Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Steiner, Robert William Prasaad

Committee Co-Chair (if applicable)

Esterhay, Robert

Committee Member

Wainscott, Barry

Committee Member

Lorenz, Doug


Medical students--Loans; Medicine--Specialties and specialists; Decision making


A shortage of primary care physicians (PCP) is present nationally and within Kentucky. The shortage is expected to worsen, unless a dramatic increase occurs in the generation of additional primary care clinicians. Geographical maldistributions of PCP also exist. Whereas 20% of the US population resides in rural areas, only 10% of physicians practice in these areas. This study explores factors that influence medical students’ decisions to select primary care residency training programs, and to practice in rural areas. Specifically, the levels of debt among 1391 graduates from University of Louisville School of Medicine (ULSOM) during 2001-2010 were examined in association with their selection of categories of residency training programs. Similarly, levels of debt among 1180 ULSOM graduates during 2001-2008 were examined in association with rural practice locations. Statistical methods included evaluations of receiver-operating curves (ROC) and multiple logistic regression analyses. The ROC analyses showed no association was present for any level of debt with either selection of primary care residency programs or rural practice sites. Multiple logistic regression analyses showed a statistically significant, positive association was present between the two extreme quintiles of medical students’ debt, whereby medical students in the lower quintile of debt were more likely select a primary care residency, compared to those students within the highest quintile. No statistically significant association was found for students’ debt with rural practice location. Multiple policy options to increase the primary care workforce were examined, including raising physicians’ reimbursements, shortening time for medical training, and altering how medical schools finance medical education. Policy makers may also consider the affinity model, whereby increasing medical school admissions among applicants from rural areas may result in greater numbers of PCP that are more likely to return to practice in rural areas. Similarly, programs to better support rural pipeline programs may be considered. Other policy solutions may include allowing nurse practitioners and other clinical personnel to work at the full scope of their training as well as a fuller utilization of health information technology. Addressing population health through the Triple Aim may provide novel solutions.

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Public Health Commons