Thomas Rosenthal, M.D. , Office of Rural Health
Chairman of the Department of Family Medicine,
State University of Buffalo
I am going to talk about rural admissions and how we can, perhaps, do a bit better job of profiling applicants to medical schools and health profession schools in order to get the product that we are looking for. There are several things that have been shown to correlate with rural practice. Obviously, the community of origin (rural background) and family practice intention is important. http://jama.ama-assn.org/issues/v286n9/abs/joc11016.html
Studies also note the importance of interest in outdoor activities, such as fishing and hunting. The MCAT scores for people that go into rural practice tend to be somewhat lower than the rest of their colleagues, but if you look at the people who get into medical school, the only real correlation is the MCAT score, so higher MCAT scores is more likely admission, and yet it is not the highest ones who tend to pick rural practice. That probably has to do with the fact that, as we’ll see later, these are people that are involved in other thing besides just their studies.
This is a study recently conducted by Howard Rabinowitz, not yet in print. He examined Blue Cross/Blue Shield data in Pennsylvania. He looked at physicians who graduated between 1972 and 1992. Those people in rural practice, as you can imagine, were from rural backgrounds; they had always planned on a family medicine career; and they were married to people from rural backgrounds. No surprise here. It once again confirmed that 79% of the physicians in rural Pennsylvania grew up in rural Pennsylvania. Very significant data to confirm things that we have always known intuitively.Physician Shortage Area Program Links and Info
How can we prime the pump? One program from Alabama took students as early as junior high and cultivated them towards health profession careers. One of the things that they discovered is that 42% of their students had made their career decision by ninth grade. The Rural Alabama Health Alliance Students not in special programs tended to make the decision a bit later, whether that is self-selection, as many of these numbers are, is unclear. Baylor College of Medicine also had a high school for health professions program. Four percent of the graduates of their special program matriculated in medical school. For the national average, only .6 percent of high school graduates in the United States go into medical school. From this, at least I conclude that
We have got to have rural experiences, academic experiences for
our rural students, and an opportunity to visualize a health career.
Rural people perhaps make decisions somewhat earlier than others (also see AAMC GQ data on rural interested students). These results are from the University of Kentucky. Regarding Admissions to Increase the Numbers Choosing Rural Practice and Primary Care They have an early admissions program into medical school where they get to apply to medical school during their sophomore year of undergraduate school, there is a slight preponderance of rural students in this group. Rural students tend to be attracted to this sort of program; they have good GPAs; they tend to track to primary care; and they are somewhat more likely to go into rural practice; so, perhaps, allowing early decisions will also facilitate our rural students.
Another early admission program in northeastern Pennsylvania, that was operational from 1972 to 1983, was fortunate enough to find in retirement the medical school faculty member, Dr. Rosell, who had followed this program and actually was keeping track of the 150 graduates. This is also unpublished data. But for these 150 graduates who spent two years at Wilkes College and four years at Hahneman, in 1996, 66% of these students, with early decisions in special programs and tracking, 66% were in primary care, and 50% were serving northeast Pennsylvania, a significant number.
Jefferson Medical College has had a special program since 1974 (Physician Shortage Area Program). This is more of Dr. Rabinowitz’s data. This is a selective admissions program with selective educational experiences and specific rural experiences built in, particularly during the summers. Today, 21% of the physicians in practice in rural Pennsylvania are graduates of this program at this medical school, a very significant number. (only 1 % of the medical students in the state go into this program) Of the people who went through this special program, you could say only 34% went into rural practice although that is still much higher than the baseline; 30% are in under served areas; 52% are in family practice; 21% are in rural family practice; and the retention has been remarkable at 87%.
Another program that many of you are familiar with is the WAMI program (now WWAMI) at the University of Washington, where they have agreements and contracts with four states to have allotments for admissions to their medical class guaranteeing some grassroots representation in their class. The students do most of their first year and most of their third year of medical school in their home state, so it is an in-depth experience in their state of origin. Fifty-three percent of these grads go into primary care, and this particular number excludes OB/GYN; and 36% into family medicine; a little over 40% go to the state of origin. Jeff has already alluded to some of Rick Blondell’s data from Kentucky, which I just received yesterday afternoon at 4:00, so I don’t have an overhead on it. But he confirms these numbers almost exactly and makes the point that it is easier to predict who won’t go into rural practice than it is who will because even with all these characteristics, still only between 40% and 50% of the people with this background will actually end up in rural practice.
At the University of Buffalo our Admissions Committee decided several years ago to ask the question, "Are you interested in primary care?" followed up by "Are you interested in rural health?" It took all of three minutes of thought for our applicants to understand that the best answers were "Yes" and "Yes." So that did not work. We have added an essay to the secondary application, and now the students write an essay that profiles what they anticipate their career to look like in 10 years, and that has really sorted out an interesting crop of people. Those people that check "primary care" and "rural" and then want to be doing neurosurgery have obviously not connected the two. But it has helped us a lot in identification and also gives an opportunity to understand more about the student.
The University of North Carolina at Chapel Hill has demonstrated in their study (Don Madison) that service orientation, Service Orientation, which is something you are more likely to get out of secondary essays (and biographies), will help you sort out the student most likely to go into primary care.
To summarize this portion, basically the medical school has to determine its mission. Is one of its missions to prepare students for the rural communities in its state? Having done that, then how do you do it? It is important to profile your applicants. You are not going to be able to do it otherwise. As I say, if you are going to breed cocker spaniels, you don’t go out and buy poodles. You start out with people who will tend to track towards that. But, to do that, you must have programs to facilitate their education. Programs that get them back out into their communities of origin as much as possible continues to cultivate their sense of community service, and you need to support their specialty intent. It is important to follow up with the students through clubs and organizations in even your own community to stay in contact. Regarding those programs where the community has sponsored a student: those programs work, when the community has stayed in touch.