As my sainted grandmother, Dr Mary, used to say, "There are two kinds of people. those that do the work and those that take the credit. Bill, try to be among the first group. For one thing, there's a lot less competition to belong." Bill Rodney
It is a dilemma, legally and politically, to not admit the best and brightest. After a century of improvements for gifted education in high school and college, the national pressures to admit the brightest are enormous. Unfortunately, the brightest may not be the students most likely to choose underserved locations. Many medical leaders have given up on being able to resolve maldistribution.
The question remains: How do you choose candidates that are likely to serve the populations that most need help?
As with most decisions of this magnitude, it is a matter of political will. Clearly institutions will not change without leadership and example. It is not a surprise that the major factor contributing to the rural graduation rates of medical schools is the rurality of the state. Medical Schools and Rural Graduation Rates - New Research 2002 After models are established, it again takes leadership to implement these changes more broadly.
Some research studies suggest a solution. There are also some past and present models. The solution involves a determination on the part of the school regarding what medical school candidates should be doing after graduation. It involves the extra work of collecting data on candidates before admission and comparing it to the outcomes years after graduation.
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
It is important to remember that older medical students have more life and health experience and are more likely to arise from lower and middle income, rural, and diverse populations. They also consistently choose family medicine, rural, underserved, psychiatry, women's health, and all front line careers involving patients in primary care, mental health, women's health, and in some degree even ER components.
Older, service oriented, primary care, broad preparation also go together in the detailed study by Madison. From - 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
This study tracked 148 grads over 13 or 14 years of practice. 34% choose generalist careers.
Results A high service index predicted strongly the choice of a generalist medical career. Conversely the absence of any clear evidence of a service orientation predicted still more strongly a non-generalist career.
"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."
The candidates were interested in service through the vehicle of medicine. Service was first, with medicine the means. Candidates with service orientation noted a general concern for society or a community of people (women, home town, underserved, elderly, third world). This was separate from the desire to "work with people, being a people person, wanting to cure cancer, desire to help people who are ill, or how much I want a medical career."
There were two service oriented items evaluated in the medical school AMCAS application for the UNC Chapel Hill Class of 1985
Reminder: AMCAS application asked for this area specifically, as opposed to the essay which was left entirely up to the candidate
Exceptionally Strong – 4% of class of students, 83% of this exceptionally strong service oriented group or 5 out of 6 became generalists. These students had a consistent history of work in a service career such as Peace Corps, pastor, teacher, community organizer
Strong – 17% of students, 60% of these became generalists. Full record of volunteer activity in college or after, vocational on non-vocational, some lack of service continuity over time
Modest – 43%, 37% of this group became generalists. Some record of volunteer activity usually in an organized group. Has to be a different activity than just gaining medically-related experience. Helping but not a clear humanitarian (vs vocation) orientation.
Low or no service record - 36% of class, 19% of these became generalists
Strong service orientation - 18% of the class, 77% of these became generalists
Modest 32% of the class, 45% became generalists
Weak/none 32% of the class, 12% became generalists
The above 2 categories (background and essay) were combined into a Service Index on a 1 thru 5 scale
0 – no service record or essay mention
5 – Exceptionally strong service record and strong essay mention
A separate analysis looked at a logistic regression of factors regarding generalist career choice.
Service orientation was the number 1 factor, socioeconomics of family was number 2, note that doing this results in gender dropping out as a factor in choosing primary care.
There were some great quotes in the article:
Next to consider is the theme of those socially and geographically different and distant in admission as compared to those narrow, science oriented, higher scoring, from professional parents.
In the AAMC studies regarding Minorities in Medicine, the 1998 study indicated that socially different medical students were older, began their path to medicine early, took more years of effort to overcome obstacles of income and education, were much more aware of the needs of those different and underserved, were more committed to service and to serving those in need Awareness and Future Physician Leaders Numerous studies indicate the value of matching up physicians to their patients in gender, race, ethnicity, socioeconomics, language, etc. The value is not only quality and perception of quality, but also clearly improved physician distribution to the most needed populations and also likely cost benefit as well.
The Rural Interested Senior student findings were a mirror of the Socially Different types of students, but in the dimension of geographic distance. Rural students are lower income in origin, less likely to be children of professionals, older in age at admission, and different in a number of dimensions from those most likely to gain admission, just like socially different medical students. Rural interested seniors were 6 times more likely to be interested in serving the underserved compared to peers in 1995 AAMC GQ data. This was essentially the same as the socially distant who had 40% levels. The rural interested seniors were a smaller and more select group (pop less than 2500 due to AAMC categories) They were older, 68% chose family medicine, about half were from rural high schools, about half of the married rural seniors had rural spouses, and they were twice as likely to have served during medical school in volunteer activities. They shaped any and all possible experiences away from major medical centers with twice the rural, international and military (other service oriented markers), and public health rotations or experiences at each of the 4 years of medical school. They also were twice as likely to be dissatisfied with their medical education. They and their non-rural interested peers both agreed on problems with primary care training.
New Models for Service Orientation now exist. The early reports are out for the Mesa Arizona model involving dental distribution.
Wayne Cottham, DMD
A.T. Still University Dental Program, Mesa AZ
This new dental model focuses on the community and public health model of
dentistry in admission, curricula, and training location. Community health
centers have become a part of all facets of the program. Graduates complete an
MPH degree. The model has integrated admissions from communities in need as
evaluated at the local level. The applicants who are referred by local Community
Health Centers are admitted at higher levels and have the same completion rates.
This is a contrast with dental schools boasting top ranking exam scores on
admissions testing while rural and underserved locations face increasing
difficulties with dental health.
Outcomes - The graduates are found in private practice at 21%. The remainder are
found across the wide range of community, public health, and CHC locations. The
tuition costs are substantial. Revenues generated from the faculty and student
activities are another source of funding. The dental school also gives up half
of the senior student dental revenues as the decentralized training is dispersed
to a number of locations, who benefit from the services of the dental students.
Debt levels may impact a few students, but finances do not appear to impact the
superior distribution levels of the graduates.
The Mesa model for medical students is newer and will face the same or greater
challenges since even more of the training involves local participation and
location. The Mesa medical model is likely to have the same outcomes regarding
distribution, improvements in health access, and service to patients in most
need of care.
The admissions choices in some of the newer primary care schools have examined service. The RMED track at Rockford has a service scale that is evaluated, they are doing well in primary care graduation (almost 100%) and early indications are great toward rural underserved. Rockford Rural Health Needs Challenge Doctors
We can choose better than the brightest, by choosing for service orientation. We can also work to insure that socio-economics are not a hindrance. If we do so there is an increasing probability that we will be more likely to get the physicians that would choose underserved locations.
Some other possibilities:
These physicians, chosen for service orientation, would be less likely to want more income. They would be more willing to deal with complex problem solving involving the community level. They would be more likely to be leaders.
There is a warning: In my experience, these students are more intolerant of bad learning environments and bad health care environments.
There are also some potential benefits for this "treatment, " at least the part involving admissions of more students interested in practicing in rural areas. The side effects might be that the resulting physicians would be more mature, less inclined for income and more likely to communicate better
AAMC and Service-Learning http://www.aamc.org/data/aib/cime/vol3no1.pdf
Rural Interested Senior Medical Students 1995 - integrates the service orientation and primary care literature
Heroes in Medicine - all about their devotion to those in need of services
Mother Theresa Servant to the Underserved
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