Admissions Choices Regarding Medical Student Types
It seems that several list serves have been talking about languages in a number of ways - rural, family medicine, health professional advisor.
From the day we were born we are taught a number of languages beyond our spoken preference language. We are taught a place in society including community, neighbor, way of life. We are taught family roles and structure and expectations. Our birth city can tell a lot about these languages, roles, or identities.
There are multiple dimensions in languages, including time. Periods of history are important and also periods in human development. We are like little sponges in certain periods of our growth but the sponge material gets less porous with time and with less human interaction.
In the development of languages that matter regarding selection of physicians, two groups of languages continue to stand out, those involving academics and also people skills. Sadly there are not enough with great academic and great people skills. This has to do with each being in great demand and being rewarded well for such abilities in a variety of careers involving medicine and many other professions.
Those choosing medicine who prioritize academics tend to choose urban locations, subspecialties. Those who prefer people skills choose psychiatry, family medicine, rural careers, and other front line people careers such as women's health, and ER. The academic group tends to be younger, urban born, Asian, foreign born, born out of state, or born in families that are higher in income and education. Higher standardized test scores are a mark of this group. The people skills group tends to be older, rural born, instate born, and lower in income and education level. Lower test scores characterize this group. The march toward academic choices & poor physician distribution has been interrupted only by the most massive health policy/cash flow changes in the nation's history from 1965 – 1978 and from 1992 – 97 and to some degree by World War and national crises such as Sputnik. I am not sure that the nation has the ability to recognize that current education and distribution problems are of a magnitude beyond the problems of Sputnik. Each crisis we have “overcome” seems to make us immune to the infrastructure changes that are increasingly needed.
A few elite medical schools have the ability to harvest the students that have both superior academic and people skills. The rest compete among themselves on a limited academic rating scale that has to do more with socioeconomics (test scores, prestigious college, test prep expenses, private schools, higher income neighborhoods and schools). Among the non-elite there are only a few allopathic medical schools that have retooled admissions to pick out students that prioritize languages beyond academics. This can be identified by comparison of the outlier schools who have chosen inordinately more people careers, including higher percentages of students choosing rural careers or office based primary care in rural or poverty locations. The schools in rural areas or poorer states do this based on the students applying, but the outlier schools clearly make choices beyond the background environments.
To do so these renegade schools have implemented a people language skill emphasis to the same or greater degree than academic languages. This different admissions process results in more rural born, more older, and more lower income students gaining admission. The match of such schools and these students may well be facilitated by advisors. Those involved at such schools could tell you much more. From my national studies I can tell you which schools are “different,” but those at the schools can tell you more about how. A common denominator of this process is increased graduation of family physicians. A common focus of the admissions has involved a focus on lower income, rural birth or upbringing, family medicine interest, rural practice interest, underserved interest, or service-orientation. Others are aware of this in America and other nations through major publications, but even among FPs there is still disbelief.
In a sad compromise, medicine has turned more and more to academic skills or measures which appear to reflect higher academic skills, but may not. There are two prime examples, the elite privileged medical student and the elite standardized test taker. Both are singled out for different treatment and different academic development and advanced placement, college preference, and professional school admissions. Often private schools or special programs are the pathway to final career and these teach a much different language than needed by people in underserved areas. Elite students and elite schools make elite career choices, away from the underserved and family medicine. Studies demonstrate that those raised most differently who have different income origins also have the least comprehension of the language of health care access (AAMC Minorities in Medicine 1998).
As students go through the process of language development, they are constantly making choices. Some of these are internal but many have external stimuli. Parents, family, neighbors, teachers, and advisors push them to develop more and more academic language prowess. Unfortunately the focus on elite academic skills, scores, and languages tends to take a great deal of time and effort on the part of students. In the process they relate less well to people, teams, and society, especially the underserved. At a time when medicine most needs mature relevant systems-oriented professionals, those who are proficient and in number of academic and people language areas, we are retarding development by the decisions that we make and encourage as a nation. This is not just in medicine, but in all decisions regarding college, higher education, professional schools, and leadership positions for the nation. It is no wonder that we grow more divided each day.
There are windows of opportunity for all students. For example, when we are challenged the most we tend to be transformed the most. Sadly we waste these windows including:
1) Age 10 - 14 years to develop people skills, now filled by academics and video escapism problem solving instead of building problem solving skills up front, relational, and personal
2) The weeks or months prior to beginning a new stage, such as just before medical school or orientation, is when students are the most plastic and moldable that they will ever be during medical training, another stage involves the transition to clinical and the transition to residency, only certain bridging programs such as accelerated programs take advantage of the power of this transformational time. Mercer's bridging preceptorship between basic sciences and clinical time involving family medicine preceptors was also such an opportunity. Minnesota's 9 month rural preceptorship reframes as well. Student volunteers at many schools offer significant change opportunities to fellow students.
3) Challenges to overcome in college (where we lose so many that are likely to become family physicians and others oriented toward people skills) involve getting people skills types of students to access the advisors and role models and student types that share and understand and value the different language that they spoke and also that help them speak better academic language. It is far too easy for the usual teachers, advisors, and situations to ignore them unless they have "numbers." Also it is far easier for those with numbers and without adequate people skills languages to appear to be skilled in people than it is for those academically more challenged to build “numbers.” It is much easier to learn superficial statements, do meaningless service experiences, and learn the appropriate interview responses than it is for the academically deprived to get better numbers. This is not impossible, it just takes more time. Much of this time involves transitions since they had different languages spoken in their home, their schools, their neighborhoods. We also do not facilitate the admissions of older and more mature and life experienced students through older student tracks like we could and should.
4) Accountability areas during medical training – With each passing year we continue to compromise efforts to probe for weakness and challenge students to be more in a parallel with how little we actually have students write and critique their writing, at every level.
5) Intentionally placing students in areas where they have no current "language" and must rapidly develop a framework of understanding different than they have done (different experiences, different cultures, and different locations, out on their own) - this is perhaps the area that is disappearing at the fastest rate. With the current shortages of faculty, the increasing emphasis on research and clinical productivity, and the rapidly escalating cost of medical education, it is difficult to set up such encounters. However without some sink or swim experiences and the carefully crafted supervision that is necessary to make these work well and safely (close enough to prevent deaths and panic, but far enough to allow maximal development) then it is unlikely that our students will test new waters and careers, including family medicine, inner city, rural, serving different cultures, research, etc.
Family medicine is characterized by emphasis placed on a different array of languages. This is a great advantage and a great curse. In the best of times FPs facilitate the best of the nation. In the worst of times FPs get crushed along with school teachers, public servants, counselors, and others that are part of the insulation that stand between the class of cultures and classes. Rarely have FPs had the opportunity to facilitate the best but I suspect this hope keeps FPs and service oriented types going.
When those raised most elitely have the most influence on medical education and health care, this can be a problem. The nation needs to have leaders that have “crossed” language lines, in other words people skills folks that have developed academic language ability or vice versa. It appears that few leaders cross over and many have apparently learned how to do so, but suppress this until it is too near to retirement to matter. The leaders who built medicine to its pinnacle in the last century had people skills origins and crossed over to academic focus. It remains to be seen if a balance can be restored with people skills focus sharing top billing with academics.
Robert C. Bowman, M.D. rbowman@unmc.edu
Chair of STFM Groups on Admissions and Rural Health
Older, married, female students were more likely to be service-oriented. Training in service orientation most effective on those who are already service oriented. Youngest students less likely. DETERMINANTS OF SERVICE ORIENTATION AMONG MEDICAL STUDENTS O'Connor SJ http://www.sba.muohio.edu/management/mwAcademy/2000/38c.pdf