Medicine, Education, and Socioeconomic Status

Robert C. Bowman, M.D.        Version as of 10/13/2004

Much appreciation to Ed Fryer and the Robert Graham Center for sharing data. Also thanks for the assistance of the Federal Office of Rural Health Policy and Tom Morris, and a very patient boss, Mike Sitorius. For them and for the parents, teachers, and patients that influence us the most:

Abstract and Summary: In this effort, the author explores the relationship between medical school admissions and socioeconomic status. Studies of individual students have demonstrated that students of higher socioeconomic status choose family medicine less often. The author uses income data applied to various ethnic groups and various birth origins to further illustrate the relationship between social status and medical school admissions probabilities and choice of family medicine. Medical schools with more urban students, more younger students, fewer students born instate, and higher Medical College Admission Test (MCAT) scores graduate fewer family physicians. There appears to be a linear relationship between socioeconomic status of student and choice of family medicine, choice of direct patient care specialties, and choice of underserved locations. Front line physician specialties in primary care, mental health, and women's health may be most at risk without broader admissions. Public education seems to play a key role in such admissions. State by state comparisons reveal that states with better graduation rates and broader distribution of education funding admit more rural born students and graduate more family physicians. Without admissions of a broader range of students, medical schools will be unlikely to graduate the physicians most needed by the nation.

Summary of Results

Direct Studies On Allopathic Graduates

Note that these values were 30 % greater than any time in the past 20 years because of increased FP choice in the 1995 – 1998 graduating classes. These choices are now at least 10 – 20 % lower than the pre-managed care years.

Medical school studies

The following involved 111 allopathic medical schools. The correlations involve the medical school of origin for the 1997 - 2003 ACGME family medicine residency programs. There is no difference using match data, FPGP data for 1994 - 2000 graduates, or groups with fewer years of graduates. This is a study comparing medical schools, not individual students!

Weighted Least Squares Regression - Weighted by rural % pop in 92

The variables associated with greater density of income and population associate negatively with FP choice and positive with the MCAT scores. Older, instate, rural, white male, FP department, and rural mission/person variables are positively correlated with family medicine choice and negative with the MCAT. The MCAT was chosen because of its primary importance in admissions. Other variables were considered, but were rejected because of collinearity with the MCAT. Longitude, high school graduation, and population density were other variables that contributed, but had the least association with the MCAT.

Only OB-Gyn, office-based primary care, and the proportion of students choosing office-based internal medicine have the same negative correlation with the MCAT as does family medicine. Orthopedics has the strongest positive correlation and internal medicine and IM subspecialties and pediatrics also share a positive correlation. In eastern medical schools student choices steer toward internal medicine, pediatrics and obstetrics-gynecology and moving west the choices are more toward family medicine.

Internal medicine and its subspecialties contrast with family medicine in the location of the medical school. Family medicine is a more common choice at medical schools in less densely populated areas, even controlling for MCAT, longitude, nonmetro population, and education. Medical schools in the most densely populated areas are not as likely to graduate physicians that distribute.

Age can be considered a socioeconomic variable with older students the lowest on the scale.

Rural birth can be considered socioeconomic with those from the least densely populated areas lowest on the scale.

Those with the lowest MCAT scores are lowest on the scale in many ways. Direct MCAT scores have not been accessible so far so direct confirmation awaits those privileged with such access. Given the other relationships, this is hardly a guess however.

The students least likely to be admitted to US medical schools are the ones most likely to choose family medicine and distribute where needed as physicians.

Introduction

The distribution of physicians to underserved areas of the nation has been a vexing problem for decades. Cures for the maldistribution of physicians by location and specialty have been a focal point for billions of dollars in grants by governments, foundations, and associations as well as some of the most innovative efforts in medical education.

It is instructive that the major gains in distribution did not result from expansion of medical schools or grant funding. They have been the result of a few dedicated individuals working with admissions at the local level to facilitate the admission of students who were "different."   Best Models Admissions

Also the national accountability efforts known as managed care impacted the medical school classes graduating from 1994-2000. This period of accountability was predicted by medical education experts such as Butler in Academic Medicine's Season of Accountability and Social Responsibility.

This brief time period gave hope to those "pushing" primary care and family medicine. This time of accountability mainly has served to mask the  longer term decline in choice of family medicine and primary care.

This decline in family medicine may be more related to who is admitted

when compared to what happens after admission.

The nation has again resumed the search for solutions, including multimillion dollar efforts from family medicine alone (FFM). In the mean time, proven solutions remain unreplicated. Those most successful in locating physicians in the most underserved areas have even been "reformed" or terminated. Others have lost their best leadership. Best Models  

Despite these successes, medical leaders deny responsibility for physician distribution, noting market forces at work. Cohen, Why Doctor's Don't Go Where They Are Needed It is easy to see that there are leaders that have a narrow viewpoint regarding non-urban parts of the nation.

The nation's workforce leaders are at odds with "market forces" leadership and "social responsibility" leadership. Both agree that better education and preparation are needed and government support is necessary for the financing of medical education, but the groups differ in many other areas. Market force leaders blame poor distribution upon the poor economies of rural and inner city areas while social responsibility leaders note that admissions of students with more humble origins results in physicians who will go to underserved areas and help address needs for jobs, services, education, leadership.

Admissions models have not been widely implemented, admissions research has been largely neglected, and medical schools continue to focus on medical school influences instead of those having impact long before admissions. There have also been great proposals that have high probability of working (see Cohen on Admissions at the end of this page).

The likely resolution is that both market forces and social responsibility approaches are correct, but there are potentially some physician specialties that must have social responsibility admissions. This is becoming a more and more difficult problem with new studies demonstrating a widening gap between poor and rich school districts, between rural and inner city and suburban, and between school districts with white students as compared to minorities (Education Trust Study Funding Gap 2004 published in fall 2004).

New research has directly associated admissions of students of lower socioeconomic status with the graduation of more family physicians (Cooter R Economic Diversity in Medical Education). This longitudinal study of Jefferson medical students matched up data from origins, admission, medical school performance, and residency evaluations. Students admitted from the highest quartile of parent income chose family medicine 13% of the time, compared to 22% from the lowest quartile.

Secondary data noted below may allow this longitudinal study to be translated across the nation and throughout past decades to help understand the impact of socioeconomic status upon medical school admissions, particularly physician workforce in primary care and for underserved areas.

In the following, the choice of family medicine is highest in the lowest income areas and areas slightly less urban and in schools with slightly lower MCAT scores

* Excluded 15 lowest MCAT schools and osteopathic. See above summary table for new data

For those who might dismiss lower income admissions as impossible in today's environment,  studies in Iowa by Kreiter have already outlined methods of economic-based admissions that are likely to meet legal standards. 

For those concerned about implementing such admissions, branch models such as Duluth have existed for years with a focus on rural and family medicine. Decentralized training has also worked at WWAMI and other locations. It may be that training locations outside of the counties of over 1 million pop may be considered enough of an impediment that the most urban students will not consider them. Working with community colleges may also screen out the more urban-oriented Small Colleges and Admissions

Also rural, older, and "different" students have been attempting admissions for years, but have been turned down. The Jefferson study by Cooter brings decades of denial into sharp focus. For years there has been a game played about admissions with many medical leaders saying that different admissions will not graduate physicians that will go to underserved areas or stay there, or both. Now the question becomes:

Will admissions committees take the time and effort to admit the physicians most needed by the nation and risk a few percentage points more of attrition, or will admissions continue in a pathway almost certain to lead to less and less direct patient care preferences for physicians and fewer physicians for underserved areas. Admissions already includes 61% of students born in counties of over 1 million population even though only 48% of US population resides there.

 

There is also a real possibility that narrow admissions will accelerated physicians quality problems.

Side Effects of Selecting for Family Medicine

As Don Madison noted in his studies of the 1985 graduates of the University of North Carolina:

"If an admission committee informs itself of "what finally happens" to those it admits, its decisions can contribute to achieving whatever policy its medical school adopts with respect to the mix of physicians it wishes to produce." Madison, Donald L Medical School Admission and Generalist Physicians A Study of the Class of 1985,  Academic Medicine Vol 69 Number 10 October 1994 p 825 - 831

See a review of this and other articles at Service Orientation

Methods

The author worked with the Robert Graham Center data files and the AMA Masterfile and assembled family medicine "match rates" by ethnicity and by type of birth origin via RUCA coding (urban, large rural, medium rural, isolated rural) and Urban Influence Coding (1993). The parent incomes listed in AAMC Minorities in Medicine XII were linked to these match rates. Also the income levels of various birth origins at the time of birth were also linked to known family medicine "match rates" by rurality.

Computations of Age and Determination of Birth Origins

Details on FP Match Rates by Ethnicity and Rurality

Plotting parent income and FP choice via ethnicity leads to the following:

Figure 1: Parent Income and Ethnicity and FP Choice 

Figures 2: Broader Distributions of Parent Income

Figure 3,4  Higher Income Distribution and Comparison

A comparison of the income distributions of the highest and lowest parent incomes is useful in understanding the importance of the lower income levels. The previous tables illustrate that the Vietnamese have the lowest income levels of any Asian group. The Vietnamese also have the broadest income distribution of any group. Korean parents are in between. The Indian-Pakistani group is the highest income group and therefore most skewed to the right with 45% having income levels over $100,000. This compares to the Vietnamese student applicants with only 12% at the highest income levels. The Vietnamese students chose FP at 28.9% while Indian/Pakistani chose FP 2 % of the time. All other ethnicities and birth origin markers fall between these extremes.

Mexican American, Black, and Native American origin students have a broader parent income distribution more like the Vietnamese group. Koreans and “Other Hispanic” students tend to be in the middle in mean income, distribution, and FP choice.

The Asian group as a whole closely resembles the Indian-Pakistani group suggesting much higher admission ratios for the higher income Asian subgroups. The Asian group as a whole and the Indian-Pakistani group are both similar in income distribution to the White group, with higher income shifts in all three.  There are relatively few lower income students compared to total students for Whites and Asians. Both groups together determine 85% of the output of US allopathic medical schools.

Birth Origin, Income, and Choice of Family Medicine: the Rural Component

There appear to be other markers for lower socioeconomic status. Rural background students are known to choose family medicine at higher rates. The following is a table comparing match rates by county type for family medicine graduates from 1997 - 2003. The income data used for each Urban Influence Code (1993 set) is the median income of the county of birth for 1959 (in 1989 dollars). This was averaged for the counties within each code.

Table of Birth Origins of Allopathic Medical Students 1987 - 2000

Figure 5, 6  County Birth Origins, Incomes, Choice of FP

This also appears to be a linear relationship with family medicine choice related to county level income involving birth origins at the approximate time of birth.

Further calculations on US medical students involve the ratios of admission by type of county. These involve comparisons of medical student origins compared to the number of live births in their birth origin counties in rural vs urban areas of the state  These range from 74 for students born in rural NC to 1300 for urban students born in Washington DC see Probability of admission tables

Figure 7 Admissions Ratio By Birth Origin

The "probability" of admission to medical school and the choice of family medicine is related to income origins, even down to the wrinkles in the Urban Influence coding system (in table above). Studies of ethnicity and social status published in the BMJ also document some of the difficulties faced by students who are not "university types" (http://bmj.bmjjournals.com/cgi/content/full/328/7455/1541 )  and the probability of admission by social status. A passage from the article by the following - Kieran Seyan, final year medical student¹, Trisha Greenhalgh, professor¹, Danny Dorling, visiting professor in social medicine² http://bmj.bmjjournals.com/cgi/content/full/328/7455/1545 .

"Using the values for 2000, we found that standardised admission ratios varied around 10-fold by ethnicity—from 6.07 in Asians (over-represented) to 0.73 in white people (under-represented)—and around 30-fold by social class—from 6.76 in social class I to 0.20 in class V (see table on bmj.com). But when we calculated the ratios by ethnicity and social class they varied 600-fold from the most over-represented group with a significant denominator (Asians from social class I, 41.73) to the most under-represented group with fewest admissions (black people from social class IV, 0.07; no black people from social class V were admitted to medical school from 1996 to 2000).

"White and black pupils from social class I were around 100 times more likely to gain a place at medical school than those from classes IV or V. Asian pupils seemed to compensate better for poor origins, but those from social class I were still 6-10 times more likely to gain a place than those from classes IV or V. The standardised admission ratio for women increased from 1.08 in 1996 to 1.15 in 2000, and that for men fell correspondingly. Sex specific standardised admission ratios did not vary significantly by socioeconomic status, but they did vary by ethnicity, with Asians having similar ratios for men and women but black and white men being significantly under-represented compared with women. "

 

Admissions Ratios Calculations

Using AAMC Minorities in Medicine 2001 data and census data included in same, compared to AAMC data on all allopathic graduates of 1994 - 2000, the calculation involves Medical Student Admissions per 100,000 18 - 24 year olds in the US. This is a better calculation than birth origin since there are so many foreign born admissions (11%). Choice of distribution is least in those that are admitted the most.

Allopathic US Medical Student Admissions by ethnicity, income, rural vs urban

Older students have 2 - 5 point higher FP and Rural choice (2 for rural born, 5 for urban born)

Male students have similar 2-  5 point increases over females in rural choice

The Medical College Admission Test

Comparing Physician Distribution and the MCAT

Standardized tests are known to be related to socioeconomic status. New studies focus on SES and less on the impact of ethnicity  (NSF Women Minorities and Disabled http://www.nsf.gov/sbe/srs/wmpd/start.htm  ). Schools with a higher MCAT do not graduate as many family physicians.

Regression studies reveal that each 1 point increase in the average MCAT for a medical school (or bioscience MCAT) is associated with a 2 to 4 percentage point decrease in family medicine choice or about 3 - 5 students in an average medical school graduating class. One MCAT point nationwide is about 500 fewer US allopathic medical students choosing family medicine. Choice of Family Medicine: Past, Present, Future  The bioscience MCAT score in the past decade has increase 1 point for allopathic matriculants (AAMC Data Warehouse).

Figure 8 MCAT Changes 1992-2002

Does this increase in MCAT for bioscience scores represent increase admission of upper SES students or is a matter of "gaming" the system with MCAT prep courses? Only individual student studies could tell. Verbal ability MCAT gains have been minimal. In either case, the likely end result is fewer admissions of those from humble origins. Jobs, debt, preparation, family support, education distribution, access to counselors and advisors, contacts with professional parents, and test taking skills are key obstacles to professional school, with more difficulties for those who start with less..

The following table was prepared to illustrate the relationships between MCAT, older age at graduation, the percentage of rural born, the percentage born in core metro areas, and the percentage choosing family medicine. For this table the FP choice was the 2003 FP match (AAFP) and the MCAT was year 2000 data MCAT Correlations . The values for each successive 10 school group sorted by MCAT score descending was averaged to obtain this table.

These tables do not include data from Puerto Rican and osteopathic schools or Meharry, Howard, or Morehouse. Meharry, Howard, and Morehouse rank in the most FP likely quartile of Allopathic Private schools, consistent with socioeconomic indicators of their admitted students.

Older Medical Student Career Choices

The common factor of socioeconomic status links rural, instate, older, parent income, and MCAT scores through choice of family medicine. 

The only wrinkle in the table involves the medical schools ranked 41 - 50 in MCAT. This group involves schools with much higher FP match percentages in MN, WI, CO, and OR. These states have larger rural populations and superb state education graduation rates and education resource distributions. The medical schools in these states have particularly strong rural and family medicine efforts. College continuation rates contribute to regressions involving FP choice at the medical school level. Continuation rates, longitude, and MCAT explain 60% of the variance in FP choice. Birth origins, ethnicity, FP infrastructure, rural measures all correlate too highly with MCAT for use MCAT Correlations.

The contribution of special admissions efforts such as Duluth is also illustrated in MN. When comparing states and rural born admissions from those born in the state, higher college continuation rates and special rural admissions tracks explain nearly 50% of the variance.

Predicting the Match

Using ethnicity, origins, or socioeconomic data from matriculants, the family practice "match" for US allopathic medical students can be predicted years in advance. The data used involved choice of family medicine for 1975 - 2000 for all students. White medical students are 80% urban born and 20% rural born. For white students the calculations involved using the percentage of choosing family medicine by birth origin, a proxy for socioeconomic status and FP choice. Of all medical students, 13.0% choose family medicine who were born in urban and urban focused locations, 20.3% of those born in large rural, 24.6% of those born in medium rural, and 26.1% for isolated rural. These values have been remarkably constant over 1975 - 1994. For other ethnicities the calculations were based on FP choices of 1994 - 2000 graduates. The following predicted match was compared to actual match data for US seniors. The most important contributors are the declining rural origin admissions (high FP choice) and the increasing urban Asian admissions (low FP choice) resulting in a consistent decline for family medicine choice over a 30 year period, with the exception of the managed care era.

Figure 9    Predict vs Actual FP Choice

The baseline of the match appears to be socioeconomic, with other influences impacting as well. Without major interventions, the US medical school component that will enter the primary care workforce can be predicted 7 years in the future.

Figure 13 Managed Care and Choice of FP

Other Influences on the Choice Of Family Medicine

Multiple linear regression can help to identify key variables that explain the "match." Obviously there are multiple overlapping variables. However even with such interactions it is possible to identify additional influences.

The dependent variable was the % choosing family medicine for each allopathic medical school for the residents graduating 1997 - 2003.

Results of model FP cohort regression

Note the strong correlations between MCAT and the % admitted from Urban Influence Code 1 and strong negative correlation with % choosing FP.

This regression explains 76% of the variance. Note the overlapping variables, however. Best regressions involve just MCAT, Longitude, and HS x college or college continuation rate.

Dependent Variable: fpchrt

Weighted Least Squares Regression - Weighted by rural92

See also

Choice of Family Medicine: Past, Present, Future 

Choice of Family Practice Update, Reasons for Decline

The persistence of longitude and education with weighting and despite the inclusion of other variables suggest further lines of research in these areas.

Other dependent variables were also used to be sure that this regression was not atypical for this group of family and general practice physicians. There was no difference in the results using this 1997 - 2003 FP board certified group or the AMA self-designated family physician category. The family medicine and general practice component also dominates a regression adding office-based internal medicine and pediatrics for a true primary care comparison. In the eastern schools students tend to choose office-based internal medicine, pediatrics, and women's health rather than family medicine, as reflected in the longitudinal variable.

Primary Care Internal Medicine

The same socioeconomic influences also move internal medicine physicians to choose more office-based practices as compared to other types of internal medicine practice activities. This is not apparent in direct regressions involving office-based internal medicine physicians, but it is clear in regressions involving the proportion of internal medicine physicians choosing office-based practice as compared to all in internal medicine in all other activities.

Internal medicine is a broad area with many different activities. Some are related to primary care and some are not. Family medicine relates to general internal medicine in many ways. Office-based primary care includes general internal medicine, general pediatrics, and family medicine. Even though the correlations directly between family medicine and internal medicine are smaller, there are close correlations between choice of family medicine by students at a school and the proportion of internal medicine physicians choosing office-based practice. This correlation is a very strong +0.619.

For the following, allopathic schools that were typical and not the lowest scoring MCAT schools were compared to each other for the following variables. The proportion choosing office-based internal medicine was very similar to the percentage of students at the school choosing family medicine. Schools with true emphasis on primary care graduate primary care physicians of more than one type. When Medicare and Medicaid were created, both family medicine and internal medicine nearly doubled as student choices. It is actually difficult to separate the office-based primary care careers.

Schools with broader admissions graduate a higher proportion of office-based internal medicine physicians. These schools have lower MCAT score averages, more rural born students, more older students, more instate students, fewer urban born students, and fewer Asian ethnicity students.

*    p < 0.025

**    p < 0.001

*** p < 0.0001

Physician Specialty Choice and Socioeconomic Influences:

The Concept of Admissions Dependent Medical Specialties

Certain physician career types appear to be admissions-dependent. In other words, medical schools with certain characteristics graduate students into certain types of careers. A regression of medical schools with preadmission student composition factors such as age, instate, urban, MCAT scores, GPA, and education opportunity can screen each major specialty for influences at or before admissions.

Just to clarify, these are not individual medical student studies. They are studies of the medical school outcomes that can be attributed to admissions decisions by medical schools over a period of time.

The following regressions did not include atypical schools with an FP or primary care mission or those impacted by such mission (Duluth, U MN, Mercer), osteopathic schools, schools with mergers (Drexel), the military school, the 6 year school, or schools with variation by ethnicity (Puerto Rican schools, Howard, Meharry, Morehouse).

Rated in order of variance explained by admissions or pre-admissions factors:

Rated in order of variance explained by admissions or pre-admissions factors:

Family medicine and primary care - The effect of MCAT is such that a medical school with a one point higher MCAT score (for example 10.8 vs 9.8) in individual science scores or average MCAT, graduate 2- 4 percentage points fewer FP or Primary Care Office-Based physicians. This regression already excluded many of the lowest scoring MCAT schools and persisted when excluding schools with less than 9 or those with greater than 11 average MCAT.

State education is important for choice of FP and is also important for the choice of office-based IM over other types of IM. Only office based IM and family medicine are related to state education opportunity variables.

Those not predicted well with correlations generally 0.3 or less.

·        Psychiatry percentages are correlated with the percentage of older students at 0.36. Schools with more rural students and lower MCAT scores tend to graduate more psychiatrists. Graphs of age and psychiatry choice note a more significant relationship that might be exploited by special admissions programs designed for older students with behavioral interest or past career experience. Age and Physician Specialty  

·        Internal Medicine as a whole as compared to office-based IM only had a tendency toward schools with higher MCAT, more core urban students, and fewer instate students.
·        General Surgery - MCAT is generally higher with a trend toward younger and urban origins. General surgery has declined slowly over decades just like family medicine. A likely line of research to pursue is involves studies of those with slightly lower SES
·        Ophthalmology  - Higher MCAT, younger, and urban correlations
·        Obstetrics-Gynecologists – Tendency toward medical schools with a slightly lower MCAT (Bioscience component negative at -0.36).
·        Pathology - a trend toward rural birth.
·        Those with no trends include pediatrics, anesthesia, and careers involving administration, work in the hospital full time, all office-based physician careers, and medical teaching.

Only the physician activity of research has admissions or preadmissions potential.

There certainly seem to be a multitude of "feeder" programs involving high school and college students focusing on research. Would such programs focused on service-orientation, service-learning, or with a different set of role models in contact with students make a difference in choice of those more likely to choose service-oriented careers?

See also MCAT Correlations. This also includes data from other standardized tests and variation by income, ethnicity, etc.

Admissions of Older Students

The direct patient care specialties most involving primary care, mental health, women's health, and emergent care are at least somewhat dependent upon admissions of students who are older and lower in MCAT scores. It may be that students are unlikely to choose these front line specialties when they are younger, urban in origin, highly educated, or from upper socioeconomic status.

Younger students may have a different concept of medicine involving disease and technology as compared to continuity or direct patient contact. This impression is expressed in recent interviews of medical leaders such as Lawrence Smith, M.D., Dean of Medical Education at Mount Sinai http://www.npr.org/templates/story/story.php?storyId=4106713

There was a -0.56 correlation between the percentage of students over age 29 and grade point average. The lower GPA of older students may impact admissions.

Younger students tend to choose cardiology and orthopedics.

Figure 11, 12, 13  Age and Physician Specialty Graphics

See also Age at Graduation and Tables on Physician Specialty

Rural "Admissions" vs Rural Mission

At least 47 medical schools listed a preference given to rural origin candidates; however there were declines in all medical schools except Morehouse over the past 20 years. Schools with a rural mission resisted the national influences better as noted in Figure 14.

Figure 14    Declines in Rural Born Admissions

At least 7 medical schools had greatly increased rates of admission of rural born students, particularly those born in the medium and isolated rural locations. Figure 15 notes the admissions at the University of Alabama after World War II. This illustrates that the nation can admit more from rural areas and even address inequities in education. The question remains, will we?

Figure 15   Rural Students Admitted at University of Alabama Post WWII Rural Origin Students

Discussion

Without admissions of students who are "different," medical schools are unlikely to graduate the physicians with the best distribution, the best quality, and the best cost savings (Baicker and Chandra http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.184v1 ).

Family medicine indeed appears to be a delicate balance between enough socioeconomic status to gain admission, and not too much to preclude consideration of family medicine as a specialty. Education distribution plays a key role in "leveling the playing field" as noted in regression that link rural origin admissions and family medicine choice to state college continuation rates.

Variations almost certainly involve environmental influence, racial bias, and education differences. These are also noted in Great Britain regarding admissions to medical school (BMJ). Those rising in social status may also have different choices than those who have long established societal position.  (http://bmj.bmjjournals.com/cgi/content/full/328/7455/1541  http://bmj.bmjjournals.com/cgi/content/full/328/7455/1545 ).

The limitations of this research involve application. Although there are clear associations on the national level, decisions for admission are based on the local and individual.

The primary use of this research should be to encourage admissions committees to study their applicants, their environments, their support capabilities, and their outcomes.

Government should also consider the findings in the design of education funding from the earliest levels throughout K-12 and college to professional education. In recent years the impediments of tuition, debts, necessity of work-study, cost of MCAT prep, and other factors may be having more dramatic impacts on those of lower income, who have previously been resistant to such influences when making career choices such as family medicine (Choice of Family Practice Update, Reasons for Decline). The lesson of managed care and accountability should also not be lost on the nation.

Any nation that truly desires to win a wars against terrorism, crime, drugs, and violence,

and the hopelessness that fuel them, must address socioeconomic issues that divide

this nation and divide this nation from other nations.

The combination of "managed care pressures" increased primary care and family medicine and resulted in the best distribution the nation has ever had in 2001 and 2002. However the admissions of those of lower socioeconomic status markers continues to decline and there seems to be a "rebound" phenomena against primary care. Rural graduation rates are declining already. As shortages reappear,  sites with more resources will out-compete underserved areas again. Broader selection has the potential to make physician incentives and apologetics such as "Why Doctors Don't Go," a thing of the past (Cohen, Academic). It is interesting that the nation's leaders, Republican or Democrat, continue to support Community Health Centers and seem to understand how critical these centers are for health access. However there is no understanding how important it is to admit the students who will go and stay in such centers and underserved inner city and rural areas.

The worst application of this research would be to indiscriminately impede
admissions of those of upper socioeconomic status.

The past history of medical education already has far too much evidence of quotas and discrimination against Jewish students, Asian students, and underrepresented minorities. The constant advocacy positions in medical education, education, and other components of this nation only work to favor groups that are more numerous or well-established as compared to those with less attention. Rural, older, instate, and lower test-taking ability students have qualities that make them as good a physician as other types of students. They just are "different" in origins. Family Physicians Are Different

Impeding access to medical school for those of the highest SES would provide the same barrier as those of lower test taking ability associated with lower SES. This would result in more games in admissions beyond those that seem to be played out in who is actually a state resident or not now.

However it seems fair to test those of upper status for their ability to relate to people of all types, just as those of lower SES have to demonstrate their academic capabilities. This is much the same as the treatment of students with MCATs of 13 or 14 on subtests. When students have near perfect scores, there is a reasonable attempt to make sure that they are not all brain with no ability to relate or communicate. If physicians are not able to relate to a broad range of people, it is unlikely that they will serve the nation well as physicians. Miscommunications and assumptions may also lead to medical errors. The relationship of status and physician quality is an excellent line of research to pursue. New studies reveal that those of lower SES have the same performance as upper SES by the end of medical school and residency (Cooter R Economic Diversity in Medical Education).  This research coupled with links between family medicine and health care quality (Baicker and Chandra) would give a reasonable expectation that broader admissions would lead to better physician performance in a number of areas.

The Medical College Admission Test, while insuring academic preparation, is also related to socioeconomic status. The MCAT is no different than the ACT or SAT in this area. Indiscriminate application of the MCAT tool compounds the obstacles of income and education. MCAT use as a ranking system for interviews or admission is a practice that must change. MCAT Correlations

Distribution of education and wealth in the nation appear to be related to distribution of health resources, since family medicine is the physician specialty that distributes according to the US population. For years medical leaders have blamed poor economics for the lack of physicians in underserved areas Cohen on Why Doctor's Don't Go Where They Are Needed. The truth is that lack of admissions of students that will return deprives such locations of the services, jobs, economics, leadership, and education that physicians, or other professionals provide. Restoration of Communities, Nations, People: Role of Family Docs  As difficult as this is with physicians, it may be worse if the same applies to the nation's schoolteachers. Physicians happen to be fewer and easier to track.

Family medicine appears to be a measure of educational quality with great potential. Family medicine is a marker of breadth in education distribution and quality. It is a measure of what education can do to facilitate the dreams of those who have less and want to "make a difference" with their lives. It may well be a marker of the success of our nation in more than education. Declines in family medicine choice may be a warning of further divisions in our nation between education and other areas and between lower and upper income levels.

Any expansions of medical education should involve replication of current successful models involving rural or inner city students or should involve admissions of older students. This would address access issues without declines in quality or excessive cost. Academic medicine's season of social accountability, predicted by William T. Butler in 1992 Academic Medicine's Season of Accountability and Social Responsibility, may finally be at hand.

Medical schools have been exhorted to consider broadening of admissions on many occasions. The 2001 address of Jordan Cohen, M.D., the president of AAMC provides a framework for admissions that might make a difference. This work is not only possible, as numerous models from rural to inner city have demonstrated, this work is also probable.

Jordan J. Cohen, M.D., President of the Association of American Medical Colleges (AAMC), issued the following statement, today, at the Association's 112th Annual Meeting in Washington, D.C.:  Our Compact with Tomorrow's Doctors    http://www.aamc.org/newsroom/pressrel/2001/011104a.htm  

Character, Color, Admissions, and Physicians   Admissions Tracks

Non-traditional Students        Age and Physician Specialty           Admissions and Social Status

"4. Stop using the average MCAT scores and GPAs of our matriculants as if they were valid measures of the relative quality of our schools. Take a look at the devastating critique of the U.S. News & World Report's rankings of the "best" medical schools in this month's Academic Medicine and see if you don't agree with what the authors have to say. In accepting without objection the use of such misleading measures as average MCATs and GPAs, let alone in ballyhooing them in our own promotional materials, we reinforce the public perception that they are, indeed, our principal criteria for admission. MCAT Correlations     

For an excellent discussion of these topics plus gender and education and college impacts, go to Women, Minorities, and Persons with Disabilities in Science and Engineering at http://www.nsf.gov/sbe/srs/nsf99338/frames.htm  especially chapter 2 and 3

"5. Use past experience to improve our ability to spot the truly outstanding prospects. As a general rule, it doesn't take long for a consensus to emerge among faculty and staff about who among each entering class of students are destined to be the best, most caring, most compassionate physicians. They are the ones who win the humanism awards, who tutor their classmates, who are elected class representatives, who are the pacesetters for student-initiated community service activities, and so on. Why don't we look back at those students' credentials at the time of admission and see if we can find some common characteristics that might be helpful in sharpening our ability to identify such stars among future applicants. And let's use even more of those star students as recruiters and as full-fledged members of our admission committees. Physician Shortage Area Program Links and Info  Small Colleges and Admissions  Service Orientation

Service Characteristics

Programs that have integrated these points as well as those that will integrate these points have will give US medical schools the best chance of meeting the nation's needs in cost, quality, and access.

For an excellent discussion of higher education, admissions, status, and testing, go to Women, Minorities, and Persons with Disabilities in Science and Engineering at http://www.nsf.gov/sbe/srs/nsf99338/frames.htm   especially chapter 2 and 3

Physician Workforce Studies

Socioeconomics and Physician Distribution

Workforce References

Side Effects of Selecting for Family Medicine

About the Site and Author

Family Physicians Are Different

Variables in the Medical School Database

Attrition Rates

Before Admissions

Admissions Summary

Admissions and Social Status

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