Robert C. Bowman, M.D.
Understanding the Medical Students Born in Areas With Over 1 Million People from the Distribution Perspective
Core Metro born students are those born in areas of over 1 million people. This is the largest group of US MD grads with 49% of the total students packed into just 6% of the land area. There are other urban origin groups, including the 23% born in metro areas of less than 1 million. The total urban origin group is actually greater than 49% plus 23% and is closer to 90% of medical students. Only 9.6% of medical students can be fully claimed by rural or nonmetro areas. About 16% of students were born in other countries and this group is well over 90% urban based on birth city. Asian students are the most urban in the nation with over 94% urban whether born in the US or overseas.
The urban origin groups across the board have the lowest choice of family medicine, rural careers, primary care, and careers involving underserved locations outside of major medical centers. This urban group of students is the least likely to leave major medical centers for practice. It is a group born, raised, educated, and trained almost exclusively in the most urban locations in the nation. This group dominates college admissions and beyond.
The major exception regarding physician distribution and urban origin students involves lower income populations born in urban areas. Black and Hispanic and Native students are a mix of those with lower, middle, and higher income origins who are often older and who often choose family medicine. When distributional types of students choose family medicine, there is the greatest distribution to underserved areas.
The Asian born, Hispanic born, and European born crowd into the core metro areas. Some spend a few years at an elite college in the US before medical school and others have been in the US most of their lives. The foreign born students were born in the most urban parts of their birth nations as well. The concentrations of income, education, and health in US are often magnified in other nations with few lower, middle, rural origin students. From the perspective of foreign born students and their families, the United States may seem to do a lot even though what is done for lower income and middle income populations is far less than what the nation invested in the 1960s and 1970s. The nation has not kept up with education and research development and higher education is at a 25 year low.
Foreign born students and their parents have long learned the value of education and academics. It has been a relatively simple matter for them to do just enough to stay ahead of those born in the US. Education may be another factor in the rise of foreign born in US admissions. The US education systems appear to be unable to compete with those educated in other nations, in private schools, and in the school districts involving top income quartile students. In lower income rural and inner city schools, medical students enter when most students are graduating from medical school. The effort for medical school may require many years of extra effort. The contributions of older medical students are stellar. (age and career)
The actual total of medical students born and raised in areas of over 1 million is actually about 61% when counting up the core metro and foreign born totals. This level would be even more, but foreign born students are not just an addition, they are also replacing core metro US born students in admissions. The rate of replacement and the areas of replacement coincide with the rise of Asian students and the counties with the highest levels of Asian students. In previous decades 57% of the total medical students involved US born medical students from areas with over 1 million. The level has declined to 47%.
The pressures from professional and higher income parents from this area of the nation to get their children in to college, top colleges, and professional schools have become enormous. The various propositions in California and lawsuits brought by rich parents and their “individual rights” associations. This is also a group that tends to favor “No New Taxes.” Taxes would also help build colleges and medical schools that would also improve admissions but this has not been a choice of those in the top quartile in income with by far the most income, wealth, and power and gaining each year.
These Asian, foreign born, and core metro born students have virtually no obstacles to medical school from income and education and are the youngest of the medical students. This group has the greatest probability of admission, the highest income levels, the students are more likely to attend the elite colleges, and the elite students also attend the elite medical schools.
It is not uncommon for the group to dominate elite medical schools with 90% of the total students in the Core Metro plus Asian plus foreign born segment. Given the impact of the most urban and highest income students, the reduction in family medicine choice in the older schools (minus 2 - 4% for schools created before 1966), and the reduction in family medicine with eastern location (minus 1% for each 300 miles east) it is not a surprise that increasing numbers of eastern elite private medical schools are graduating zero family physicians and the lowest levels of primary care, underserved primary care, and rural career physicians. Those graduating from the most elite schools have over 80% remaining in major medical centers in practice.
From the standpoint of percentages choosing distributional careers, this group is not contributing. However since this is by far the largest group, most of the rural and underserved physicians come from this group. About 90% of students are urban origin. About 70% of rural physicians are urban origin. This is an increase from the 50% level of recent decades. The percentages are lowest but the actual numbers are highest. Even a few percentage points of change in this group can do much to directly or indirectly fill underserved and rural areas, as in the managed care era. (managed care)
There are also gender differences in this group that are important. When considering family medicine, males have 3 – 5 percentage points of advantage in rural location in every group, except core metro born females. In this group female family physicians distribute at the same or slightly higher levels compared to males. There are about 15 medical schools where female family physicians distribute to rural locations at significantly higher levels compared to 28 schools with male advantage. Origins, education, opportunities, and traditional expectations regarding gender shape distribution.
One of the best indicators of this group involves studies of the Asian component, particularly populations that exclude lower income Vietnamese. Veloski did a study of medical students in 14 medical schools and found that Asian students had higher MCAT compared to USMLE 1 and basic science evaluations. Whites had the reverse. It is likely that the Whites and other groups with similar demographics also had higher MCAT and lower USMLE 1. Those with few barriers have peaked out performance years before. Whites are more of a mix of older and lower income however the major difference involves where whites are born and raised. Whites have their lowest concentration in core metro areas of over 1 million, the areas with the highest income, education, and professional levels. Whites are also farthest away from major medical schools and major universities, another factor in admissions and in performance on standardized testing. It is not a surprise that Whites are also being replaced in medical school at the most rapid rate with the very lowest income groups already gone and the lowest quartile reduced by half in the past 7 years. The combination of reversals of affirmative action, the pressures of rich parents, the loss of the ability to assess non-cognitive areas, and a major focus on MCAT and standardized test scores at the college and medical school level have resulted in a clear advantage for those with advantages existing from age 3 to 23.
Core Metro Main Counties Are Often Losing Population
The baseline growth of core metro counties from 1970 – 2000 was 38%. Most of this growth has been in cities such as Houston, Los Angeles, and Atlanta or in cities in Arizona and Florida cities. These are cities with the most individuals who are in the fastest growing populations in the United States, Asian, Hispanic, or Black. The shrinkage of cities with Black populations (except Atlanta) are some of the most dramatic in the nation, as are the lowest high school graduation rates in such areas.
Counties with over 2500 people per square mile lost population in the past 30 years. The major metro area counties have been losing 5 – 15% a decade since 1960 in Washington DC, New Orleans before Katrina, Milwaukee, Philadelphia, and Detroit.
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It takes a lot to accomplish this over many decades of changes. These are areas with significant advantages in location, people, property values, income, travel, purchasing power, trade location, and more.
All of these areas have had evidence of major multisystem failures in schools and health and economics dating back for decades. They have become a major part of the most inefficient places in America with incredible costs of living, energy, housing, property, education, security, and more. They also have the highest health care costs, the highest prison costs, the greatest welfare costs, and the most problems with unemployment. Multisystem failure impacts education the most and also education impacts multisystem failure the most and brings the most inefficiency through all major systems.
Core Metro Areas are areas that concentrate wealth and that concentrate poverty. These are areas with the highest rates of abortion with these rates limited significantly to those in the most poverty with the lowest education levels. These are areas that are least likely to invest in children in education and health. Life itself may well have less value in such areas and hopelessness reigns in many neighborhoods.
The population growth also influences the numbers that have entered the age of admission to medical school. Those age 18 – 24 year olds are larger in certain populations. Asian and Hispanic populations have 12% who are 18 to 24 years old compared to 8 – 9% for white and middle ranges for Blacks. Asian parents have the highest income levels, the most professional degrees, the most concentrated core urban origins, and the most children in medical school age. This is a significant and powerful group with a lot of ability and motivation. The concentration on science and technology and academics may far outweigh a concentration on people. Success in admissions is most likely, however success in distribution is most unlikely.
Family medicine is a near impossible task for core metro areas. To graduate family physicians, areas must invest in middle and lower income children and schools. Those growing up should see some advantage for a broad focus and generalism. Such areas should also invest in colleges and medical schools to make sure admissions remains accessible to a broad range of students.
Areas that concentrate wealth, income, and education do not invest in lower and middle income peoples. As a result these are areas that have the lowest achievement test scores, a measure of how many have already been left behind at the earliest ages. These are peoples that either came from even lower income populations or have been shoved to the bottom through chronic recurrent poverty and family destruction.
Family medicine needs a broad spread of income and education. Medical school admission rates depend upon higher income and education levels and urban origins. Family medicine is more likely with lower income level, lower college graduation rates, higher high school graduation rates, and less urban origins. Core metro areas concentrate children, students, and people in all of the wrong directions for family medicine and underserved careers.
This is not enough however. Core metro areas are the expensive and inefficient places on the planet. They are the most atypical locations for family physician types regarding education, college, medical education, and graduate training. They are expensive places to live and work, especially for the family physicians that have the lowest income, the lowest reimbursement, and the highest overhead costs. The cost of labor, office space, and supplies are highest. Health policy is often lowest and the most urban areas have some of the most complex patients. In the new era of Pay for Performance, the nation will likely have even greater exodus of family physicians from such areas. This will not be a performance problem, it will be the fact that family physicians will get paid even less for taking care of the poorest and most complex patients and will not be able to stay in the marginal high cost of living areas.
Family physicians already move sequentially away from core metro areas over time from birth origins to medical school locations to practice locations. DC, CT, MA, CA, and NJ lose those born instate or doing medical school instate in the greatest numbers. NE, MT, SD, CO, and IA gain family physicians over the period from birth to medical school to practice. Family physicians move from areas with
To areas with broad education, health policy, better support, and a better opportunity to practice the full range of family medicine.
Future research is demonstrating more and more that are consistent with research about education distribution, the attitudes of students growing up in urbanized areas, and efficiency. The areas of perhaps greatest concern involve areas that may well be related to physician quality, cost, and access.
Urbanized children are socialized into a lack of awareness, a lack of a personal touch, and a lack of involvement. These all may be having a devastating impact upon medicine and also every other system across education, health, higher education, economics, politics, and more. Medical schools are concentrated in such areas with 67% located in these areas with 50% of the population and 6% of the land area.
Core metro areas represents the origins of the most students and therefore the most physicians, even for rural and underserved areas, however core metro students have the lowest percentage choices of distributional careers.
Core metro areas are concentrations of poverty and income and education and ignorance
Core metro areas are also concentrations of health resources and medical schools and most other factors
Whites in core metro areas are only 71%, their lowest concentration. Over 90% of most other groups except Natives are urban.
Core metro areas are extremely powerful with most of the wealth, income, education, and power. Professional and high income parents can exhort enormous pressure to admit their children to college and high school
Enormous political pressures to lower taxes for the rich from professional and high income parents
Major factors in funding gaps at all levels of education and higher education, as well as the Propositions
Core Metro Areas
No surprise that managed care and primary care work in the Midwest where better equity in income, health, and education are there
No surprise that major metro areas want to control their own health and education
New Jersey was the home of prospective payment and what worked there was replicated to parts of the nation that had natural cost barriers, they suffered the most
Concentrations are also a major part of overspending for both rich and also the poor with less than high school education, making these the most expensive