A number of findings emerged when the physicians were compared by different variables. The physician-patient ratio was similar in both rural and nonrural areas (rural, 1:1782 persons, or 56:100,000; nonrural, 1:1753, or 57:100,000). Despite similar physician ratios, rural areas have greater spatial distribution of physicians to population. There was one rural primary care physician per every 182.4 square miles of rural county and one nonrural primary care physician per every 22 square miles of nonrural county.
32,33
The differences in prevalence of male and female osteopathic physicians in primary care and rural primary care practice are also of interest. Of the 11,884 primary care physicians in Texas in 2003, 10% were osteopathic physicians, and most were located in nonrural areas (only 517 primary care physicians practiced in rural locations). The smaller number of osteopathic physicians in general and female osteopathic physicians in particular may be overlooked in assessing access for vulnerable populations. Although they comprise only 2% of the study population, female osteopathic physicians were more representative than other physicians in their choice of primary over non–primary care practice and were 2.5 times more likely to be in rural primary care than female allopathic physicians. Compared with male allopathic physicians, female osteopathic physicians in Texas were 4.7 times as likely to practice primary care medicine.
There are several limitations to this study. The first is that a prevalence study does not necessarily reflect trends, thus limiting the conclusions. Also, this study did not consider the tendency for physicians to establish practices in the state in which they were educated and trained. Specialty and location theory is complex and requires a large number of qualitative and quantitative variables.
Economic location theory would suggest that physician distribution will be based on an area's need and ability to support their practice. Thus, the overall growth of the physician supply should result in a “trickle down” effect to smaller communities. Although there have been small increases in some areas of the United States in the number of rural physicians, that overall need remains unmet.
1,29
There are drawbacks to the practice of rural medicine that make it unattractive to many physicians.
29,33,34 No attempt was made in this study to explain why an osteopathic physician of either sex is more likely to select rural practice. This analysis did not attempt to parse out differences beyond sex, type of medical degree, primary care specialty, and rurality. Many differences affect practice patterns—age, nationality, undergraduate and Medical College Admission Test qualifications, and predoctoral differences in medical school and practice site selection.
29 Future studies should examine these and other factors to determine which variables lead osteopathic physicians to practice in rural primary care at a higher rate than their allopathic colleagues. Studies should be undertaken to determine whether osteopathic physicians, men or women, are willing to accept a lower rate of return on their education by selecting less lucrative rural practices, and if so, why.
35
There continue to be disparities in access to healthcare in the United States. This is especially evident for rural and other underserved communities, where practice conditions leave many physicians reluctant to locate. These disparities are in part spurred by a practice climate that encourages specialty over primary care and in which women, who tend to not choose rural practice, play a greater role than ever before. Osteopathic medicine has emerged as one of few consistent remedies for these inequities. In contrast with allopathic physicians, most osteopathic physicians choose primary care specialties. Furthermore, the literature suggests that osteopathic physicians practice in rural areas relatively more than their allopathic colleagues. With more than 50,000 physicians licensed to practice in Texas, the impact of the relatively small but increasing number of female osteopathic physicians should not be overlooked.
When the focus is narrowed to rural primary care practice, female osteopathic physicians continue to distinguish themselves. They outpace female allopathic physicians in rural primary care practice by more than 2.5 times, a finding that holds special significance when viewed in light of the increasing numbers of women practicing medicine.
These results suggest that policies intended to produce rural primary care physicians must consider the effects of gender and medical education on physicians' practice and location choices.
Numerous governmental and private initiatives exist to improve rural health and healthcare delivery. Many of these initiatives focus on producing family physicians and promoting “rural track” training, including residency programs.
1 One of the most prominent efforts is through the US Department of Health and Human Services' Office of Rural Health Policy (Washington, DC), which is conducting dozens of programs and studies to examine the rural health landscape. Although many physician workforce studies have been done, none of them, to our knowledge, have considered the circumstances described in this study.
36 Despite these efforts, there remains a need for additional study of physician supply dynamics, including models that can better forecast rural physician supply. Such forecasts can then be combined with studies such as ours to offer practical solutions to this health policy challenge. The allocation of federal and state financial support must be supported by rational, empiric study. Osteopathic physicians, especially female osteopathic physicians, have an important influence on the nation's rural healthcare system. The promotion and support of osteopathic medical colleges and the encouragement of medical school candidates to consider osteopathic medical training will increase the numbers of physicians practicing primary care in rural areas.