What can you do to encourage the servants that are growing up right now in your own community? Do your part to remind medical schools and all who train health professionals that service is the top priority and the rest will take care of itself. RCB 2001
An admissions effort that hopes to address basic health access recovery in the United States must understand the basic principles of health access.
Admissions Ratios and Distribution - leaving significant gaps in who is admitted leaves gaps in physician distribution, when the populations most likely to choose family medicine are replaced, the specialty that fills in the gaps is replaced
Assessing Languages in the Process of Admission: Academic Vs People Skills - we all have roles, attitudes, expectations
Florida State - A focus on Meeting State Needs - extensive document regarding admissions and curricula
Family Physicians Are Different
FPs Are Different Table
Admissions and ORIGIN new project, open for your own admission and participation
Rural background students used to be 27% of the entering class of 17000 each year or about 4000 students. This declined to 2000 or 16% by 1999 (AAMC Data publish yearly). MCAT data from 1991 - 1999 reveals no changes in the distribution of students taking the MCAT. Rural background students are just not getting admitted. Admissions criteria are screening out many of the students that will become family physicians and rural doctors. see Evidence Based Admissions
AAMC has a workshop for admission committee members that is useful for looking at more than just scores to consider admissions. This seminar is useful for minority admissions, but the principles for rural admissions are the same. http://www.aamc.org/meded/minority/emae/start.htm
The first three graphic depictions at this link will give you a perspective on the problem, and part of the solution RME: Best Kept Secrets in Med Ed Also links at this site for medical school and residency program data, data by state, also presentations suitable for adapting to admissions, faculty meetings, etc.
American health care is in trouble. America's medical schools are not able to find enough of the kids that will serve and care. A good portion of these kids just don't have the same preparation. These include rural and minority kids. The common ground shared is lower socioeconomic background, parents not knowing the ropes, schools and advisors with less resources and knowledge about preparation, lack of access to shadowing, fellowships, and other orientation and admissions enhancement programs, etc.
America needs more serving docs. There needs to be a balance between service and intellect in the candidates themselves, as well as each class admitted. Patients desire a wide range of doctor types, in discipline as well as in personal characteristics.
National leaders cry out for better admissions. Research tells us how to do better admissions. We have admissions training programs, but each year we have fewer and fewer. Declines in rural education and affirmative action have made matters worse. See Affirmative Action.
Evidence Based Admissions
Admissions Can Impact Maldistribution and Access
There have been many changes in the last 5 decades of medical education. Nearly all factors and changes have driven us away from graduating doctors for small towns. The following are critical areas that admissions committees must understand.
I. Decrease in Acceptance of Rural Background, Lower Income, and Middle Income Students
II. Need for Special Consideration of Rural Background Students
III. Success of Rural Background plus Family Medicine interest
IV. Hope: Students from the underserved and for the underserved
V. Partnerships involving medical schools and rural colleges
VI. Potential Impact Upon Quality of Physicians
I. Decrease in Acceptance of Rural Background Students - It appears from the AAMC data below that there has been no change in the distribution of applicants from any of the geographic areas.
Size of Hometown MCAT examinees for the years 1991 - 1999
1991 to 1999
|Large city over 500k||27% and steady|
Moderate city 50-500k
Small city 10-50k
11% and steady
Town 2500 - 10k
11% and declining to 8%
increasing from 2 to 5%
|Total Rural||16% plus share of large non-responder group|
The total from both rural areas, the ones that are 2 - 7 times more interested in rural practice as seniors, is the same at 16%. The large amount of non-responders has been stable at 30% from 1991 - 1999
The two smallest categories taken together have not changed. However the numbers of rural background students admitted to medical schools has consistently fallen. Each 1 % decline in rural background students is matched by a 1% or more decline in senior students interested in rural practice.
Kassebaum also noted this decline (Kassebaum DG, Szenas PL. Rural sources of medical students and graduates choice of rural practice. Academic Medicine 1993;68;3:232-6.) The reasons for declines in the numbers of rural background students admitted are not fully known, considerations include screening MCAT and GPA scores that tend to keep rural background students from getting interviews and serious consideration or applications and interviews that are not as strong. Pressures on admissions committees to admit students that are unlikely to experience difficulty or failure (because of student problems such as debt and institution difficulties), or pressures to admit students that are more likely to choose research and academics Best vs Brightest: What is the Best Fit For the State (or Nation) See Wheat Article at Small Colleges and Admissions Rural Background
This decline in the number of "different" students admitted to medical school may have more far-reaching impact. The same situation may exist for other health professional schools and other professions as well. This decline may well represent a failure of leadership in legislators, medical schools, education, rural communities, and Americans in general. Clearly those who have responded to rural needs across these areas, have managed to admit, train, and locate more rural health professionals.
Admissions Changes Table 1967 to 2005
II. Need for Special Consideration of Rural Background and other "Different" Students - The Basco article is a study in Georgia that highlights the potential for greater numbers of rural applicants to be seriously considered and it points out that strict screening of candidates for admission can exclude many rural background applicants. Basco, W.T., Jr., Gilbert, G.E., & Blue, A.V.(2002). Determining the Consequences for Rural Applicants When Additional Consideration is Discontinued in a Medical School Admission Process. Academic Medicine, 77, S20-S22. http://www.aamc.org/students/mcat/research/bibliography/basco002.htm RESULTS: Across all four years the adjustment for being a rural applicant had a marked positive effect for rural applicants while having minimal effects on non-rural applicants. The adjustment for rural status did not ensure an admission interview for every rural applicant, but it did mean that a large majority of the rural applicants received admission interviews in all four years. Without the adjustment, fewer than half of the rural applicants would have received admission interviews in two of the years evaluated-1997 and 1999. Australia is moving faster than anyone in this effort to address rural needs. http://www.health.nsw.gov.au/public-health/phb/june01html/rmededjune01.html
· Special considerations for rural and underserved students are justified. Studies demonstrate that traditional assessment methods are not applicable to students from diverse backgrounds with the usual screening methods. Testing Fails to Predict Performance or Future Location Predicting Success, Jordan Cohen Wheat JR, Brandon JE, Carter LR, Leeper JD, Jackson JR. Premedical Education: The Contribution of Small Local Colleges. Journal of Rural Health, 2003;19:181-189.
· AAMC studies note that psychosocial indicators are better measures of eventual performance throughout medical school. http://www.aamc.org/students/mcat/research/bibliography/hojat001.htm
· Service indicators are better predictors of primary care (and likely underserved choice) as well as volunteerism and international service during medical school, and military service. Interestingly, those most likely to choose military careers (white male osteopathic fp docs) are also most likely to choose rural practice (50%). A common serving pool for military, rural, and underserved may exist. Graduates with families, debts, a bit older may opt for secure military careers rather than less comprehensive and less available financing programs for the underserved.
Characteristics of Rural Interested Students Service Orientation Admissions and Involvement
III. Success of Rural Background plus Family Medicine interest - Rabinowitz, Howard demonstrated that 78% of the choice of rural practice was determined by these two factors. Students from a special admissions program included only 1% of the total medical students admitted in all medical schools in the sate of Pennsylvania, but in 25 years this became 21% of the rural family physicians in the state because of improved numbers choosing rural practice and also greater retention of rural doctors who graduated from the Physician Shortage Area Program at Jefferson http://jama.ama-assn.org/cgi/content/short/286/9/1041 Lower and middle income origin students and older graduates have greater than national average choice of rural locations, underserved locations, primary care, and family medicine
The following document some of the reasons for special considerations for rural and underserved students.
· The State By State Education Status web page demonstrates the inequitable distribution of state education resources, with the most inexperienced teachers and the highest turnover rates of teachers and the least resources in the rural and underserved areas with the greatest challenges.
· Centralization and Regionalization decisions introduce difficulties in a systematic fashion through state government and state higher education, especially in times of recession or reductions in educational expenditures, such as now. This is documented in rural education, rural health, and rural public health.
· The Closing and Consolidation Costs in Rural Education and Consolidation and Bonding demonstrate the disastrous adoption of School Consolidation, often with coercive financing formulas by state legislatures. The impact on rural background students is suspected to be negative in educational quality and also in the potential for these students to return to small towns.
· Affirmative action notes the relationship between acceptance rates and the decline in FP graduates from various minorities. It may be that decreasing the available slots for rural, for minority, etc, may make it less likely to admit the serving types and more likely to admit the more intellectual group.
IV. Hope: Students From the Underserved, For the Underserved this page documents interactive low-cost methods of encouraging students from rural and underserved backgrounds by volunteer rural student interest group students traveling to rural secondary schools. Other feeder programs such as AHECS and urban magnet schools have had success in increasing the diversity of applications and even overcoming the reversal of affirmative action. Linking future rural doctors (current rural interested students) with the future students that will join them or replace them in practice, is a powerful reinforcing intervention.
V. Partnerships involving medical schools and rural colleges have assisted the finances, admissions, and academic quality of the rural colleges, thus allowing more students from rural high schools to make an important first choice to live in rural areas for college (RHOP Links) . Such a choice also increases the probability of marrying a rural spouse and perhaps more importantly, one that will have a career more likely to be available in rural locations. The success of these partnerships are due to extension of the Flexner reforms to rural and underserved areas, which were left behind during most of the 20th Century Flexner’s Impact on American Medicine. Flexner was a high school principle who did a national study on college education and then did his tour of American medical schools and report. He brought his understanding of the need for improved education at all levels. Too bad we have let so many schools fall behind, and their students, and their neighborhoods and communities. Outstanding success stories such as RHOP show how little effort is needed, but working in partnerships and removing the negative reinforcements. Community
VI. Potential Impact Upon Quality of Physicians - Selecting for rural interest and underserved backgrounds can also impact medicine in ways greatly needed in medical education and medicine
Characteristics of Rural Interested Students
Character, Color, Admissions, and Physicians
What Is the Risk If We Train Too Many To Serve the Underserved: None! plus great positive side effects
Admissions and Medical Errors
Special admissions plus special training is even better for quality Why a Preceptorship Is Better
Institutions promising to deliver more rural physicians are as legendary and as prevalent as medical students promising that they want to become a small town family physicians. Both are interested in getting what they want without having to make a commitment. RCB 2002
Duluth 20 Questions
Character, Color, Admissions, and Physicians
Service Characteristices and Rural Practice Choice
Physician Workforce Studies
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