Robert C. Bowman, M.D.
A common posting on the Health Professional Advisor list serve is the ratio of those attempting to go to medical school compared to those who gain entry. Many colleges claim rather incredible rates, but of course the question is the denominator. This essay expands the denominator beyond college to education and our choices as a nation.
It would be interesting to see attrition rates by who took the Medical College Admission Test (MCAT) at each college. There are other ways to measure admissions ratios. Admissions of "gifted" students are really not too dependent upon advisors and education. The ones that really need advisors and education are the ones with the least access to both. Those who acquire test taking ability by virtue of parent, urban origin, education advantage, or facilitated training are less in need of assistance. Those gifted with speeded intellect really don't need as much. These two groups have the advantage in current admissions, especially with the way admissions committees in college and medical school use standardized tests. MCAT Correlations
Comparing the demographics of those admitted versus those rejected (AAMC data and studies) there are lower ratios for admission of older students, those with less income, those with less educated parents, those from states with less education expenditure/poor distribution of education funding. Those most likely to choose rural practice and poverty locations are older, less urban, and lower income in origin - basically those who face obstacles of education and income.
Admissions Ratios and US Medical Students
The highest ratios of admission are reflected in Asian students who have parent income levels as high as they get, the highest parent education and degree levels, and the best college prep (AAMC Minorities in Medicine). The ratio of admission based on 2001 AAMC data is 1967 Asian student admissions per 100000 Asian students who are age 18 - 24 in the US census. The lowest ratios of admission are black students and rural students at about 250 per 100000. The ratio is even lower for black males and rural males since each group is less likely to gain admission. This is related to less emphasis on higher education and admission to college that has a premed emphasis. The lowest choice of family medicine is 2.2 % for the Indian Pakistani group of students who are the group increasing the most in Asian medical students, the ethnicity that has increased the most. One of the higher choices of family medicine is Vietnamese students at 18 - 22%, the lowest income group of Asians. Black, Mexican American, low income White, all with lower income origins and career choices of service and distribution. Again it is not ethnicity that is the factor, but income, parenting, and test taking that makes a difference. Admissions of lower income students requires much more time and effort. Their scores and grades in high school and college are more difficult to interpret. Without additional effort however we are unlikely to solve some of the persistent inequities in our nation.
Medical school attrition rates have the advantage of a better defined denominator. The attrition rate for medical school from the lowest income quartile for Jefferson students was 6 %, the middle quartiles 2 %, the upper income quartile (and rising fast in income nationwide) was 1 %. The choice of family medicine in the lowest income students was 22 % (Cooter, Jefferson Longitudinal studies, this and other reference in Workforce References).
Birth Origins and FP Choice
The FP choice in the highest income group was 13 %. Students born in the most urban areas and those born in other countries (14 % of US allopathic admissions and rising) have the lowest choice of primary care, rural practice, and family medicine. Choice of urban poverty location is a slight advantage of the urban born internal medicine physicians (1 percentage point out of 13 %), but in family medicine and pediatrics, those not born in core urban areas choose poverty locations at a higher rate. The older medical students, as young as 28 or 29 years at graduation from medical school and increasing with older age, have an impressive and increasing higher rate of choice of family medicine, psychiatry, rural locations, and poverty locations Age and Physician Specialty. It may well be that younger students with a primary academic focus may not have the experiences that they need to be comfortable with working with direct patient care in those with the most complex care needs. It is likely that those admitted younger have higher income origins and more technology focus. They clearly choose high tech careers such as research and cardiology. FP choice, student career choices from lower MCAT medical schools, older student choices, lower income student choices, poverty choice by grads, and rural practice location choice all flow consistently together in multiple studies. All are different choices from those most likely to gain admissions to US allopathic schools. Family Physicians Are Different
Medical school admissions are not the only area of concern. When the nation has supported primary care, the physicians graduating have responded with a higher choice of primary care, rural locations, and poverty locations. Choice of rural poverty locations is a marked advantage for those of rural origins (17 % vs 12 %). Understanding Poverty and Physician Workforce Comfort with the complexity of underserved medical practice (and probably underserved elementary and secondary education) involves students who share origins and understandings with those that they teach and serve.
When the nation has turned its back on primary care, the reverse has been our lot Reimbursement and Physician Distribution. This is very evident now where we are approaching the lowest choices of rural practice, rural family medicine, and poverty locations in the past 30 years. The institution of Medicare and Medicaid (1965) and the 1990s with major increases in primary care funding relative to specialty care plus managed care plus specific underserved efforts all were times of great increase in choice of primary care, rural location, and poverty location. Now we have cuts in all of these areas with the most impact on primary care physicians. State cuts in Medicaid patients, copays, and reimbursement may be the most devastating right now. In some ways the managed care 1990s era boosted primary care in a way that masked the overall changes that we had in medical school admissions of those less and less likely to distribute well as physicians. Without reimbursement change, the decline in primary care would have been worse as we have admitted higher and higher income students from more and more urban areas. Many of these declines are related to the way we manage education in our nation. Now we face an even greater concern.
The nation needs about 20 % of graduating college workforce to choose education in the next 15 years (Snyder). This pool of students is also needed for underserved careers in medicine, careers in counseling, advising, nursing, public service, and more. The nation needs many more who are much more interested in service-oriented careers of all types. Unless we do much more to expand this pool by partnering high school to college and college to professional school, there is no way we can cover the increased education needs due to the baby boom echo, and replace retiring teachers, and upgrade education in a meaningful way (Snyder DP Edwards G Folsom C The Strategic Context of Education in America 2000 to 2020, http://www.ingentaconnect.com/content/mcb/274/2002/00000010/00000002/art00001 ) We are only a few years away and not even a hint of national discussion in education or higher education about this area of need.
As we have found out in health care, throwing money at the problem doesn't work unless we have managed to master the stream of dedicated and understanding individuals that can and will serve effectively and where they are most needed. Resources and accountability and dedication means hope and a future. Lack of any one of these means more hopelessness and poverty and more complex interactions to address.
The task in admissions and advising is great because we are teachers, advisors, and national leaders in this important area. Until our emphasis is much sooner than the last few years of college, and involves improved emphasis on teachers and funding for underserved areas and students, we will have a narrower and narrower group of students admitted who are less and less likely to meet the needs of the nation in education and physician workforce. Sadly, it is not only the less advantaged who are impacted by our current efforts. As long as we admit primarily based on test taking and academics without major increases in consideration of people skills and orientation, those who are "gifted" or acquire speeded intellect will have no major incentive to get involved with people of all walks of life. As educators, scientists, or physicians, their work will lack relevance, efficiency, understanding, and quality.
Students, parents, and advisors must know that the pathway to leadership (and income) in our nation must involve significant efforts working with a variety of people who are different in some way from their own origins. When all admissions groups in college and professional school make this effort, those intending admission of any type will have had to build an impressive track record equal to their academic efforts. When we move in this direction, then efforts to improve US education and health care have begun.
Until we make such efforts, we will continue to watch as health care costs, prisons, and social costs eat up our state budgets and take care of fewer and fewer people and erode education expenditures more and more and steal more and more of the ability of our less advantaged students to access college. My work as a physician serving the underserved, as a parent of learning disabled and ADHD children, as a Christian (perspectives of fatherless, widows, orphans), as a historian following civilizations over time, as an educator, as an advisor to those with difficult challenges, as a husband to a schoolteacher, and as a researcher tells me:
Our hope in America resides in the paths chosen by those who are forced to walk a more difficult pathway, either by their birth origins or because we disciplined ourselves as a nation to force future leaders to walk a similar pathway for at least a time in their life. There is no power as awesome as human potential facilitated. There is no force so deadly as human potential wasted. This lesson of our time will be written on our cornerstones or on our tombstones.
The hope of America is how we translate this effectively to the world.
Attrition is not just a matter of affordability, it is a matter of survivability. Insulation is not working, Education and facilitation are the only methods that truly work.
Robert C. Bowman, M.D.
Physician Workforce Studies