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THE ROBERT GRAHAM CENTER
Med School Mapper User-Guide
February 4, 2011
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Table of Contents Introduction .................................................................................................................................................. 1
Who built the Med School Mapper? ......................................................................................................... 1 Why was the Med School Mapper developed? ......................................................................................... 1 How will the Med School Mapper be used? .............................................................................................. 1 Who are the targeted user groups for the Med School Mapper? ............................................................. 1
Data ............................................................................................................................................................... 2 What geography is used for mapping and analysis in the Med School Mapper? ..................................... 2 What types of data are used in the Mapper and what are their sources? ............................................... 2 Data Accuracy ........................................................................................................................................... 2 Data Limitations ........................................................................................................................................ 2
Poor response to physician practice changes ....................................................................................... 2 Self-reporting of specialty ..................................................................................................................... 2
Functions of Footprint View ......................................................................................................................... 4 Tools in the Map View ............................................................................................................................... 6
Legend ................................................................................................................................................... 6 Refine Data on Map Tool ...................................................................................................................... 6 Advanced Tool....................................................................................................................................... 7 Map Layers Tool .................................................................................................................................... 7
Medical School Footprint: Service Area by County............................................................................ 7 Penetration Rate: Graduates per Total Population .......................................................................... 8 Penetration Rate: Graduates per Physicians ..................................................................................... 8
Rollovers................................................................................................................................................ 8 State Rollover .................................................................................................................................... 8 School Rollovers ................................................................................................................................ 8 County Rollovers ................................................................................................................................ 9
Tool Resources and Help ............................................................................................................................. 10 About ....................................................................................................................................................... 10 Other Resources ...................................................................................................................................... 10
Tools and Data .................................................................................................................................... 10 Constituents ........................................................................................................................................ 10 Articles and References ...................................................................................................................... 11
Help ......................................................................................................................................................... 12 FAQs .................................................................................................................................................... 12 Tutorials .............................................................................................................................................. 12 Data Definitions .................................................................................................................................. 12 Glossary ............................................................................................................................................... 12 Knowledge Base .................................................................................................................................. 12
Contact Us ............................................................................................................................................... 12 Appendix A: Project Team Bios .................................................................................................................. 14 Appendix B: Data Dictionary ...................................................................................................................... 15
Map Layers .............................................................................................................................................. 15 Medical School Footprint: Service Area by County............................................................................. 15 Penetration Rate: Graduates per Total Population ............................................................................ 15 Penetration Rate: Graduates per Physicians ...................................................................................... 15
Graph Area Fields .................................................................................................................................... 15 Rural Areas .......................................................................................................................................... 15
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Shortage Areas (HPSA/MUA) .............................................................................................................. 15 Primary Care ....................................................................................................................................... 15 General Surgery .................................................................................................................................. 16 Family Medicine .................................................................................................................................. 16 Low Income Areas ............................................................................................................................... 16
State Rollovers ........................................................................................................................................ 16 Population to physician ratio .............................................................................................................. 16 Population to primary physician ratio ................................................................................................ 16 Number of graduates trained in this state (in direct patient care) .................................................... 16 Number of graduates remaining in state (in direct patient care) ....................................................... 16 Percent of graduates remaining in state ............................................................................................ 16 Schools providing the most graduates to this state ........................................................................... 16
County Rollover ....................................................................................................................................... 16 General ................................................................................................................................................ 16
Population 2007 .............................................................................................................................. 16 Population density .......................................................................................................................... 16 Total physicians practicing in county .............................................................................................. 17 Population to physician ratio .......................................................................................................... 17 Population to primary care physician ratio ..................................................................................... 17 Schools providing the most grads to this county ............................................................................ 17
State selected ...................................................................................................................................... 17 Graduates ........................................................................................................................................ 17 County doctors per [state] grad ...................................................................................................... 17 County pop per [state] grad ............................................................................................................ 17
School selected ................................................................................................................................... 17 Graduates ........................................................................................................................................ 17 County doctors per grad .................................................................................................................. 17 County pop per school graduate ..................................................................................................... 17
Medical School Rollover .......................................................................................................................... 17 Number of graduates trained at this school (in direct patient care) .................................................. 17 Number of graduates remaining in state ............................................................................................ 17 Percent of graduates remaining in state ............................................................................................ 18
Advanced Tool ......................................................................................................................................... 18 Specialty. ............................................................................................................................................. 18 Practice type ....................................................................................................................................... 18 Graduate Practice Locations ............................................................................................................... 18 Health Professional Shortage Areas .................................................................................................... 18 Medically Underserved Areas/Populations ........................................................................................ 18 111th Congressional Boundaries ........................................................................................................ 18 State Upper Senate - Boundaries of the state’s Senate districts. ....................................................... 18 State Lower House .............................................................................................................................. 18
Appendix C: Glossary and Frequently Asked Questions ............................................................................ 19 Glossary ................................................................................................................................................... 19
Dominant grantee ............................................................................................................................... 19 Federally Qualified Health Center Look-Alike ..................................................................................... 19 Federal Poverty Level (FPL) ................................................................................................................. 19 (Section 330) Grantee ......................................................................................................................... 19 Penetration rate .................................................................................................................................. 19
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Zip Code Tabulation Areas (ZCTAs) ..................................................................................................... 19 Frequently Asked Questions .................................................................................................................... 20
Footprint/Service Area view ............................................................................................................... 20 Penetration of Total Pop View ............................................................................................................ 21 Penetration by Total Physicians View ................................................................................................. 21 Refine Data on Map box (Advanced Mode) ........................................................................................ 21 Other ................................................................................................................................................... 22
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Introduction
Who built the Med School Mapper?
The American Academy of Family Physicians’ Robert Graham Center for Policy Studies in Family Medicine and Primary Care coordinated the Med School Mapper project with funding provided by the Josiah Macy, Jr. Foundation. Partners on this project include HealthLandscape LLC and the Health Foundation of Greater Cincinnati, and Blue Raster, LLC. More information about each of these organizations can be found by following the links or by looking in Appendix A.
Why was the Med School Mapper developed?
Amidst AAMC and COGME recommended expansion of medical education, principally through expansion of existing training sites, there is little mention and measurement of how the large investments of public dollars meet the needs of the citizens. In response to this, the Macy Foundation is funding the Medical Education Futures Study. This response is consistent with Macy’s mission to promote and evaluate the social responsiveness and mission of each medical school. Its ranking of schools by social accountability is a novel first step in understanding their social impact on a national scale. However, as state policymakers attempt to direct expansion funding with accountability to their own regional social and health care access needs, they have few tools for understanding the local and regional impact of schools. Neither national rankings, nor workforce models can capture the regional impact of training sites. The Robert Graham Center has been studying means of demonstrating such impact, using geographic and policy analyses of individual medical schools’ graduates.
How will the Med School Mapper be used?
Due to the collective lack of tools to effectively measure the impact of individual medical schools on community policy objectives, there is a critical knowledge gap as states call on strained budgets to expand local capacity for medical education. Local and regional effects on physician access are often recognized only after the fact. Using novel approaches to analyzing and displaying regional impact, the Med School Mapper will give planners essential information for directing and evaluating medical school expansion and its impact on access and other social aims.
Who are the targeted user groups for the Med School Mapper?
Association of Academic Health Centers (AAHC)
American Medical Association (AMA)
Association of American Medical Colleges (AAMC)
Medical Education Futures Study (MEFS)
American Association of Colleges of Osteopathic Medicine (AACOM).
Council on Graduate Medical Education (COGME)
Other policy makers and planners (state, local, community)
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Data A complete data dictionary can be found in Appendix B, however, the most current information about
the data currently used in the site can be found at: http://www.medschoolmapper.org/data.cfm.
What geography is used for mapping and analysis in the Med School Mapper?
Physician data are aggregated into counties. Each county displays population statistics, physician to population ratios school/state medical graduates, and the schools providing the most graduates to that county. State level population and physician data is also available.
What types of data are used in the Mapper and what are their sources?
Data used for the Med School Mapper comes from the 2009 American Medical Association (AMA) Physician Masterfile. The AMA Masterfile’s goal is to capture every physician in the US, including those who are not members of the AMA, osteopaths, and international medical graduates. In contrast to the National Provider Index (NPI) Registry and other census-style datasets that provide only demographic information, the AMA Masterfile also provides information on physicians’ practices and educational background.
Data Accuracy
While there has been some debate regarding the accuracy of the AMA Masterfile, previous work by the Robert Graham Center has shown very little duplication of records or invalid values, with a maximum of 22 duplicate entries out of 892,978 in the May 2001 Masterfile[i]. Furthermore, the NPI is not actively tended for the purposes of purging out of date information or providers that have ceased to practice. State licensure data for all 50 states would be exceedingly difficult to collect and maintain on an annual basis, risks overcounting and duplication for physicians that serve in multiple states, and doesn’t capture information for the purposes of workforce study.
Data Limitations
Poor response to physician practice changes Compared with other sources of information, the AMA Masterfile is slow to record changes in practice setting, deaths, or retirements[ii]. A recent study found that in comparison to direct physician survey and medical license analysis, the sensitivity of the AMA Masterfile[iii] regarding departure from clinical activity was 9.0%, with a positive predictive value of 52.9%. One possible explanation for this discrepancy is the AMA’s reliance on periodic physician surveys to ascertain physician practice, as it may be years between surveys for a particular physician. When compared to the US Census Bureau Current Population Survey (CPS), the AMA Masterfile, in general, has a larger number of older physicians and a smaller number of younger physicians in the workforce, again indicating that the AMA Masterfile is insensitive with respect to changes in the workforce[iv].
Self-reporting of specialty
The AMA Masterfile surveys allow physicians to self-report their primary specialty and a secondary specialty they practice. This may overestimate the number of generalist physicians by incorporating specialists who dedicate some of their practice to providing primary care[v]. According to some calculations, the AMA Masterfile may overestimate the number of primary care physicians by 25%[vi].
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These limitations are important to keep in mind, particularly when using the AMA Masterfile to develop physician workforce supply projections. While the Masterfile may not represent a real-time look at the national physician workforce and may overestimate the number of primary care physicians, it is a comprehensive, robust dataset that aids in analyses of the workforce at the national, state, and local level.
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Functions of Footprint View
Unselect state or school
button
Clicking either of these
buttons will take you back
to the Welcome Screen
Find information about
the partners and
background for the
project
Links to tools and data,
constituents and partners,
and scholarly articles
Training and support resources:
FAQs, Tutorials, Data definitions,
Glossary and Knowledgebase
Link to HealthLandscape, LLC Logout button
Get more information,
reset your map or go
back to the welcome
screen
Title
of
active
map
layer
Zoom/Scale
bar
Refine data on map
tool- Select a state or
med school for its
footprint
Zoom the map to the
Continental US,
Alaska, Hawaii or
Puerto Rico
Print/Export map
Info button
Slide bar- Allows for
adjustment of the
threshold for inclusion of
graduates (100% includes
all graduates of that
school or state)
Advanced tool button- switch to
Advanced Mode for more options
Zoom to selected
state or school
Switch between active map
layers
Collapse data module State (or school) selected
Graph Area- shows the percent of
graduates in specific fields (national and
in-state), and corresponding raw data
and rankings for the selected state or
school
Legend for active
map layer
State view or
school view
Map scale
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When you first click through the welcome screen, you will see a map of the continental United States. If a state is selected, that state will be highlighted in yellow and the national graduate footprint (at the default 70%) will be visible. If a school is selected, the state will be highlighted in yellow, the symbol representing the school will be outlined in green. The selected school’s national graduate footprint (at the default 70%) will be shown on the map.
The title for the currently active base layer, in this case “Medical School Footprint: Service Area by County,” is displayed immediately above the map to the left. Just below the map title, there is a scale bar that allows you to zoom in and out in the map.
To the right of the map title, is a zoom feature which allows the user to choose to zoom to the continental United States, Alaska, Hawaii or Puerto Rico. Once a location is selected from the drop down box, the map will automatically zoom to that area.
To the right of the ‘Zoom to’ feature is the ‘Refine Data on Map’ tab. This allows the user to select a state for analysis and zoom to it by clicking the zoom button to the right of the drop down menu. When a state is selected, that state’s medical schools will become visible on the map and in the ‘Refine Data on Map’ tab. Clicking on a school will select it, and clicking the zoom button to the right of the school will zoom to that school’s location on the map. The graduate footprint can be adjusted from its default 70% by sliding the slide bar in either direction with your mouse, or using the left and right arrow keys.
At the bottom of the ‘Refine Data on Map’ tab, there is a large blue ‘Advanced Tool’ button, which expands the tab, and provides new layers and data to be added to the map. After selecting the desired options, click ‘Run query’ to display the desired data on the map. ‘Graduate practice locations’ can be visualized by clicking the corresponding button in the Advanced tab. You can return to basic mode by clicking the ‘Return to Basic Mode’ button at the bottom of the tab. This will remove any changes made to the map in Advanced mode.
In the lower right corner of the map is the main map layers tab. The default status for this tab is ‘Medical School Footprint.’ The two penetration rate layers, ‘Graduates per Total Population’ and ‘Graduates per Physician’ change the main layer shown on the map by clicking their respective buttons.
To the left of the main map layers tab is a bar graph showing the percent of graduates in rural areas, shortage areas (HPSAs and MUAs), primary care, general surgery, family medicine and low income areas. The blue bar represents the percent of national graduates practicing in that particular field, while the nested gray bar represents the percent of in-state graduates practicing in that field. The raw number of physicians practicing in one of these fields is given for in-state and national to the right of the bar graph. The rank for each school (out of 160) or state (out of 47) is also given, and is based on the percentage of practicing physicians rather than the raw number.
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Tools in the Map View
Scale bar Allows you to change the scale of the map from a maximum of 1:591,657,528 to a minimum of 1:72,224. You can change the scale by clicking on the plus (+) or minus (-) signs at either end of the bar. You can also click and hold the scale indicator and drag it to your desired scale.
Legend Shows a description of the current active map layer and the symbol for a medical school on the map. When in Advanced mode, the legend also displays the symbol for graduate practice locations.
Refine Data on Map Tool The Refine Data on Map Tool houses several important functions. It allows the user to select a state, zoom to that selected state, select a school within that state and zoom to the selected school.
In the ‘Medical School Footprint’ view, this tool also allows the user to adjust the % of Grads included in the footprint measurement by sliding the blue icon to the left or right with the mouse or left and right keyboard arrows. This slide bar is only available in the footprint view, and not in the penetration rate views.
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Advanced Tool
The Advanced Tool provides more analytic options for users. This tool allows a user to filter the footprint or penetration maps with customizable data regarding physician gender, specialty and practice type. The tool also allows the time period for the data to be adjusted. One or multiple schools must be selected to obtain data while in Advanced Mode. Once the data of interest have been selected, clicking the “Run Query” button will display that data on the map and in the graph area. The tool also allows for visualization of graduate practice locations for the selected schools (always representing 100% of a school’s graduates, and the addition of layers to the map. The layers available are: Health Professional Shortage Areas (HPSAs), Medically Underserved Areas/Populations (MUA/Ps), 111th Congressional boundaries, State Lower House boundaries and State Upper Senate boundaries. The transparency of these additional layers can be adjusted by utilizing the slide bar.
Map Layers Tool This tool allows you to toggle between the three map layers, the Medical School Footprint and the two penetration rate layers. Only one layer can be selected at a time. The default setting for the footprint layer captures 70% of state/school graduates (this percent included can be altered), while the penetration rate layers capture 100% of state/school graduates, and cannot be changed.
Medical School Footprint: Service Area by County
Footprint maps can be used to show which counties a state or school's graduates are serving. The counties that are served (corresponding to the percent of graduates included) will light up as red when this map layer is selected.
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Penetration Rate: Graduates per Total Population
Pentetration maps can be used to show which counties a state's or school's graduates are serving and how intensely. This penetration rate is calculated by dividing the number of graduates (from the selected school or state) in a particular county, by the number of people living in that same county. Those counties with more school or state graduates per population will shade more intensely on the map.
Penetration Rate: Graduates per Physicians
Pentetration maps can be used to show which counties a state's or school's graduates are serving and how intensely. This penetration rate is calculated by dividing the number of graduates (from the selected school or state) in a particular c ounty, by the number of physicians practicing in that county. The counties with more school or state graduates per total physician will shade more intensely on the map.
See Appendix B for data source information.
Rollovers At all zoom levels, rollover information is available for states, schools and counties.
State Rollover
These rollovers contain information about the physician and graduate data from that state. Data include:
State name
Population to physician ratio
Population to primary physician ratio
# of graduates trained in state (in direct patient care)
# of graduates remaining in state (in direct patient care)
% of graduates remaining in state (in direct patient care)
Top five schools providing the most graduates to that state
School Rollovers
These rollovers are available when a state is selected, and the mouse cursor is hovering over a school on the map. Data include:
School name
# of graduates trained at school (in direct patient care)
# of graduates remaining
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in state (in direct patient care)
% of graduates remaining in state (in direct patient care)
County Rollovers
These rollovers are available when a state or school is selected. Counties outside of the selected state also provide rollover information. Data include:
County name and state
County population (from 2007)
County population density (from 2007)
Total physicians practicing in county
Population to physician ratio
Population to primary care physician ratio
Graduates (from selected state)
County doctors per Missouri graduate
County population per Missouri graduate
Top five schools providing the most graduates to that state
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Tool Resources and Help
About
This diction contains information about the Med School Mapper, including project background,
advisory group information, targeted users, and project team biographies. All of this information
can be found in the Introduction and Appendix A of this user guide.
Other Resources
Tools and Data
American Medical Association Physician Masterfile HealthLandscape.org Direct from NIH or NIH Rankings Compiled by Blue Ridge Institute
Constituents
American Medical Association (AMA) Association of American Medical Colleges (AAMC) Workforce The AAMC Center for Workforce Studies conducts assessments on workforce needs and seeks to increase the availability of data on physician supply and demand. American Association of Colleges of Osteopathic Medicine (AACOM) The AACOM represents and supports osteopathic medical schools. Council on Graduate Medical Education (COGME) COGME was authorized by Congress to provide assessment of physician workforce trends. It advises the Department of Health and Human Services, the Senate Committee on Health, Education, Labor, and Pensions, and the House of Representatives Committee on Commerce. COGME's 16th Report called for a fifteen percent increase in medical school enrollment.
Medical Education Futures Study (MEFS) MEFS is an initiative funded by the Josiah Macy, Jr. Foundation that examines the social mission of medical education during the period of medical school expansion. The website’s policy briefs, blog, newsletters, and publications provide analysis on current workforce debates.
Towards Unity for Health (TUFH) TUFH is an international organization that is affiliated with the World Health Organization and composed of academic health institutions. It promotes social accountability in medical schools such that these institutions direct their resources towards addressing the priority health concerns of the community they serve.
Association of Academic Health Centers (AAHC) The AAHC represents and supports academic health centers (which consist of a medical school, one or more other health profession schools, and one or more teaching hospitals) nationwide.
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Rural Health Research Centers: http://ruralhealth.hrsa.gov/policy/RHRC/rhrccoop.htm The Rural Health Research Centers program helps policymakers understand the health care access problems unique to rural communities. The centers assess measure that improve rural access, interpret how policy influences rural communities, and communicate their findings to stakeholders. Washington, Wyoming, Alaska, Montana, and Idaho Rural Health Research Center (WWAMI) Maine Rural Health Research Center North Carolina Rural Health Research & Policy Analysis Center South Carolina Rural Health Research Center Upper Midwest Rural Health Research Center – University of Minnesota and University of North Dakota West Virginia Rural Health Research Center
Articles and References
Association of American Medical Colleges. AAMC Statement on the Physician Workforce. Center for Workforce Studies, AAMC. June 2006. Association of American Medical Colleges. 2009 State Physician Workforce Data Book. Center for Workforce Studies, AAMC. November 2009. Boelen C, Heck J. Defining and Measuring the Social Accountability of Medical Schools. Geneva: Division of Development of Human Resources for Health, World Health Organization; 1995. Document WHO/HRH/95.5. Council on Graduate Medical Education. Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020. Council on Graduate Medical Education. Rockville, MD, Department of Health & Human Services, 2005. George E. Fryer, PhD; Jessica L. McCann, MA; Martey S. Dodoo, PhD; Larry A. Green, MD; Thomas Miyoshi; Robert L. Phillips, MD, MSPH. Access, health, and wealth: The impact of the National Health Service Corps in rural America, 1970-2000. Robert Graham Center, 2006. Hyer J, Bazemore AW, Bowman R, Zhang X, Petterson S, Phillips RL. Medical school expansion: An immediate opportunity to meet rural health care needs. Am Fam Physician. 2007 Jul 15;76(2):208. Hyer JL, Bazemore AW, Bowman RC, Zhang X, Petterson S, Phillips RL. Rural origins and choosing family medicine predict future rural practice. Am Fam Physician. 2007, Jul 15;76(2):207. Karpf, Michael MD; Lofgren, Richard MD; Perman, Jay MD. 2009. Commentary: Health
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Care Reform and Its Potential Impact on Academic Medical Centers. Academic Medicine: November 2009 - Volume 84 - Issue 11 - pp 1472-1475 Lindsay D, Bazemore AW, Bowman R, Petterson S, Green LA, Phillips RL. Will medical school expansion help to diversify the physician workforce? Am Fam Physician. 2007 Jul 1;76(1):38. Meyers D, Fryer GE, Krol D, Phillips RL, Green LA, Dovey SM. Title VII funding is associated with more family physicians and more physicians serving the underserved. Am Fam Physician 2002;66:554. Reese VF, McCann JL, Bazemore AW, Phillips RL Jr. Residency footprints: Assessing the impact of training programs on the local physician workforce and communities. Family Medicine. 2008;40(5):339-344.
Help
FAQs
A comprehensive list of Frequently Asked Questions. The FAQs developed to date (November 1, 2010) can be found in Appendix C.
Tutorials
Video Tutorial of Use-Case and Med School Mapper Functions.
Downloadable user-guide documents, including the most up-to-date version of the user guide (currently 1.0).
Data Definitions
Description and source information for data used for the footprint and penetration rate measures, as well as state/school rankings and the data tables. The information in this section of the Med School Mapper site (as of November 1, 2010) can be found in Appendix B.
Glossary
List of relevant/useful terms and their definitions. The information in this section of the Med School Mapper site (as of November 1, 2010) can be found in Appendix C.
Knowledge Base
Search function of available articles submitted by Med School Mapper administrators (i.e., regarding FAQs, known issues, glossary terms, references, articles, etc.).
Contact Us
Feedback form with the following fields:
First name
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Last name
Phone
Preferred contact method
Feedback Type o Usability/technical issue o Data-related o Recommendations for improvement o Other
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Appendix A: Project Team Bios Macy Foundation: The Josiah Macy, Jr. Foundation provides funding for projects in the following four areas: 1) Projects to improve medical and health professional education in the context of the changing health care system; 2) Projects that will increase diversity among health care professionals; 3) Projects that demonstrate or encourage ways to increase teamwork between and among health care professionals; and 4) Educational strategies to increase care for underserved populations. Robert Graham Center: The AAFP's Robert Graham Center for Policy Studies in Family Medicine and Primary Care is a research center sponsored by the AAFP but operated with editorial independence. It was established a decade ago to provide evidence for policy-making and to bring a family medicine and primary care perspective to health policy deliberations. The Robert Graham Center staff are experts in the use and analysis of large datasets using Geographic Information Systems (GIS), and have a strong and team-based approach to GIS-related work and application development. AAFP: The American Academy of Family Physicians (AAFP) is the national association of family doctors. It is one of the largest national medical organizations, with more than 94,600 members in 50 states, D.C., Puerto Rico, the Virgin Islands, and Guam. The Academy was founded in 1947 to promote and maintain high quality standards for family doctors who are providing continuing comprehensive health care to the public. HealthLandscape LLC and the Health Foundation of Greater Cincinnati: HealthLandscape LLC develops, administers, and markets geospatial analysis software tools and professional services. The LLC is a subsidiary of the nonprofit Health Foundation of Greater Cincinnati, which worked with the AAFP and Robert Graham Center in the successful development of the HealthLandscape mapping platform. This group has extensive experience in GIS applications relating to health centers and primary care and works closely on all projects as a team. Blue Raster LLC: Blue Raster LLC is a GIS application development group skilled in rapid application development. They have 20 years of experience in every aspect of GIS mapping using partner solutions and web and database technologies, and developed the HealthLandscape prototype together with the investigators. The Blue Raster staff includes advanced application architects, RIA developers, and GIS analysts that are critical for developing mapping tools.
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Appendix B: Data Dictionary
Map Layers
Medical School Footprint: Service Area by County - (Data from 2009 AMA Masterfile) This map colors a county if physicians from a selected state or medical school practice within that county. The default threshold is set at 70% inclusion of all graduates, meaning that only those counties with a higher number of graduates are shaded. The “% of graduates included” can be adjusted (in increments of five), to include more or less graduates in the map view. At a 100% threshold, all counties with one or more of a state’s or medical school’s graduates will be shaded.
Penetration Rate: Graduates per Total Population - (Data from 2009 AMA Masterfile) This map displays the penetration rate of state or medical school graduates in a county as a ratio of the population in that county to the selected state or medical school graduates in that same county. In other words, for each county, the total population is divided by the number physicians trained in a selected state or medical school. Lighter shaded counties therefore have fewer graduates per total population, while dark shaded counties are densely populated with graduates. The threshold for this measure is always 100% (includes all graduates) signifying that unshaded counties have no graduates from the selected school or state.
Penetration Rate: Graduates per Physicians - (Data from 2009 AMA Masterfile) This map displays the penetration rate of state or medical school graduates in a county as a ratio of the total physician population in that county to the selected state or medical school graduates in that same county. In other words, for each county, the total physician population is divided by the number physicians trained in a selected state or medical school. Lighter shaded counties therefore have fewer graduates per total physicians, while dark shaded counties are densely populated with graduates. The threshold for this measure is always 100% (includes all graduates), signifying that unshaded counties have no graduates from the selected school or state.
Graph Area Fields
Rural Areas - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in rural areas. The U.S. Census Bureau's classification of "rural" consists of all territory, population, and housing units located outside of urbanized areas and urbanized clusters[vii]. These areas are by definition lightly populated and removed geographically from an urban center. The problem of access to health care in rural areas is an overall dilemma rather than a matter of income.
Shortage Areas (HPSA/MUA) - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in a designated shortage area. More information about shortage areas can be found in the data definitions for the Advanced Tool.
Primary Care - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in a primary care specialty.
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General Surgery - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in general surgery.
Family Medicine - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in a family medicine specialty.
Low Income Areas - (Data from 2009 AMA Masterfile) Displays the percentage (in-state and national), raw number and rank of graduates from a state or medical school practicing in a low income area. An area is designated as low income if more than X% of its population is at or below 200% of the Federal Poverty Line.
State Rollovers
Population to physician ratio - (Data from 2009 AMA Masterfile) Displays the total population per physician practicing in that state.
Population to primary physician ratio - (Data from 2009 AMA Masterfile) Displays the total population per primary care physician practicing in that state.
Number of graduates trained in this state (in direct patient care) - (Data from 2009 AMA Masterfile) Displays the number of reported graduates from all medical schools within that state that are involved in direct patient care. Data collection stretches from 1950 to 2009.
Number of graduates remaining in state (in direct patient care) - (Data from 2009 AMA Masterfile) Displays the number of reported graduates from all medical schools within a state who practice direct patient care in that same state. Data collection stretches from 1950 to 2009.
Percent of graduates remaining in state - (Data from 2009 AMA Masterfile) Displays the percent of a state’s medical school graduates who remain in that state for practice (in direct patient care). Data collection stretches from 1950 to 2009.
Schools providing the most graduates to this state - (Data from 2009 AMA Masterfile) Displays the ratio of reported Section 330 patients (from all Section 330 grantees reporting more than 10 patients in that ZCTA) to the number of total residents. Because of the mismatch in reporting years, this measure is only an estimation and should be interpreted as such.
County Rollover
General Population 2007 - (Data from 2008 Area Resource File) Displays total population of the selected county. Population density - (Data from 2008 Area Resource File) Displays the total population of the selected county as a ratio to the square mileage of that county.
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Total physicians practicing in county - (Data from 2009 AMA Masterfile) Displays the total number of physicians practicing within the selected county. Population to physician ratio - (Data from 2009 AMA Masterfile) Displays the number of people per physician within the selected county. Population to primary care physician ratio - (Data from 2009 AMA Masterfile) Displays the number of people per primary care physician within the selected county. Schools providing the most grads to this county - (Data from 2009 AMA Masterfile) Displays the top five schools where the greatest number of physicians practicing within the selected county were trained.
State selected
Graduates - (Data from 2009 AMA Masterfile) Displays the number of in-state medical school graduates practicing within the selected county. County doctors per [state] grad - (Data from 2009 AMA Masterfile) Displays the ratio of total physicians to physicians trained in-state in the selected county. County pop per [state] grad - (Data from 2009 AMA Masterfile) Displays the ratio of total county population to physicians trained in state practicing in the selected county.
School selected
Graduates - (Data from 2009 AMA Masterfile) Displays the number of graduates from the selected medical school practicing within the county of interest. County doctors per grad - (Data from 2009 AMA Masterfile) Displays the ratio of total physicians to physicians trained at the selected medical school within the county of interest. County pop per school graduate - (Data from 2009 AMA Masterfile) Displays the ratio of total county population to physicians trained at the selected medical school practicing within the county of interest.
Medical School Rollover
Number of graduates trained at this school (in direct patient care) - (Data from 2009 AMA
Masterfile) Displays the total number of reported graduates from the selected medical school.
Data collection stretches from 1950 to 2009.
Number of graduates remaining in state - (Data from 2009 AMA Masterfile) Displays the total
number of reported graduates from the selected medical school who practice within their state
of medical education. Data collection stretches from 1950 to 2009.
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Percent of graduates remaining in state - (Data from 2009 AMA Masterfile) Displays the
percentage of the selected medical school’s graduates who remain in that state for practice (in
direct patient care). Data collection stretches from 1950 to 2009.
Advanced Tool
Specialty - (Data obtained from 2009 AMA Masterfile) This button allows the user to select one or more specialties and subspecialties to filter the map data. All specialties included in the AMA Masterfile are available.
Practice type - (Data obtained from 2009 AMA Masterfile) This button allows the user to select
one or more practice types to filter the map data. All practice types included in the AMA
Masterfile are available.
Graduate Practice Locations - (Data obtained from 2009 AMA Masterfile) This button adds the practice location of 100% of the graduates from the medical school or medical schools selected. It is based on the same data as the footprint, but pinpoints physician addresses rather than counties of practice.
Health Professional Shortage Areas - (Data obtained monthly from the HRSA Geospatial Data
Warehouse using Adobe GoLive software) This layer displays primary medical care Health
Professional Shortage Areas (HPSAs), which may be designated as having a shortage of primary
medical care, may be urban or rural areas, population groups, or medical or other public
facilities. For more information, see http://bhpr.hrsa.gov/shortage/.
Medically Underserved Areas/Populations - (Data obtained monthly from the HRSA Geospatial
Data Warehouse using Adobe GoLive software) This layer displays Medically Underserved
Areas/Populations (MUA/Ps), which may be a whole county or a group of contiguous counties, a
group of county or civil divisions, a group of urban census tracts in which residents have a
shortage of personal health services, or Exceptional/Governor designated. Medically
Underserved Populations (MUPs) may include groups of persons who face economic, cultural or
linguistic barriers to health care. For more information, see http://bhpr.hrsa.gov/shortage/.
111th Congressional Boundaries - Boundaries of every congressional district and its seat-holder
in the 111th U.S. Congress.
State Upper Senate - Boundaries of the state’s Senate districts.
State Lower House - Boundaries of a state’s House districts.
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Appendix C: Glossary from and Frequently Asked Questions about
www.medschoolmapper.org (as of November 1, 2010)
Glossary
Dominant grantee - The dominant grantee is the Section 330 grantee with the highest number of patients in a ZCTA. Federally Qualified Health Center Look-Alike - an organization that meets all of the eligibility requirements of an organization that receives a Public Health Service Section 330 grant, but does not receive grant funding. Federal Poverty Level (FPL) - the threshold of poverty (based on income) determined annually by the U.S. Department of Health and Human Services (for more information on the 1999 FPL used for Census 2000 data, see the following HHS website) (Section 330) Grantee - a public and private non-profit health care organization that meets certain criteria under the Medicare and Medicaid Programs (respectively, Sections 1861(aa)(4) and 1905(l)(2)(B) of the Social Security Act and receives funds under the Health Center Program (Section 330 of the Public Health Service Act) (i.e., Community Health Centers, Migrant Health Centers, Healthcare for the Homeless Programs, and Public Housing Primary Care Programs). For more information on section 330 grantees see the HRSA website.
Penetration rate - is a ratio of all patients (from Section 330 grantees with over 10 patients in that ZCTA) to a sub-population (such as the total population or low-income population). In other words, for each ZCTA the number of reported Section 330 patients is divided by the number of low-income or total residents.
Note: Because the UDS does not distinguish the income of Section 330 patients at the ZIP Code level, this measure is not perfect, particularly when dividing the number of Section 330 patients by the number of low-income (as not all Section 330 patients are low income/at or below 200% FPL). But because it is known that approximately 92% of Section 330 patients nationally are low income, the basic utility of the calculation in assessing the role of Section 330s in serving the community is not changed. Such penetration rate measures should be considered the starting point for exploring potential unmet need, not the final answer.
Zip Code Tabulation Areas (ZCTAs) - are generalized representations of US Postal Service ZIP Codes. Each ZCTA is built by aggregating Census 2000 blocks, whose addresses use a given ZIP Code, into a ZCTA which gets that ZIP Code assigned as its ZCTA code. While in most instances the ZCTA code equals the ZIP Code for an area, not all ZIP Codes have their own ZCTA. The UDS Mapper contains updated national ZCTAs reflecting U.S. Postal Service ZIP Code changes through October, 2002; there will be no further updates of ZCTA boundaries until required for the 2010 Census. See http://www.census.gov/geo/ZCTA/zcta.html for more information. In their annual preparation of Uniform Data System data from Section 330 grantees, JSI assures that every valid ZIP Code maps to the ZCTA that best fits its location (based on centroid).
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Therefore, reported Section 330 patients are never left out of counts/analyses due to new or changed ZIP Codes.
Frequently Asked Questions
Footprint/Service Area view What is the '% of Grads Included'? Why is it set to 70% by default? To create a graduate 'Footprint', we calculate the number of graduates from a selected state or program in each county, rank these counties from highest to lowest, and select counties to be shaded that have the highest number of graduates in them until 70% of all graduates are accounted for. For example, if a program has 100 active graduates practicing in the U.S., and 50 are practicing in County A, 15 in County B, 5 in County C, and 3 each in Counties D- M, only Counties A, B, & C (which constitute 70% of graduates) will be shaded in the Medical School Graduate Footprint map. This methodology, which borrows from business industry literature on market service area, is thought to be a reasonable standard for gauging the core service area of a medical school program(s). In the event of a tie (two or more counties have the same number of graduates) that crosses the footprint threshold, the county with a smaller population is included in the footprint first (using 2000 Census data); in other words, out of counties with the same number of graduates, those that might be presumed to be less dependent on those graduates are ranked lower. However, you have the option of adjusting the percentage to reflect the footprint threshold most appropriate to your situation, needs, or interests. What data are used to create the footprint? We use physician practice location information from the 2009 American Medical Association (AMA) Physician Masterfile. From a geocoded Masterfile, we extract practice location (including county) for each active physician practicing in the United States. We then use this information to attach each physician to a current medical school program (graduates from closed medical schools are not included in the footprints) and a county of practice. The AMA Physician Masterfile is perhaps the most widely used dataset in studies of the national physician workforce, but it is not without limitations. Not every physician is captured, nor can we guarantee that every physician whose data is captured has accurate business address and school of training information, despite the following statement from the AMA:
"The AMA seeks to achieve a high degree of accuracy in the organization and publication of physician data. Physicians' records are subject to change and are continuously updated through the extensive data collection and verification efforts performed within SDR."
How to I change the % of Grads Included? You can adjust the '% of Grads Included' in the Refine Data on Map box at the top right of the screen using the mouse or the left and right arrow keys on your keyboard. How can I use the Medical School Graduate Footprint map? Footprint maps can be used to show which counties a state or school's graduates are serving, whether a state or school's graduates are caring for underserved communities, whether a state or school's graduates are working in rural communities, and whether graduates are practicing in their state of training. Such maps are useful for program funding and advocacy.
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Penetration of Total Pop View What data are used to create the penetration of total population map? We use physician practice location information from the 2009 American Medical Association Physician Masterfile. From a geocoded Masterfile, we extract practice location (including county) for each active physician practicing in the United States. We then use this information to attach each physician to a medical school program and a county of practice. Lastly, we calculate a penetration rate by dividing the number of graduates (from the selected school or state) in a particular county, by the number of people living in that same county. What is the difference between penetration and footprint maps? A footprint provides information on the geographic distribution of graduates, while penetration gives information about how much a geography depends upon the graduates of a particular medical school(s). How can I use the Medical School Graduate Penetration per Total Population map? Pentetration maps can be used to show which counties a state's or school's graduates are serving and how densely they are served by those graduates. Similar to the basic footprint maps, penetration maps can also show whether a state or school's graduates are caring for underserved communities, whether a state or school's graduates are working in rural communities, and/or whether graduates are practicing in their state of medical education. The maps can also be used to identify the communities that depend on a program's or state's graduates. Such maps are useful for program funding and advocacy. Penetration by Total Physicians View What data are used to create the penetration per total physicians map? We use physician practice location information from the 2009 American Medical Association Physician Masterfile. From a geocoded Masterfile, we extract practice location (including county) for each active physician practicing in the United States. We then use this information to attach each physician to a medical school program and a county of practice. Lastly, we calculate a penetration rate by dividing the number of graduates (from the selected school or state) in a particular county, by the total number of physicians in that same county. How can I use the Medical School Graduate penetration per Total Physicians map? Penetration maps can be used to show which counties a state's or school's graduates are serving and how densely they are served by those graduates. Similar to the basic footprint maps, penetration maps can also show whether a state or school's graduates are caring for underserved communities, whether a state or school's graduates are working in rural communities, and whether graduates are practicing in their state of medical education. The maps can be used to identify the communities that depend on a program's or state's graduates. Such maps are useful for program funding and advocacy. Refine Data on Map box (Advanced Mode) What is the 'Specialty' filter? With the 'Specialty' filter you can choose to display only graduates who are practicing a specific specialty(ies), as listed in 2009 American Medical Association Masterfile, as well as by speciality
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groupings developed by the Robert Graham Center, including Primary Care and Family Medicine. ALL specialties with data collected that are listed by the AMA Masterfile are included. What is the 'Practice Type' filter? With the 'Practice Type' filter you can choose to display only graduates of a specific practice type(s), such as Direct Patient Care (default) or Research, as listed in the 2009 American Medical Association Masterfile. What are 'Graduate Practice Locations'? Graduate practice locations are based on the practice addresses provided by physicians in the 2009 American Medical Association Masterfile. This is perhaps the most widely used dataset in studies of the national physician workforce, but it is not without limitations. We cannot guarantee that every physician whose data is captured has accurate business address and school of training information. This layer includes 100% of the graduates included in the data selection and cannot be adjusted. When the footprint is also set at 100%, these measures are aligned. Other Can I save this view of the map? This function is not yet available. Can I export the map on the screen to a PDF file? As of now, this function can only be accomplished by using a third party application such as Cute PDF to "print" the image as a PDF document. An export feature is planned but not yet available. Can I export the raw data of the map that I am viewing? This function is not yet available. How do I print the map on the screen? A map can be printed directly from the mapping screen by clicking the 'Print' icon above the map to the right. How do I see Alaska, Hawaii, or Puerto Rico? Alaska, Hawaii, or Puerto Rico can be seen by using the 'Zoom To' tool toward the top right of the mapper, or you can manually zoom and drag the map itself.
How are ties determined for the top schools serving a state or county?
The school with the greater number of overall graduates wins the tie.
[i] Robert Graham Center, “The Physician Workforce of the United States: A Family Medicine Perspective,” Accessed online at http://www.graham-center.org/PreBuilt/physician_workforce.pdf on April 21, 2010. [ii] Rittenhouse DR et al, “No Exit: An Evaluation of Measures of Physician Attrition,” Health Services Research, 39:5:1571-88. [iii] Ibid
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[iv] Staiger, DO et al. “Comparison of Physician Workforce Estimates and Supply Projections,” JAMA 2009;302(15):1674-80. [v]Grumbach, K et al. “The Challenge of Defining and Counting Generalist Physicians: An Analysis of Physician Masterfile Data.” Am J Public Health 1995;85:1402-7. [vi]Grumbach, K et al. “The Challenge of Defining and Counting Generalist Physicians: An Analysis of Physician
Masterfile Data.” Am J Public Health 1995;85:1402-7 [vii]http://www.census.gov/geo/www/ua/ua_2k.html
