Real Diversity Extremes in Physician Workforce

Robert C. Bowman, M.D.

Diversity is a misnomer with regard to admission to medical school. Diversity is often associated with minorities, but real diversity is about those extremely different. Those extremely different are those that dominate admission to US medical schools and entry into the US workforce. US physicians are very different than all but a fraction of the populations that they serve.

Those most normal in the United States are normal in origins. Those in the middle income quartiles in America are most normal, but they have lower probability of admission and declining rates of medical school admission.

Few understand that half of the physicians entering the US workforce did not even have families in the United States before 1980. Those multiple generations in America in lower and middle income and lower and middle population density origin steadily are losing out on admission. They are losing out in admission just as the populations that they represent are losing out in basic access to health and education. The students, the parents, and the populations involved are losing out on the economic distributions afforded by education funding and health care funding. It is quite ironic that health and education funding designs that are believed to play a role in uniting nations can actually contribute to divisions. In the current designs, those with concentrations appear to be gaining even more in concentration while the rest of the nation is being left behind.

Medical students from parents making over $100,000 per year represented the top income quartile of admitted US allopathic medical students in 1997 matriculants. Children of parents making more than $100,000 have nearly doubled while the lowest quartile origins have been cut 50% (parents making less than $30,000) and the “normal” origin children from the two middle quartiles have decreased 30%. The top status children from combinations of concentration are increasing and replacing those more normal.

Top status parents can get their child past the hoops necessary to get into a medical school. Their children have multiple choices (all school types), multiple chances (early, normal, repeated admission), and are more likely to attend a more prestigious medical school. Children of privilege face a different array of opportunity. The barrier is less likely to be the one illustrated by most medical education experts: the challenge of getting into medical school. Children of privilege can choose any career shaped by optimal family structure, nurturing, child development, and social organization that leads to top standardized test scores and fixation on the path to higher education and opportunity. The barrier to medicine for children of privilege is more about choosing medicine (or being pushed into medicine by parents or advisors) as compared to choices in business, engineering, law, or other health professions.

Asian Indian US children are admitted at a rate 8 – 10 times their level in the medical school age population (18 – 24 census denominator). They could actually have 12 or 15 times greater probability if more chose medicine. This is the advantage of top income, top rates of college educated parents who can help their children with the best career advice, top rates of parents who are professionals and physicians, top rates living in the most urban and highest income areas with top property values and most funding for education and top access to prestigious private schools and preadmission medical school programs. Other children of the same parameters (most urban, highest income, closest proximity to concentrations of physicians) not Asian Indian also have similar rates of admission to medical school defined by combinations of concentration in background.

Race and ethnicity matter less than concentrations in origins and especially combinations of concentrations. All most concentrated share the top probability of medical school admission, the most likely admission to an allopathic private or top ranking medical school rated by top MCAT scores, the top choice of the most specialized careers, and the lowest levels found in basic health access careers.

The changes over time also indicate a move toward more exclusive in parent income, in scores, in a more narrow range of elite colleges, and away from most needed health access careers for the US medical schools, allopathic and osteopathic. Caribbean and International Medical Schools are already vehicles for the most exclusive to gain admission as noted by their origins, career choices, and practice locations.

Lower and middle income children in America can be defined by 65%, 70%, or 75% left behind the top quartile or quintile. They are joined in a global competition with children from all over the world moving to a nation of top concentrations in search of top concentrations of opportunity. Those only in America for one or two generations do very well in census studies and in medical school admission.

Those generation after generation in America often have a different situation. The lowest income quartile origin US children only have 3% that gain a top 146 college, already a major requirement for those hoping to gain medical school (Left Behind). Only 30 – 70% of lower and middle income children gain college opportunity (Post Secondary Education). Their barriers extend back through deficient advisors, deficient college prep, and fixation by their earliest standardized test scores taken only months into their formal education – a guarantee that those with advantages birth to age 5 remain in superior position for life regardless of superior effort. Once they reach age 8, the velocity of learning is relatively fixed. Those hoping to make up the gap and gain admission must work longer and harder to overcome the barriers, resulting in older age at medical school admission for those that succeed. Multiple attempts are often required. Also these attempts usually require other careers prior to medicine such as teaching or another health career, ideal preparation for the most complex health careers involving underserved populations.

They face the barriers of getting into medicine each month and each year from birth to admission. This results in delay in admission to older age, a measure of barriers in birth to admission. Those that do manage to gain admission indicate in studies (AAMC Minorities in Medicine) that they began their efforts toward medicine earlier and their older age indicates that they worked much longer to gain admission.

Exclusive origin children have top probability of admission but as physicians are found in basic health access careers at the lowest levels. Children of more normal origins are consistently found in family medicine, primary care (because of family medicine), rural practice, and underserved practice. Birth origins, age, family medicine, training, and policy all conspire for most needed health access. The origins, ages, and training required for most needed health access are not extremes of income, poverty, oldest age, lowest standardized test scores, training, or policy funding distributions. All that is needed is a move steadily toward more normal and steadily away from most exclusive in origin, in age, in training, and especially in policy distributions.

Health access is a steady move toward more normal. Concentration of physicians away from basic health access needs is a steady move toward more exclusive. The United States has been moving more exclusive with birth to admission, with admission, with training, with career choice, and with policy distributions for decades if not for centuries.

Every intervention moving toward more normal and away from most exclusive has worked for decades if not for centuries. The most effective approaches combine origin, career choice, training, and policy at the medical school (health access school), state (statewide coordinated approach), or national level (1970s created medical schools, 1965 – 1978 policy, 1990 to 1995 policy).

All it takes to move away from most needed health access is to forget that it takes a great deal of coordination and planning to meet the most basic nurturing, child development, basic education, basic public health, and basic health access needs. Lack of awareness makes it difficult to even recognize the serious deficits in systems. And the United States has the worst case of lack of awareness in history with No Child Left Behind policy while most children in America are left behind in basic education, with failure in basic public health principles, with failures in basic health access such as primary care training that fails to even produce a majority of graduates in primary care, and with failures in housing, nutrition, and public security.

Nations that fail to understand the system elements that shape advantage for more exclusive and shape disadvantage for those more normal, fail to understand system failure. Such nations fail to understand the value of a broad middle class that consistently has the highest voting rates and the most participation in decision making. Such nations fail to recognize a health system design that continues to shift more and more income and revenue into the hands of those with top income and revenue already, including those not even delivering health care. Nations that fail to understand the importance of lower and middle income children doing well so that they can become teachers, nurses, family physicians, public servants, and all who serve on the front lines of serving human infrastructure and what these occupations mean to lower and middle income children who will become human infrastructure and will also translate what is really going on in a nation to the leaders who have different origins and upbringing that impair their awareness, such as most exclusive in origin, in training, in career choice, and in their first 30 years of life experiences.

Experiential place is commonly used to describe the extremes of most rural or lowest income origins and how these life experiences shape most needed health access careers. The fact is that extremes of exclusive origins shape exclusive career and location choices just as much, but because admission is only 20 – 30% normal and 70 – 80% exclusive, the impact is far more dramatic for children of concentration or combinations of exclusive concentration. It is not a surprise after 30 years of such exclusive top concentration life experiences shaped by domestic US policy, that 75% of physicians are found in 3400 zip codes in 4% of the land area with top levels of people, income, and health resources. Since these are areas with top concentrations of social organization and media, movement toward more normal and less exclusive becomes more and more difficult with each passing day. Also other nations that do have systems that favor more normal more than United States systems, have more children doing well and will continue to do even better compared to the United States. The typical response led by lack of awareness is more funding devoted to high school and college when the most basic requirements are neglected – family structure, nurturing, child development, basic health access, and basic education. Children that have the basic elements can manage the rest. Children that fail to have the basics, face the most difficult obstacles and can do the least for the nation or even the worst. Great society in America is not about the most exclusive or the best social programs. It is about birth to age 6 in America or in any nation. Children that have a future can do anything. Children that lose a future in the first years of life may overcome these barriers, but the burden on them and on an entire nation may eventually be too much.

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True Recovery in the United States of America  Also includes references for the birth to admission process required for America to resolve health care cost, quality, and access problems