitz , Arleen , Marquis , Kent H. , Marquis , M. Susan , Phelps , Charles E. , Brook , Robert H. , . (1981) Some Interim Results from a Controlled Trial of Cost Sharing in Health Insurance. New England Journal of Medicine 305:25, 1501-1507
Full Text44
Louis J. Goodman, James E. Swartwout. (1981) Socioeconomic issues in dermatology. Journal of the American Academy of Dermatology 5:6, 711-720
45
Moore , Francis D. , . (1981) Rhode Island: Surgical Manpower Changes over Seven Years. New England Journal of Medicine 305:22, 1341-1343
Full Text46
Iglehart , John K. . (1981) Shrinking Federal Support Brings New Era to Education in the Health Professions. New England Journal of Medicine 305:17, 1027-1032
Full Text47
Wallace V. Epstein, Curtis J. Henke. (1981) The nature of u.s. rheumatology practice, 1977. Arthritis & Rheumatism 24:9, 1177-1187
48
(1981) Changing Geographic Distribution of Specialists. New England Journal of Medicine 305:6, 348-348
Full Text49
BernardS. Bloom. (1981) MEDICAL MANPOWER IN THE UNITED STATES. The Lancet 317:8235, 1417
50
P. Coursaget, P. Levesque, J-P. Baudet, G. Leroy, J.M. Greco. (1981) NON-A, NON-B HEPATITIS IN BURN PATIENTS. The Lancet 317:8235, 1416-1417
51
Donald L. Madison, Charles D. Combs. (1981) Location patterns of recent physician settlers in rural America. Journal of Community Health 6:4, 267-274
52
Urs Gessner, Bruno Hornberger. (1981) Erfassung und Analyse des Kosten- und Leistungsaufwandes in Arztpraxen und Spitälern zur objektiven Bewertung von medizinischen Massnahmen. Sozial- und Präventivmedizin SPM 26:1-2, 93-96
