Robert C. Bowman, M.D.
Physician distribution is the result of a coordinated effort involving education, admissions, medical schools, states, and nations. Without a coordinated effort, physician outcomes are a matter of market forces. Those who can pave the way for their children to gain admission to medical school have the highest levels of income and the most urban origins. These parents are often professionals or physicians. The medical students most closely associated with major medical center locations (MMCs) before admission have the highest probability of admission.1 Distribution is highly unlikely for those spending their first 30 years in or near MMCs.
The top income quintile in the United States has contributed a consistent 60% of medical students despite origins involving only 20% of the population. The second quintile matches up with 20% of medical students from 20% of the population. The bottom 3 quintiles of 60% of the population only manage 20% of US MD Grads. The bottom quintile contributes 2 - 3% of medical students despite 20% of the population.2 The gap between the top and bottom quintiles is widening. Measurements by quintiles tend to hide the major increases in higher income populations and medical school matriculants. Those most likely to gain admission are the most likely to remain in MMCs.
In the past 20 years, admissions has narrowed. The rise of higher income, Asian, and foreign born medical students is a reflection of socioeconomics and proximity to medical schools.1 Higher income dominates admission with students from parents making over $100,000 increasing from 24% to 43% of total admissions for the 2004 matriculants compared to 1997. Out of a steady 16,000 admissions each year during this period, the changes now mean 3000 more matriculants from the top income level (parent income over $100,000), 1500 fewer from the lowest income group (less than $40,000), and 1500 fewer from the middle income group that formerly represented half of medical students. The narrowing in income level is mirrored by a narrowing in the higher scores that are related to higher income. Last standardized in 1993, the MCAT scores continue to increase in all three subsections but most dramatically in the biosciences section with 0.1 units of increase each year for admitted medical students. The MCAT mean and parent income medians are at record high levels.3 The narrowing is not limited to medical school choices. The nation’s top 146 colleges make the same decisions with 74% admitted from the top income quartile.4 About 70% of medical students share origins with the top 30% of the United States population. The remaining 30% of medical students represent 70% the lower and middle income populations of the United States, they have the highest levels of distribution, and they have the lowest probability of admission. Those with the highest income levels and the greatest probabilities of admission are replacing those most likely to distribute.
Changes in Admissions in Allopathic Medical Schools
Even when not choosing family medicine, medical students with origins outside of major medical centers exceed the current 11% rural or 7% underserved physician distributions. With choice of family medicine the distribution levels are 3 – 5 times these national averages. The non-distributional student types exceed national averages only when choosing family medicine. Subspecialty needs outside of MMCs are extremely dependent upon admissions of medical students with origins outside of MMCs. Facilitating Physician Distribution
There are those that may attempt to convince the nation that distribution is not possible. They are correct only because the nation admits a concentration of students from the top 20% and has constructed health policy that concentrates health funding into MMCs. Market forces education efforts exclude the most distributional physicians and market forces health policies concentrate funding within MMCs. When the nation has admitted a few more percent from distributional origins and especially when it has tailored health policy to shift small percentages of funding outside of MMCs, physician distribution has been maximal.
Physician distribution rests on a foundation of distributional admissions, distributional career choice, and health policy that supports primary care and physician location outside of MMCs. The nation is making the opposite choices. The least distributional students are replacing the most distributional types. Those that can leave primary care or return to MMCs are doing so, including all physician and non-physician primary care outside of family medicine. The structured “perfect storm” distribution of the 1990s has been followed by a market forces nightmare that is only just beginning.
1. Bowman R. County Level Probability of Admission; 2006.
2. AAMC. Medical Student Education Costs and Student Debt Available at https://services.aamc.org/Publications/showfile.cfm?file=version35.pdf&prd_id=121&prv_id=137&pdf_id=35 Accessed July 2006. Washington DC 2005.
3. AAMC. Matriculants and Graduates 1993-2004. 2005.
4. Carnevale A, Rose S. Left Behind: Unequal Opportunity in Higher Education, Reality Check Series. In: Kahlenburg R, ed. New York: The Century Foundation Press; 2004:p. 106.
For info on the databases, sharing research, or ideas - rbowman@unmc.edu