A primary task of medical schools is selecting and training the next generation of physicians. One of the most challenging and expensive tasks in medical school administration is service on the admissions committee (article on changes). The admissions committee often receives information on the last few entering classes, but long term information is often missing on what happens to graduates. It is much easier to concentrate on qualities that would insure academic success.
Medical schools have had a critical role in shaping education over the last century. Medical school prerequisites have helped define high school and college education. As a result, it is easy enough to select those who can grasp the complexities of medical knowledge and use their gifts of intellect. Jordan Cohen and others have noted the need to look at more than just numbers and intellectual potential. Madison's study notes "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."
Example: For many years medical schools pursued underrepresented minorities. Recent years have seen this decline as well. Selecting underrepresented minorities continues to be important because they are 4 times more likely to choose underserved urban populations (AAMC data X handbook). Selection for other characteristics is less well understood, mainly due to the lack of regular collection of such information. Studies do indicate that admission committees can select for service and there is some benefit in doing so, including more primary care graduates.
Admission committees can
They obviously need the full support of the Dean and other medical leaders in order to resist several influences that might spoil their effort. These include powerful, rich, or professional parents and alumni, the push for higher board scores, and the need to perform well for accrediting bodies. Character, Color, Admissions, and Physicians They also face individual faculty members who have multiple other responsibilities. Time on the admissions committee may be costly to the institution income or to themselves in income or academic progress.
Those committees who take the task to heart will need good information and regular training sessions to be able to select the kind of candidates that will have the desired outcomes.
Sometimes more innovative approaches to admissions can better meet the needs of the institution to value faculty time and select for outcomes. These include working with small college health advisors, rural physicians, or rural people. Small college advisors have the advantage of knowing the candidates before they learned what to say at interviews and how to act. Small college advisors work closely with the Physician Shortage Area Program at Jefferson in Pennsylvania. The success of this program is well documented. Other efforts with feeder small colleges have been successful (Nebraska RHOP, others). One department of Family Medicine at the University of Nebraska Medical Center acknowledges this program and the other efforts of the admission committee as responsible for their successful Rural Program of the Year Award from the National Rural Health Association in 2001. This department graduates over 65% into rural practice through a wide variety of rural graduate and undergraduate programs, including one program that places 70% in towns of less than 5000. The Rockford RMED program selects those that they feel can successfully negotiate medical education and then leaves final selection to rural people. The candidates selected often differ from those preferred by Rockford faculty. The program involves about 14 students at year and early data indicates nearly all select family medicine with a few others choosing pediatrics or medicine. The program has received recognition as the Innovative Program of the Year from the Society of Teachers of Family Medicine in 2000. The WWAMI system involves rural physicians in the selections process.
Some approaches have not worked as well. Efforts in Missouri to keep gifted students from leaving the state have not resulted in more going to state medical schools. These students took state tax dollars and left the state anyway. There is need to select the best students but not necessarily the brightest.
Which to follow? Should committees choose the brightest to receive the accolades of research and academic prestige or should they choose the best, the ones more likely to meet the needs of people? It is no easy task to resist either pole of the magnet. Physicians can be caught up in addiction to knowledge or addiction to service. The history of medicine is a series of famous researchers. The pursuit of new knowledge is one of the most selfish but necessary acts of physicians or researchers. It is a major challenge to maintain personal and career balance and still pursue research. The pursuit of knowledge has devoured many persons, departments, and institutions. Institutions can crumble if they fail to meet the needs of people. Other disciplines can move in and take their role, destroying an entire profession. Similarly complete devotion to service can destroy marriages, departments, and institutions. There are other consequences when institutions move to far toward research. If serving physicians continue to choose careers outside of medical schools, then the institution loses service as a value and priority.
Candidates for admission have a wide range of backgrounds, preparation, and characteristics. There is a basic requirement that physicians be able to do complex problem-solving. This is tested cognitively. Interviews attempt to estimate the ability of the candidate to do more than tests. Our understanding of multiple types of intelligences is poor, but there is growing recognition of areas such as emotional intelligence and other factors that reflect the ability to relate to people. The best way to fine tune admissions is to define the characteristics of the graduates that are most desired and then gather the appropriate information at or before admission so that better choices can be made. This may take some institutional bravery to gather the information and use it appropriately. It is tempting to destroy such information in fear of the legal consequences, but this destroys the potential to graduate the best physicians.
It is important to understand that recruitment to rural communities is not the same as retention of rural doctors in rural communities. Recruitment involves selecting those with rural background and rural practice interest. Retention is less well understood, but it seems to involve characteristics most linked to training after selection has occurred in addition to the match between the doctor, the family, the community, and the practice.
Key fact: No program or medical school without rural-oriented admissions can graduate doctors who serve in rural practices.
Those with rural background do not stay in practice any longer than those with urban background. Those with rural spouses do not stay longer than those without (Pathman). Simple selections for rural background and rural practice interest can increase the probability of a rural location by 5 or 6 times (Rabinowitz). Although medical leaders would have you think that the reasons for poor maldistribution are economic and cultural (Cohen), it is clear that selections has a major role.
It is not hard to predict the result of failure to select candidates that can choose rural practice. Over several decades, doctors will increasingly crowd into major cities. Small towns will not be able to find doctors to replace those who leave and retire. These towns will face economic decline as a result of loss of rural doctors, hospitals, health systems, and jobs. The economic impact of physicians in the smallest towns can be measured in dollars, but the impact of a loss of physicians is far more devastating without timely replacement. Towns cannot attract and maintain jobs if businesses even think that the health care is unstable. The loss of those likely to become young professionals in rural areas will result in fewer young professionals of all types locating in rural areas. In desperation towns will strain to try to adapt to other types or providers or part-time practitioners. They will make some bad decisions that will cost them dollars, reputation, and even control of their health care. Governments will attempt to remedy the situation with more programs and more tax dollars, but with little relief. This is the current situation in rural health right now. Certainly not all of the problems in small towns are the result of poor selections by admission committees, but selecting doctors who will go to small towns is critical.
For many years it was possible to assert that the studies had not been done to demonstrate that rural doctors could be selected. Now there is no question that this can be done. The Physician Shortage Area Program in Pennsylvania has involved only 1% of the medical school graduates in the state, but graduates of the program comprise 27% of the rural family physicians in the state (Rabinowitz). Other programs in various states have demonstrated similar effects when selecting for rural background and rural practice interest.
With many interventions and treatments in medicine, there is the potential for side effects and even death. Regarding the intervention of selecting for rural practice there seem to be seems to have few drawbacks and some major benefits. Those who were interested in rural practice in towns of less than 10,000 as senior medical students were twice as likely to serve in local underserved clinics and overseas missions.
There is the potential in some states that selecting for rural characteristics can lead to selections of those at more academic risk. This will involve more careful work by admissions committees. It may mean that some remedial work would be needed by a few students.
Basco, W.T., Jr., Gilbert, G.E., & Blue, A.V.(2002). Determining the Consequences for Rural Applicants When Additional Consideration is Discontinued in a Medical School Admission Process. Academic Medicine, 77, S20-S22. http://www.aamc.org/students/mcat/research/bibliography/basco002.htm RESULTS: There were 2,033 in-state applicants with complete data (not missing MCAT scores) in the four cohorts. Rural applicants comprised between 8.5% and 9.7% of applicants, depending on the year. MCAT science scores for rural applicants were significantly lower in three of the four, but Verbal Reasoning scores were not significantly different between rural and non-rural applicants. Mean GPAs were not significantly different either. In three of the four years, rural applicants were half as likely to have attended undergraduate schools in the more competitive Barron's categories, but these differences reached statistical significance in only one year-1998. Without the adjustment for rural applicant status, the median ranks of rural applicants were lower than those for non-rural applicants in all four years. Across all four years the adjustment for being a rural applicant had a marked positive effect for rural applicants while having minimal effects on non-rural applicants. The adjustment for rural status did not ensure an admission interview for every rural applicant, but it did mean that a large majority of the rural applicants received admission interviews in all four years. Without the adjustment, fewer than half of the rural applicants would have received admission interviews in two of the years evaluated-1997 and 1999.
After spending most of this time convincing you that recruitment and retention are separate issues, there is some potential that the two may share some common medical student characteristics. These include the characteristics of service, mission orientation, and stability.
It may be that those who have more complete mastery of the practice of medicine are more comfortable pursuing learning in areas such as how to adjust to more difficult practice situations and more challenging patients. For years those who have shaped medical education such as Flexner, Osler, and deans at countless medical schools have made statements that the best physicians need to choose small towns. Only in recent decades has there been mention of the best physicians "wasting their lives" in rural practice or even giving the practice of medicine over to midlevel providers in small locations.
Use a two step method to screen candidates. This is the same method recommended by AAMC and MCAT materials. First screen and review all candidates and define a group that will be able to survive medical school and graduate. Then among these candidates, prioritize those who will choose careers of service. These are the ones that will meet the mission of the school, the city, the region, underserved areas, underserved medical careers. Try not to set the cutoff points so high that only the most intellectual students are chosen. These are some of the least likely to choose rural practice. This does not mean those less smart choose rural practice, it means that those interested in rural practice (and other serving careers in need such as geriatrics, psych, primary care) have a wider variety of interests and less focus on purely academic pursuits.
Develop or support programs that enhance career and preprofessional preparation in minority and rural background candidates. see Flexner’s Impact on American Medicine,
Work closely with small college advisors to maintain or improve the ability of small colleges in rural areas to get their students admitted to medical school. PreProfessional Advice and Information
Facilitating More and Better Rural Docs