Robert C. Bowman, M.D.
Should we increase the number of US physicians graduating from medical school and if so, how should we expand?
Expansion Good Bad Ugly and Best
Summary - Past expansion left rural and minority candidates far behind and actually decreased the probability of admission for these groups Probability of admission tables. These groups are proxies for lower socioeconomic status Medicine, Education, and Social Status. Without expansion that emphasizes "broader" admissions, costs are likely to increase, quality will likely decrease, and access will not improve. Rapid undisciplined expansions are likely to widen the gaps between urban and rural, between schools with and without, and between various ethnicities with and without. Expansions coupled with "no-cost" tuition for those committed to family medicine and true primary care and no-fault liability for those on the front lines of patient care, would greatly improve access, and would likely improve quality and provide the greatest value for the US health dollars.
A thorough review of the following documentation of cost, quality and access would be helpful - Baicker and Chandra, Medicare Spending, The Physician Workforce, And Beneficiaries Quality of Care, Health Affairs April 2004 http://content.healthaffairs.org/cgi/reprint/hlthaff.w4.184v1.pdf or Starfield's efforts with Phillips http://www.aafp.org/afp/20040801/editorials.html or Starfield, Barbara. Primary Care: Concept, Evaluation, and Policy. New York, Oxford University Press, 1992.
National and state medical associations, the Association of American Medical Colleges, the Council on Graduate Medical Education, and a variety of medical education and health experts are on record as supporting expansions of United States medical schools. All are citing "market forces" and national health demand. Increased supply has not addressed quality concerns and might worsen costs, quality, and/or access. Previous Mature models of medical education are available that could expand workforce, especially access, and do this without increasing costs or decreasing quality. Without careful implementation, workforce expansion could result in deterioration in all three. Any expansions should be slow, steady, and carefully monitored. A key component is admission of more diverse students that offer additional value regarding medicine and medical education, particularly in understanding of systems, teamwork, and relationships. Such expansions must also address current problems with medical education quality, which can only worsen without specific measures. Socially and fiscally responsible expansion depends upon improvements in K-12 and college education. Finally, the nation is at war. It is again a time of sacrifice in this nation and all national leaders must recognize this and act appropriately. Partnerships between government, education, medical education, and underserved communities continue to offer the best solutions for physician workforce in terms of improved costs, better quality, and improved access. Such partnerships offer an example to the world in how to improve education and health in all nations.
There are a number of reasons why new medical schools and increases in class sizes will not help the nation.
I. The Lesson of Managed Care
II. The Lesson of Coordinated Workforce Efforts and Economic Impacts
III. The Paradox of Past Medical School Expansion
IV. Getting the Best First and Perhaps Also the Brightest
V. Admissions Priority: Different
VI. No Expansion Without Improvement in Quality First
VII. Acceptable Modes of Expansion
VIII. Addressing Medical Education Retardation
IX. Education Must Be the Top Priority
X. Education is Opportunity and Supervision
XI. Family Medicine As a Measure of National Success
XII. A Time to Sacrifice
Medical leaders must understand that market forces do not apply as well to some specialties. They also continue to assume that market forces and production of more physicians will improve access to care. These are dangerous assumptions that have been disproved by past expansion and other factors noted below.
Market forces do have impact when there are not other factors. If any student can choose and enter medical school and choose any specialty and choose any location, then market forces might have a chance. However relatively few students can enter medical school, medical school admissions favors students of certain types not likely to choose underserved areas, medical specialty selection is highly regulated and not freely competitive, and physicians make decisions based on far more than economic factors, Thank God!
A key factor is admissions to medical school. Studies demonstrate certain types of students are more likely to choose family medicine. Family medicine is most associated with cost, quality, and access. There have been fewer and fewer admissions of students likely to choose FP Origin, Admissions, Family Medicine Without admissions of students who will choose FP, market forces do not have have a chance to take effect. The nation will have no choice but more physicians, more costly physicians, and likely medical care that will be declining in quality.
Failure To Launch - What is the Lesson of Counties without admissions, the ones that need physicians the most, including references to Florida and expansion.
I. The Lesson of Managed Care
The coalition of business and government known as managed care was clearly a move in the opposite direction from the current recommendation to let "market forces" decide physician choices. Managed care resulted in the best distribution of physicians that the nation has ever had. Market force-driven expansions will not address the needs of the underserved, uninsured, underinsured, poorly educated, and those without access. It is far more likely that market forces will widen the gap between advantaged and disadvantaged people.
II. The Lesson of Coordinated Workforce Efforts and Economic Impacts
When primary care, family medicine, and rural medical education lined up for a brief time, underserved areas enjoyed the best access to care. Perhaps just as important was that such areas also had additional jobs, services, leadership, and economic activity. Since that time, fewer physicians have chosen rural locations, a trend that will continue under current conditions. Each lost rural family physician alone is over one million in decreased economic impact.
Current medical education leadership holds beliefs that are not evidence-based regarding economics and physician choices. Many have expressed disbelief that physicians would choose rural areas and stay there (Cohen). Although there is certainly some impact of poor economics on the lack of physicians in underserved areas, just as important is the poor economics of rural areas resulting from failure to admit the right students and prepare them appropriately for underserved areas. Medical education leaders need to read the medical education literature more thoroughly and visit rural areas and a few of the physicians that continue to serve rural communities, for life instead of a few short years.
The lesson of state legislatures is instructive. The Minnesota Legislature held the University of Minnesota responsible for workforce outcomes over 30 years ago and funded the effort known as the Rural Physician Associate Program. With the help of the Duluth admissions efforts, this program has brought 2.2 billion dollars in economic impact to rural Minnesota alone. It has resulted in far greater numbers going into primary care, family medicine, and rural practice, and staying in such locations. Other legislatures and the federal governments should also take this position with medical education.
III. The Paradox of Past Medical School Expansion
The era of past expansion of medical students from 1970 - 1981, a doubling 8000 to 16000 admitted per year, resulted paradoxically in the lowest probability of admission of students born in rural areas. The probability of admission of students born in rural areas dropped from 70% that of urban students to less than 50%. There was also little improvement in numbers of underrepresented minorities admitted to US medical schools from 1970 - 1981. The urban advantaged students were the only students with gains during this time period.
Admissions in Allopathic Schools by Urban Influence Code of Birth
This graphic demonstrate the admissions of students from the most urban parts of the nation (codes 1 and 2), increasing with the last expansion of medical schools. Code 1 is those born in counties of over 1 million and code 2 is metro birth less than 1 million. There were decreases in the probability of rural born admissions at this time Probability of admission tables
Given current priorities in admissions, urban "advantaged" students are the only ones that medical schools will have available and ready to admit. Rural and inner city and disadvantaged students can be admitted in greater numbers, especially older students, but this will take more time, substantial changes in current practice, and hard work involving medical schools, colleges and education. The medical education quality and workforce is more than worth the effort. Such a partnership approach will also improve education at the state and local level, particularly in rural and inner city areas.
During the time period of medical school expansion, the "served areas" got more services and the underserved areas fell further behind. After expansion and with the discipline of managed care and the influence of 3000 by 2000 on broader admissions policies, students born in rural and inner city locations were admitted in higher probabilities. Another expansion period implemented in a rapid, haphazard fashion as before would seriously impair access to care by further depriving access to medical school of those most likely to provide access in family medicine, primary care, and underserved rural and inner city areas.
IV. Getting the Best First and Perhaps Also the Brightest
Medical education that interacts with education in a number of areas can restore education and improve medical care. Interactions with science teachers, math teachers, and career counselors can open young minds to the realms of higher education and health careers. Opportunities to advance the studies of middle and high school students should not be limited to academic campuses and research fellowships, and research and sub-specialty role models. These should be broadened and decentralized to high school and college campuses and partnerships. Those reaching out from academic institutions have more to gain from such interactions than can be explained sufficiently. The additional emphasis also needs to be different and more than the usual and current opportunities for potential medical students who are intellectual, academic, and research-focused. The new outreach efforts should attract and encourage the service-oriented, primary care, public health, and behaviorally inclined.
Medicine has far more influence than it realizes on focusing a certain type of student toward medicine, and other types of students away from medicine. Declines in total applications and the increasing lack of diversity in who is admitted, regardless of external appearance, should be sending a message. Current students may make the brightest physicians, but they are not bringing the nation the best physicians.
V. Medical education must address admissions problems leading to fewer physicians able and willing to go to underserved areas, especially family physicians and primary care physicians. Poor admissions policies and procedures are the primary reason for decreased choice of family medicine and primary care, not market forces (MCAT regressions, FP choice regressions, rural birth origin, older student studies, past literature regarding differences in test taking ability in primary care, family medicine). Admissions of rural, lower income, older, inner city, and other "different" students must proceed before medical education deserves to be allowed to expand. All of these types of students tend to choose primary care and family medicine, and also other careers in need in the nation.
Without admissions that is different, that admits students who are different, and prepares them differently, medical education cannot expect to make any progress in addressing physician workforce access, cost, or quality concerns. Blaming rural communities or inner city problems or government is only a cover for poor admissions and medical education quality.
Asking local leadership to participate in the selection process could be a major opportunity for medicine. College health advisors and a variety of rural people have added greatly to selecting particular types of physicians needed most for the nation. An expanded participatory process could also bring government, education, and business together to help shape physicians and medicine itself. It would be an opportunity to admit students who would bring a wider variety of talents to the physician pool. Such a process could result in admissions of 15 - 20 % of medical school classes. Mature learners with a variety of experiences and backgrounds would bring a rich texture to the medical school environment that would likely be the envy of other professional schools. It would also demand a medical education learning experience that was absolutely first rate and would help medicine in key areas such as understanding systems. Working collaboratively, student, faculty, and school, would do much to give medical education a better approach and long term solutions to chronic problems.
VI. No Expansion Without Improvement in Quality First
Medical education leaders must address a variety of medical education quality concerns before the consideration of any expansion, especially the impact of liability and dysfunctional health systems and loss of indigent care settings upon the quality of training. In the past few years there have been several major meetings regarding problems in teaching and the quality of medicine and medical education (Millenium Conferences, Foundation-supported conferences, major reports, national inquiries, a gathering body of medical literature). Leaders have not even begun to address these problems in an effective manner. Additional money thrown at the problems will not fix them. Again medical education has been offered many chances to improve medical education in a number of ways.
Specific training models have improved the quality of medical education, increased medical education capacity, and reversed declines in teaching qualitycal education continues to turn a deaf ear and a blind eye. Long term preceptorships, community-based/community-driven medical education, and partnerships with underserved communities, colleges, and health advisors remain in the hands of only a few schools.
VII. Acceptable Modes of Expansion
Replicating models with successful track records involving selection and training of the physicians most in need in America would be the only current acceptable plan for expansion. Over three decades of evidence and multiple students have demonstrated the effectiveness of such programs.
Government involvement with other forms of expansion should
1. Require specific outcomes
2. Reward medical schools that embrace national needs, and
3. Punish those that do not comply.
4. Allow medical schools as much creativity and innovation to allow them to meet such goals.
In education now, the Matthew principle is a key point of discussion. Matthew 25: 29 notes "For everyone who has will be given more, and he will have an abundance. Whoever does not have, even what he has will be taken from him." This is the interpretation given in our society and in the current context of education, an education that faces a widening gap between advantaged and disadvantaged. Those given less do tend to get less and those given more tend to gain more.
However the context of the entire chapter in the first book of the New Testament is quite different. Those given talents that turned them into more talents were rewarded with additional reward. The servant who hid his talent was punished. Medical schools that use their talents to improve physician workforce should be given the opportunity to train more students. Those who focus on areas of little or no interest to the "master" (the interests of our nation) have given the nation the least. According to the context of the chapter, they should lose what they have been given. For medical schools this would mean that they would lose access to the national talent pool, which they have not brought to full potential. Their “talents” should be given to those who invest in talents in a wiser fashion. For medical schools not meeting national needs and priorities, the application of this would mean reductions in medical school class sizes and possibly additional penalties.
The government does not need to micromanage medical education, however it does need to set expectations, rewards, and punishments. Most of all medicine must have a system that rewards those schools pursuing national priorities, those most connected with the national interest. For the past 30 years, medical schools that have most attempted to meet such goals have had smaller class sizes, have been punished by medical education funding mechanisms in GME and NIH, and have faced declining income through reimbursement methodologies. It is no wonder they have had declining status. New schools attempting to meet national needs have been discouraged and punished by accreditation, other medical schools, and medical leadership. The recent lesson of Florida State gives evidence of how far allopathic accreditation must come before expansion should even be considered. A school embracing missions for rural health, minority health, and the elderly should be a new model for the nation. After all, Johns Hopkins was only a few years old when it became the model for today’s medical schools.
Again the lesson of the past is useful. The "new medical schools" created nearly 100 years ago took over control of medical education and medicine because of correct alignments with national needs.
The current connection between accreditation, medical associations, and medical businesses needs to be replaced by accreditation that is separate and aligned first and foremost with national health priorities, even when funding mechanisms distort true national interest.
VIII. Addressing Medical Education Retardation
Medical education must address the impact of poor and deteriorating medical education on choice of certain specialties. It is the lack of intensity, poor orientation to key specialties, and confidence gained by medical students that results in fewer choices of specialties in most need in the nation, including rural family medicine, inner city medicine, obstetricians, general surgeons, and others. The nation needs implementation and replication of more rigorous models of medical education, not regulation, termination, and accreditation headaches.
Accelerated models recently terminated by current workforce leadership are a primary example. More rigorous training in family medicine with accelerated family medicine residency programs resulted in twice as many choosing rural locations, especially smaller rural locations. Accelerated graduates did not have rural origins or preferences or rural locations of training. They just were allowed to fulfill their potential and did, and chose rural because of it. This was a particularly effective model for older students. Given the exclusion of rural born students and those more likely to choose family medicine, the nation needs a better concentration of graduates going to the locations in most need, not more numbers choosing underserved areas even less. Long term preceptorships offer the chance for students to do more, learn more, and support underserved workforce.
Currently over 95% of medical education and graduate medical education occurs in urban areas. The research and graduate medical education support packages alone are great economic support for urban areas. Decentralization of medical education to rural and underserved areas can improve education, economics, medical education, and health access.
Current studies involving medical student choices compare two different scenarios facing medical students. Studies involving the classes graduating from 1994 - 2000 are impacted. During this time, the choices of US medical students were very different during this "Perfect Storm" of managed care. Those making comparisons involving this time period must allow for this impact. The primary care Title VII studies showing improvements in primary care choice ended during this time period and had a number of other flaws. The lifestyle choice studies currently popular in medical education originated with students during this time period. Changes over the past decade have been dominated by the managed care impact on the changed decision-making of medical students, not lifestyle or declining interest in primary care or family medicine. Lifestyle studies have other flaws that will not be apparent until medical educators realize that the quality of medical education must improve and address a much wider range of orientation and preparation and intensity.
Today's medical students are not lazy, or any more lifestyle-oriented than similar groups of greater age. In fact they have had to focus far more than most faculty and physicians to gain entry to medical school. The primary problem with today's medical students is that their medical education needs are being neglected. Liability, medical school funding, and health systems dysfunction are all a part of this, but the final decisions in medical education are being made by medical educators.
IX. Education Must Be the Top Priority Short and Sweet on Education and Med Ed
Education must again rise to become a top priority in the nation, immune to impacts by other lesser considerations. The nation currently has plans for a 63% increase in population from 1970 to 2020, a 64% increase in schoolteachers, a 56% increase in family physicians, and at least a 270% increase in physicians. This will be 300 or 400% with expansions. National leadership that prioritizes schoolteachers over physicians will be more likely to likely improve the quality of education, health, infant mortality rates and other outcomes, as well as improve government costs in prisons, legal, social programs, and more.
Health care costs are already eroding education in state and federal budgets. The nation must have increased taxes or decreased health care costs and likely both for the nation to continue to have a viable future. Rural and inner city education costs more, need the most improvement, and have the least favorable financial sources of support. They have been left behind by property tax modes of finance as old as the nation.
Disruptions of education also contribute to distortions in physician workforce, since the specialties most responsible for cost, quality and access is most impacted. Study after study notes that family medicine and general practice is most associated with lower health care costs, higher health care quality, and increased access to health care. Studies demonstrate that family medicine, primary care, and generalist practice depend upon state education, inner city, rural, older, and instate sources. Admissions of more out of state students, more intellectual students, students from the most prestigious private schools/colleges, and students from higher income, highly educated, and/or highly professional parents are far less likely to meet the cost, quality, and access needs of the nation. Admissions of students that are more likely to choose CQA also must involve education in disadvantaged areas of the nation. Forcing dependence on state and local education will result in improved education. Continuing to admit more and more students from out of state and out of country sources will discourage investment of time and resources in education.
X. Education is Opportunity and Supervision
Nothing stimulates education as well as the combination of opportunity, continuity, and supervision (responsibility). Students who can do more and do it earlier progress faster and succeed more. This can occur only in the setting of adequate and active supervision and nearly invisible supervision. Students and supervisors placed together for longer periods learn more about each other and medicine and work together more effectively. It is the same for schools and students, at any level, from pre-k to medical school. Rural and inner city schools given opportunity can do much more than the current environment allows.
Medical education has real quality problems. Students and residents trained in other countries, faculty from other nations, and those in our own nation have raised concerns regarding the passive modes that are increasingly common in US medical education.
Accelerated family practice residency programs, long term preceptorships, rural training tracks, and other training models place patient care responsibilities in the hands of medical students and residents at an advanced rate. These programs apply the principles that have developed physicians for millennia. This combination of opportunity, continuity in teaching, and responsibility results in arguably the best education in current medical education and the best distribution of graduates in the nation. Students in such programs move up compared to peers in academic performance, catch them, and even surpass them in evaluation studies and location outcomes. The terminations and limitations of such stellar programs is witness to problems in the quality and breadth of medical education leadership and a lack of emphasis on understanding physician workforce at all levels.
XI. Family Medicine As a Measure of National Success
Medicine, Education, and Social Status
Graduation rates of family physicians are not a measure of market forces or even student influences.
The graduation rate of family physicians is a marker for national success in education, medical education, and health access.
Barriers to education and maldistribution of educational resources impacts family medicine and no other physician specialty. Schools that graduate more family physicians can graduate a wider and more flexible group of physicians. Such a school will provide a better diversity of physician types and locations.
This does not mean that family medicine should be the only approach. However admissions and training that graduates more family physicians is also more likely to be the kind of medical education that is most needed by the nation.
The admission of more students born in rural areas, those who are older, and those who come from disadvantaged backgrounds is not the most important emphasis. But admissions that involves more such students is admissions and medical education that will lead to physicians that are more likely to meet national needs and priorities.
The only marker more important for the nation is perhaps the graduation of schoolteachers of greater numbers and quality.
Deterioration in selection of family medicine is a failure of education, medical education, and leadership in government.
XII. A Time to Sacrifice
Most importantly, medical leadership must be reminded that we are at war with terrorists and all who pursue violence, theft, and distrust of authority, in this nation and globally. Without trust, the task of a physician, or any professional, is impossible. Without trust in government, people, communities, populations, and institutions cannot survive. Health care has become a primary measure of the effectiveness of government. Failures in medical education can have far-reaching effects on this nation and others. It is not a time for personal, intellectual, or academic pursuits. The war on terrorism can only be addressed by better education and better health as measured by access, not technology. It will not be won by taking advantage of bioterrorism funding priorities. The nation needs long term solutions not short term costs or temporary cures. The war on terrorism is a global effort that primarily involves much better education and health for the most disadvantaged in this and other nations. The widening gap between rich and poor, between advantaged and disadvantaged, between hopeful and hopeless, drives the ability of terrorists to make progress. It must be a time of sacrifice, and all national leaders must think of the needs of this nation and other nations first, especially those responsible for an increasing share of national expenditures, taxes, and investments. Not getting more widespread access to the latest in therapy or slower discovery of the next advance in treatment and technology will not result in the violent overthrow of a nation or recurrent recession or depression. However further increases in research spending, additional pressures to adapt the latest technologies, massive adaptation to "convenience store" medicine, and continued "theft" of the best and brightest from other nations just might tip that balance in any of a number of nations, including our own.
The influence of President Kennedy on the above is freely acknowledged, especially his call for sacrifice on the part of all Americans, his words regarding disadvantaged peoples and nations, his encouragement of schoolteachers, his disgust for those who take advantage of tax loopholes and special government efforts. Many remember this as the "Man to the Moon" speech, but this was a minor part of his overall call to the advancement of oppressed peoples. The fact that his efforts were focused on the threat of communism, not terrorism, should not distract the reader regarding his Blueprint for a great nation that he left.
Now, after a period to divide medical education, it is time to re-unite. It is possible to have expansions, better education, better distribution and access, and better quality. But it will take much additional effort in ways that medicine and medical education have not embraced.
There is a common point of agreement for both "sides" in the workforce debate:
"Without vigorous efforts to strengthen the infrastructure of K-12 education, adequate support for students to succeed in postsecondary education, and effective long-term planning of the medical education enterprise, these assumptions may prove to be incorrect." From Richard Cooper Medical Schools and Their Applicants: An Analysis
Health Affairs 22 4 71-84
The improvements in education would reap benefits to medicine and many other areas through better distribution of all types of young professionals. Without such improvements, the nation should not proceed with expansion of physician workforce, or any other expansion of young professionals other than schoolteachers.
Expansions should be slow, steady, and targeted to bring a more diverse variety of students that offer additional value regarding medicine and medical education. Socially and fiscally responsible expansion depends upon improvements in K-12 and college education. Partnerships between government, education, and medical education continue to offer the best solutions for physician workforce in terms of improved costs, better quality, and improved access.
There is major disagreement on the role of increased numbers in satisfying the needs of underserved peoples. The data is clearly on the side of responsible medical education efforts and partnerships, not simply more numbers. If nothing else, the efforts over the past 30 years have demonstrated the futility of current medical education approaches, and the versatility of approaches adopted by underserved medical education, in rural and inner city areas.
Butler and Academic Medicine's Season of Accountability http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1546997&dopt=Abstract The author declares that academic medicine has entered a new and stormy "season" of accountability and social responsibility, due to public concerns about the overall health care system. He reviews earlier seasons, identifying paramount issues or activities that dominated the specific eras the Association of American Medical Colleges (AAMC) has responded to since the twentieth century began. He recommends how the AAMC can achieve several near-term solutions to pressing demands of the current season, such as the needs to manage academic medical centers more efficiently and to restore public confidence in the integrity of biomedical research. Next, he focuses on proposals for academic medicine to provide leadership, through the AAMC, in two major areas: preparing more generalist physicians, and assuring greater access to health care for those who live in underserved urban and rural areas. He describes models of existing, successful programs. The author concludes by proposing to create a "National System of Regional Medical Care." He urges the AAMC to continue its leadership by designating a task force to examine how such a regional system could be established within this decade.
Dr. Butler, the Chancellor at Baylor College of Medicine
now, also mentioned RPAP
http://www.rpap.umn.edu/ and PSAP
http://www.tju.edu/psap/home/index.cfm and inner city magnet schools
http://hs.houstonisd.org/debakeyhs/ However despite
excellent results from all, plus awards, etc., few have been replicated.
This is consistent with the 1990 effort by AAMC
Rural America: A Challenge for Medical Education
Special Discussion of Admissions at MCAT Correlations
Admissions of physicians with the same set of characteristics is unlikely to change existing patterns and problems regarding health care in America. Although medical education leaders often discuss the need for different admissions, they rarely lead the way to such efforts. Different admissions should include more admissions of students who
1. Understand health access barriers and other chronic health problems by previous experience (personal or work experience);
2. Have better teaching skills and an emphasis on improved outcomes for patients and the education of a variety of others (underrepresented minorities - Minorities in Medicine);
3. Have overcome obstacles of income and education and other barriers with greater potential for maturity and a wider range of previous job experiences that will bring additional value to medicine and medical education (older, rural, URM);
4. Are comfortable working out health care solutions in multiple dimensions including biosciences, behavioral, and educational, but also involving social, financial, cultural, relational; and
5. Have experienced a continuity medical home, value such an experience, and desire to continue patterns of continuity of care and extended responsibility for patients as physicians (rural, less mobile, stable suburbs).
Regardless of origin or characteristics, the nation must have more who
1. Understand and embrace systems of care and can work effectively in teams (similar to law students, information technology training, business types);
2. Will respect the privilege of being a physician (less privileged origins);
3. Will work effectively with a variety of professionals throughout our society to solve individual, family, community, state, and national problems involving health care (communications and relational skills);
4. Will implement effective models of medical education and patient care with documented success in meeting the needs of those in most need of health in the nation (priority upon effective outcomes, willing to be open to new approaches);
5. Will realize that health care resources must be utilized efficiently and effectively and cannot erode into education and other important components in our nation and globally (priority on education, fiscal responsibility, global interdependence, recognition of medicine as only a part of societal concerns with the need for integration with education and other components).
Variables in the Medical School Database
Birth Origin Studies
The AMA Masterfile includes data on physician birth city and state for 478,841 physicians who graduated from US medical schools from 1965 - 2002. This data was coded into rural and urban birth location. The data was divided into pre-expansion data involving the urban born US medical school graduating classes of 1965 - 1976, expansion data involving the 1977-1989 classes, and post expansion data involving 1990-2002. Data for the urban born medical students from each state became the numerator. The denominator was the number of urban live births in state census data approximately 27 years previously. Data from the 1942 census corresponded to the pre-expansion group, 1955 for the expansion group, and 1966 for the post expansion group. After determining this ratio for urban born medical students vs urban births, the process was repeated using rural born medical students and non-metropolitan births. States with a lower percentage of metro or non-metro population were excluded from consideration since the smaller percentages distorted the ratios.
Probability of admission tables
County Level Probability of Medical School Admission: Distances and Differences
Choice of Family Medicine: Past, Present, Future
Probability of admission tables
Short and Sweet on Accelerated Family Medicine Training Programs
State Education and Medical Education
Admissions of students depends upon state situations such as existence of a public medical school. Beyond medical schools however is state education and private schooling that can assist students in achieving admission even if the state or local education is inadequate. Students with gifts of intellect, particularly the speeded intellect as measured by the Medical College Admission Test, can do well regardless of educational disadvantaged. Such students are not as likely to choose the specialties in most need. The choices of physicians are not true market forces. They involve biases toward intellect and away from shortage and access needs in the nation.
Students born in some states are far more likely to gain medical school admission than those in other states. Students born in rural areas have a much reduced chance of being admitted to medical school. The gap between urban and rural born admissions widened during the period of medical school expansion.
Rural born admissions are associated with state education opportunity. The college continuation rate provided the clearest picture of this change. Special admissions tracks improved rural admissions.
Rural "Emphasis" Compared to Structured Rural Admissions Programs
At least 47 medical schools have documented policies of special admissions for students from rural areas (Barzansky). The reality is that schools are not pursuing such policies aggressively. Studies in South Carolina note that rural students failed to gain interviews in 2 out of 4 years studied. Schools with a rural mission or rural emphasis admissions had declines in rural admissions. In fact all but 2 US medical schools had declines in rural born admissions.
The regressions do show an impact of special admissions programs that involve personnel and commitment, such as branch campuses, tracks, and personnel. Admissions of more rural born students must involve more organization and a more formalized approach than just rural origin emphasis. Perhaps efforts with little real investment of time and resources have little impact.
Rural origin admissions were clearly linked to the graduation rates of family physicians and primary care physicians in regressions, with some contributions for ophthalmologists and pathologists.
The Medical College Admission Test
Perhaps no test has been as successful at improving rates of attrition. It is also likely that no test has been as successful at excluding students who are different. Rural, older, white, learning disabled, and minority students are just a few who have lower scores. Those who become family medicine physicians and primary care physicians also have lower scores. Regressions above note that the MCAT appears to screen out family medicine, primary care, and obstetrician-gynecologists.
Perhaps more concerning is the unwillingness on the part of AAMC to pursue studies regarding the potential for an MCAT impact on workforce. My conversations with Ellen Julian, vice president of AAMC and in charge of the MCAT, were most interesting. Although I can see that it is important to focus primarily upon the use of the MCAT to predict USMLE 1 passage by medical students, medical education leadership cannot have blinders on regarding potential impacts upon physician workforce. Also the dependence of the AAMC upon income generated by the MCAT is a concern.
The regression studies also reveal that individual studies of student decisions could do much to define the impact of family origins involving higher income, professional parents, and higher levels of education. Age, work experiences, service-orientation, and various career interests could add much to the ability to predict workforce outcomes by student characteristics.
Beyond the negative impacts of past expansions or possible future ones, there are major concerns to address. The US must work with medical education to deal with
Educational Quality Issues.
It makes no sense to expand US physician workforce until medical education quality concerns are addressed. These include
Many forces are at work that drive US physician workforce away from the needs of states and the nation and underserved areas. There is also a need to reduce the regulation and bureaucracy involved in such efforts. Medical educators can be extremely creative, when given appropriate resources and guidelines. Currently there is little help given and less resources involved.
The primary means of meeting workforce goals is to reward schools that move toward such goals. This should include financial incentives and increases in class size. Those schools that place less emphasis on workforce needs must have decreased class sizes such that they have less impact on US physician workforce.
With guidelines in place, medical schools are able to do the appropriate studies on their own students and involving local and state conditions in education and other key areas. By placing a priority on workforce outcomes, admissions and other factors become more important, and receive more attention. Those schools that choose more research or clinical revenues are free to do so. Those that prioritize education and the workforce needs of the nation are rewarded.
Tuition Concerns
Discussion
There is nothing wrong with allowing market forces to shape physician workforce, after national needs and priorities are addressed. Education and health care access must remain higher priority areas than market demands. Health care costs cannot be allowed to erode education funding at the state and federal level.
"Convenience" health care, research priorities, and the possibility of higher income in such specialties should not be allowed to influence physician choices away from better distribution to underserved areas or specialties important to access, cost, and quality.
Rapid expansions of US medical students in previous years decreased the probability of admission of rural born students. During this time period of expansion there was very little improvement in admissions of minority students. After this time period, medical schools did focus on improved admissions of underrepresented minority students and more have graduated. During this same time period post expansion, the probability of admission for rural born students increased.
State and national leaders must step forward to insure that medical schools are held accountable for any changes in workforce. Medical schools must be more responsive to national and state needs regarding workforce.
Undisciplined expansion can worsen health care quality and access and is likely to worsen the quality of education in our nation. Physicians are already increasing at a pace nearly 3 times the growth of the US population, even without expansions. Previous expansions actually decreased admissions of students who are the most likely to address cost, quality, and access needs. Expansions can proceed in a steady and organized fashion that will increase access to those in most need, insure minimal increased health care costs, and improve health care quality.
It appears that US physician workforce can best meet the needs of the nation by statewide and nationwide efforts to admit more students with different characteristics, including age, work experience, and different origins.
The equilibrium between education, colleges, college advisors, and medical education is much more delicate than currently recognized. During periods of rapid expansion, only those students and schools in the more privileged status may be able to adjust. Those familiar with the development of special admissions tracks for rural or underrepresented students are well aware of the additional time it takes for academics to improve and for adjustments to be made in the students and in the college advisors and faculty. It takes time to establish "feeder" programs and outreach, eventually improving the academic preparation and orientation.
Sudden changes in physician numbers may upset important efforts to graduate more physicians who will serve underserved areas in the nation.
Slow disciplined expansions of the workforce are more likely to meet needs in workforce and education. Such improvements can meet the needs of patients of all types and locations across the nation. Special tracks and branch campuses can stimulate education and college involving rural and inner city students and the high schools and colleges that prepare such students. Perhaps one of the primary impacts is reassuring those of less socioeconomic status and educational background that they do indeed have potential that can be fulfilled.
Special types of medical school expansion are far more likely to meet the national need for more physicians and also improve costs, quality, and access concerns. Models exist and have done far beyond expectations to meet national needs. Replications of existing models should be the primary consideration of any expansion. Replications that yield similar or better results should also allow transition from "model" status to accepted medical education approaches. Models with 15 - 30 year track records of graduating rural physicians, family physicians, primary care physicians, and physicians who are retained in rural and underserved locations for longer periods of time include the 2 year branch campus models (Duluth, Upper Peninsula), special admissions tracks involving rural high schools students (RHOP), rural colleges, physicians, and citizens (RHOP, PSAP, IL RMED, WWAMI), college health advisors (PSAP, RHOP, WWAMI), decentralized education (WWAMI, Arkansas, Georgia), and a host of similar efforts in inner city and disadvantaged populations.
Models of Rural Medical Education
Efforts to admit more from rural, diverse, lower socioeconomic status, older, and "different" origins should continue, but this has to be more than just words in a mission. Such programs need skilled, dedicated personnel, support from medical school leadership, and top priority status. Without clear and convincing evidence of such approaches, no medical school should be allowed to proceed with expansion.
Even if medical schools fail to embrace students who are different, they must all embrace the kind of admission candidates that are more likely to have a "make a difference" attitude. Before medical schools can expand, medical education must assure US citizens that they will admit more students who are able to communicate, to listen, and to relate to the real needs of patients, families, and communities.
Reforms also must include a priority concern to resolve the problems generated by the current use of the Medical College Admission Test. The current reliance on the MCAT score to rank medical students should be replaced by a more global approach. The MCAT, like other medical tools, is a great instrument. It just needs to be used more wisely. Medicine can well afford to give up a portion of the high correlations between MCAT and urban origin, professional background, and National Institutes of Health dollars to gain more physicians who relate in a broader sense to patients, communities, and the nation. Rewarding more and more focus on academics is not likely to change the course of medicine and medical education. Integrating different types of students with a wider variety of backgrounds and approaches, with MCAT used as a screening tool, can be a more effective approach. Taking the sting out of academic delay and failure could facilitate admissions that were a bit more risky, but that offered great potential in the careers of a new generation of physicians.
Medical leaders would be better off converting the hundreds of millions of dollars in MCAT generated income each year to help offset tuition costs and finance medical education. Since the beginning of intelligence testing, from Thorndike to the present time, top experts have cautioned that there are limits to such tests and even greater limitations regarding the ability of MCAT and similar tests to predicting anything beyond test taking ability. Successful models have demonstrated that additional time evaluating service-orientation can predict primary care and that college health advisors and a wider range of community involvement in admissions can be much more helpful in the admissions process at little extra expense.
The problem with medicine is the problem with professionals of all types, including professional politicians: Without a broader, more diverse type of professional student, there will be less access to professional services for those most in need. With a more diverse group of students entering medicine, law, teaching, other professions, there will be more professionals that are more likely to return to such areas to provide services. Also there will be more that understand the languages, culture, and obstacles to access that cost the nation so much in so many areas.
Closing Comments
Medicine during the first half of the 20th century demonstrated how effective it could be when it aligned itself with education, public health, the care of indigent, and the needs of a nation at war. Medicine during the last half of the 20th century has grown detached from the needs of the nation.
Significant efforts have attempted to engage medicine in societal needs and medicine has yet to pay attention.
· The lesson of family medicine so far is that medicine refuses to change admissions, curricula, support, and training to embrace this modern integration of care techniques and approaches. Medicine appears willing to take from family medicine and use family medicine to insulate itself from responsibility for health care, but not willing to adapt and grow through this experience. An engaged medicine would have connected education, admissions, training, and support in a more effective manner to facilitate the growth of family medicine and medicine itself. The "Future of Family Medicine" is far less important than reinvesting in education so that the entire nation has a better future.
· The lesson of sub-specialization and research and public health and birth outcomes and cancer approaches and socioeconomic status research and the impact of education on health outcomes (birth to death examples) and quality of care and teamwork/integrated/interdisciplinary efforts and …. is that medicine continues to seek cures rather than approaches and long term problem solving. The lesson of managed care is that medicine appears to be unable to sustain the effort necessary to graduate the physicians who are more effective and efficient at meeting national health needs. Nor can medicine reign in inappropriate costs without outside interventions or changes in who is admitted to medical school and how they are trained and influenced.
· The lesson from leadership in medicine, family medicine, and government leaders is that there is no longer any time to delay. State and federal budgets must be changed to prioritize education, with health care taking the leftovers, rather than vice-versa. This means representatives will have to risk the attacks much more serious than those of the "Greatest Generation" in who attached former Representative Dan Rostenkowski in Chicago in 1988 and ushered the nation way far along the path of irresponsible health spending. Politicians will soon face a difficult decision. As always, they can pursue solutions or deflect responsibility. Regarding the current course of the nation regarding medicine and health care and costs and erosion of education and other important priorities, they will soon need to find scapegoats to blame. Medicine is emerging as a prime suspect.
Those who plan for expansion to help the nation will agree to help education, not hinder it. They will prioritize national health needs. They will work with leaders in government, business, and industry to promote a more effective workforce and provide a solid front line in the war against terrorism.
Expansion Good Bad Ugly and Best
Probability of admission tables