The United States Relies on Family Physicians, Unlike Any Other Specialty
Designation of a county as a Primary Care Health Personnel Shortage Area (PCHPSA) depends on the number of primary care physicians practicing there. Without family physicians, an additional 1332 of the United States' 3082 urban and rural counties would qualify for designation as primary care HPSAs. This contrasts with an additional 176 counties that would meet the criteria for designation if all internists, pediatricians and ob/gyns in aggregate were withdrawn. The United States relies on family physicians, unlike any other specialty.
In 1995, 784 of this country's 3082 counties were wholly designated Primary Care Health Personnel Shortage Areas (PCHPSAs). We studied the other 2298 counties that had only a partial PCHPSA designation or none at all, i.e. those considered to have a more adequate number of primary care physicians. The 1999 Area Resource File (ARF) was the data source we used. It contains information from as early as 1970 for each county in the United States pertaining to its PCHPSA designation, its general population, and the number of non-federal patient care physicians practicing there, by specialty. A lack of required detail in the ARF characterizing osteopathic physicians prevents a comprehensive analysis for any year since 1995. Thus, 1995 is the most recent year for which all required data were available.
Family practice (FP/GP), general pediatrics, general internal medicine, and ob/gyn currently constitute primary care specialties for the purpose of Federal designation of PCHPSAs. The principal criterion for awarding such designations to counties or smaller geopolitical units is that there are more than 3500 people per primary care doctor. Unusually high need for medical services and other variables (e.g., proportion medically indigent, ethnic minority) may also be considered to justify designating a special population or part of a county.
The geographic distribution of physicians is known to vary substantially by medical specialty. We assessed every county's reliance on each of the specialties on which PCHPSA designation depends. A measure of reliance was constructed by withdrawing in turn the physicians of each of the respective primary care specialties, then determining if the county met the population to physician criterion.
In 1995, 2298 U.S. counties were not fully designated PCHPSAs and had population-to-primary-care-physician ratios less than 3500:1. For 1332 (58.0%) of these, this ratio would deteriorate to more than 3500 people per primary care doctor if FP/GPs were withheld from the calculation. Few counties were similarly dependent on the services of other specialties, even in aggregate. For the large majority of all U.S. counties that would warrant whole-county PCHPSA designation with the loss of their general internists (40 of 45; 88.9%), pediatricians (9 of 11; 81.8%), or obstetricians (8 of 9; 88.9%), withdrawal of just their FP/GPs would also justify that designation.
Table. Counties that would become a PCHPSA without physicians from specialty (N = 2,298)
|Specialty: FP/GP||Number: 1332||Percent: 58.0%|
|Specialty: General Internal Medicine||Number: 45||Percent: 2.0%|
|Specialty: Pediatrics||Number: 11||Percent: 0.5%|
|Specialty: Obstetrics||Number: 9||Percent: 0.4%|
|Specialty: IM+Ped+OB simultaneously (All but FP/GP)||Number: 176||Percent: 7.7%|
This table portrays a national picture, including urban and rural areas. Restricting the analyses to rural counties shows an even greater reliance on family physicians. Rural regions (Non-Metropolitan Statistical Areas) accounted for 1548 of the 2298 counties not wholly designated PCHPSAs (67.4%). Without FP/GPs, 1050 (67.8%) of these rural counties would exceed the 3500:1 threshold for PCHPSA designation. Without general internists, only 33 (2.1%) would exceed the threshold, and only 8 (0.5%) would exceed the threshold without pediatricians or without ob/gyns.
The information and opinions contained in research from the Graham Center do not necessarily reflect the views or the policy of the AAFP.
Published in American Family Physician, May 1, 2001. Am Fam Physician. 2001;63:1669. This series is coordinated by Sumi Sexton, MD, AFP Associate Medical Editor.