Admissions and Social Status

Robert C. Bowman, M.D.            

See also Medicine, Education, and Social Status for data and tables and graphics and updated work

This is going to be a "hard" read and it will take some time and perspective. I hope that you know me well enough to not dismiss me as intolerant or inflammatory. I struggle to read the writing on the walls just as all of us do. I have been blessed with the opportunity to do some detailed studies of US medical students over time and have explored this via a number of research perspectives such as those of different origins and backgrounds. As a person I am aided and hindered by various  perspectives, teen who was mistreated by neighboring teens, naive, suburban city kid, Baylor Med school grad, Waco TX for FP and family and health systems, rural OK practice (2yrs prosperous town, 2 yrs disastrous), medical educator in OK, TX, TN, NE; AMA delegate, observer of Families of Family Medicine rural activities or lack thereof, leader in rural med ed, spouse of a 5th grade teacher, father of challenging children, and advocate of FP and of young professionals as a means to restore neighborhoods, communities, states, and nations.

One of my long term efforts involves improving medical school admissions of rural and inner city students. The similarities and differences have been most instructive. Not sure how I came across these recently, but I found these two articles below most helpful in defining some of the social barriers to admission.

http://bmj.bmjjournals.com/cgi/content/full/328/7455/1541

http://bmj.bmjjournals.com/cgi/content/full/328/7455/1545

Additional encouragement to read the BMJ article on Methods, from the article:

"We calculated standardised admission ratios using data from the Universities' Central Admissions Service database ( www.ucas.ac.uk/figures  ) on UK medical school admissions from 1996 to 2000 (the last year for which full figures are so far available, and the last year in which socioeconomic status was measured in traditional social class bands) as a numerator and the labour force survey (http://www.statistics.gov.uk  ) as a denominator (see figure).

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."

Sounds much like the US. The BMJ study used workforce demographic distributions as the denominator. I used birth cohort comparisons. For those entering medical school 1990 - 2002 (admits of 1986 - 1998) I compared data from 27 years before using a denominator of births in a state in 1966. This was repeated for rural and for urban born students.Probability of admission tables  http://www.unmc.edu/Community/ruralmeded/probability_of_admission_tables.htm   The variation:   from a rate of 74 students admitted per 100,000 live births from non-metro North Carolina (census of 1966) to a rate of 1300 metro born students per year born in the District of Columbia admitted  You could probable run a straight line regarding education, income, infant mortality, life expectancy, and other data. Actually low status in metro dc and in other inner city areas probably has the even lower admission rates mentioned in the BMJ. Education Weekly just ran an article about the % of school districts not meeting requirements and the failure rates were highest in the states admitting the least.

Also did these tables found at Medicine, Education, and Social Status seen below (see the page for details on calculations using US med school data)

Admissions Ratios, Parent Income, and Choice of Family and General Practice

52444 physicians with unknown birth

About 65% of the medical students from Urban Influence Code 1 were born in counties with a medical school, increasing the probability of admission by 80 - 100% compared to those born in other Urban Influence 1 counties without a medical school. Those born in medical school counties have 5% choice of family medicine. Those born in Urban Influence 1 counties without a medical school have 18% choice of FP. These calculations involved 1991 - 2000 graduates compared to 1970 population.

Ranking by MCAT by groups of ten from top ten schools down to lowest MCAT schools

These tables do not include data from Puerto Rican schools, osteopathic schools or Meharry, Howard, or Morehouse.

The 5th group above includes both Wisconsin and Minnesota, states with much better than average education and with a higher % of rural population, and medical schools with much better than average admissions with rural admissions emphasis. Better education and rural track admissions result in more rural born admissions in regressions based on probability.

Upon review of the above, social status is an important consideration in medical school admissions. With review of many of my findings, the medical student indicators of FP choice that I see in my research such as rural, instate, older, are likely proxies for lower social status.

This also helps explain why some older students tend to not only choose FP, but choose FP and then rural practice, particularly when they get appropriate intensity of training (something more and more difficult to obtain in the US). My bet is that they are from lower social status, or they have seen "the light" through other careers and experiences and understand how important it is to make a difference in underserved communities. Others of higher status also may have had some experiences that gave them a chance to view their training and practice from a different perspective. Having to overcome difficult obstacles may be particularly important for those with most of the advantages of status.

I learned from studies at the University of Toronto Barriers To Entry that those of higher income were being admitted in greater numbers. This is a trend in Great Britain and Canada and perhaps in many nations, especially those nations that only allow skilled, educated, or professional people to enter and stay in the country. It is not a surprise that some nations have more and more admissions of those of higher status and less admitted from lower status. Another read is that education and other conditions conducive to social mobility are declining across the board or at least in areas with lower social status, with the result that it is more and more difficult to access medical education. Again proxies are not perfect markers, since they are indirect.

It has been an interesting week of reflection. I just returned from a med school roommate's 25th Anniversary in Chicago. Over the weekend I was surrounded by surgeons and cancer surgeons and lawyers, all great folks, but all with a common connection to each other through academics, prestigious Universities and family position.

It is this high status group that is most favored in medical and professional school admissions, clearly in GB and Canada studies, and strongly implicated in the US from a variety of different indirect studies. Income, higher education levels, and professional families are closely connected with this high status. There is nothing wrong with high status and becoming a physician, as long as such physicians realize that they will have to do more to understand the need of most of the nation that have not had the advantages that they have. This is a difficult task, particularly for medical leaders who often move right up into leadership positions before they have ever learned this important lesson. Those who have captured this throughout their lives can be inspiring. Those who have not can be repressive.

Social Status and Prep for Med School

There is no doubt in my mind that there will be great and growing divisions in any nation that does not address this issue, for physicians, for teachers, and for all young professionals. One of the major questions of this or any nation is:

How do we level the playing field?

Many and perhaps most would rather not deal with this at all. For some this would mean a complete leveling. Most who think about it at all are in the middle somewhere. Some would want just enough effort to prevent instability and "insulate" the higher levels from problems. In the US, our default policy comes closest to this latter phrase. With efforts in legal, education, social, insurance, health and other areas coming far enough to insulate, but not much more.

A true effort to resolve this involves many professions, but we are involved in one particular profession that has a key role to play in society, mobility, etc. As family physicians, we are intimately involved in health and education, perhaps the two key modifiable areas involving social mobility. Access, quality, and cost of young professionals are a key factor and we are a part of picking them for the nation.

We are also dependent upon education. My studies in the US note that state education opportunity is a key variable. Choice of Family Medicine: Past, Present, Future  States with better education graduate more family physicians. There are certain states that have little chance of graduating family physicians, particularly from rural and inner city areas. Short and Sweet on Education and Med Ed

Although there are FP docs who have advantaged origins (the massive numbers favor this), the percentages choosing FP are much lower from this group. The Asian group is a fascinating group to study directly and indirectly. Asians have more uniformly high status in the US and in Great Britain (Indian, Pakistani, Chinese, Korean). The studies above in BMJ note the higher ratios of admissions of Asians. In the US the Asians group has grown from 400 to 4000 admissions a year. In the US, only 5 - 8% of Asians choosing FP, about half or less the rate of other students. Whites in the US are mostly urban and advantaged, but about 20% are rural and there is a mix of older and instate, which makes the data and status indicators more difficult to study without individual student data on income and education. Such students tend to have lower MCAT scores and are admitted in lower ratios.

Good studies in the US in this area do not exist. The best studies that we have in the US involve The Minorities in Medicine studies X - XII by the AAMC.

https://services.aamc.org/Publications/index.cfm?fuseaction=Product.displayForm&prd_id=89&prv_id=87&CFID=158704&CFTOKEN=1b99223-c39af4b0-8bdb-4e2f-9f83-c10a0f04b40b

Now the US is planning for expansion of physicians. Currently the US population will increase 63% from 1970 - 2020, schoolteachers will increase by 64%, family physicians by 56%, and total US physicians are already estimated to increase to 270% before this new expansion. When US physicians doubled during 1970 - 1981, the group admitted was entirely urban. The probability of both rural and minority students getting admitted to medical school dropped precipitously. It is likely that massive rapid expansions allow only those of high status to respond. Lower status and education sources take more time. The prospect of rapid expansion without a few years to bolster rural and inner city education is concerning.   

For US rural workforce predictions see my effort at

Rural Workforce and Health Policy in the United States

Points for Discussion:

Studies involving status, income, educational background, parent profession and income are key to understanding admission, especially admissions of more who will choose FP.

Instate, older, and rural origin admissions are probably markers for lower status, and as such it is not a surprise that such origins predict FP choice at 55 - 300% increases. Sadly instate and rural origin is declining, by 17% and 47%, in the past 25 years. The bright spot of FP admissions, older students, are increasing at a very slow rate. Ratios of admission of older and rural students are much lower than other students.

It was easier to see how the MCAT with high correlations to urban, professional family, income has become a symbol of admission and of my concerns regarding admissions. MCAT Correlations

Those of us in family medicine work in a group whose very survival depends upon social mobility in this nation. To have more family physicians we depend upon efforts to improve education at the very lowest levels. In my regressions of all other major physician specialties, state education opportunity variables correlated only with family medicine.

Admissions of those from any group other than the top social status is likely to improve the graduation of family physicians.

There is one other area that is important to consider. How do we address the tendency of those of higher status to dominate leadership positions? Clearly we have leadership that is out of touch with the reality of primary care, family medicine, and underserved communities. Again it is the role of rural medical educators and rural physicians to continue to educate our leaders and drag them out with us on trips and visits.

There is also a concern regarding family medicine leadership. Do we fail to educate them, keep them in contact with rural and underserved needs, or allow them to take control when it is obvious that they do not understand and might never? Just because someone appears comfortable with leadership and often pursues it, does not mean that they will be the best leader.

One would hope that all leaders would understand their membership, origins, groups, etc., even those who have come from higher social status.

However leadership in such a group as family medicine is a major challenge. If we have leadership in programs, departments, associations, boards, groups, committees, etc., that involves those who are less aware of how much FP depends upon breadth of status and culture, it may be difficult for Family Medicine to understand the decisions that must be made to insure our future. In such situations, can our leadership make the tough decisions that would separate them from colleagues of similar origins and social status at the highest levels?

What I am seeing, and I hope others see it too, is that academics and intellect will not be enough. We must change education and medical school admissions, for FP and for our nation.

Again a final question from the perspective of the admissions committee member or student doing the interview or evaluation review:

When it boils down to a final consideration of admission of a student or not, with scores and grades and other indicators so similar, who gets in, someone like me, or someone different?

Robert C. Bowman, M.D.

[email protected]

See also Gender and Ethnicity in FP Graduates 1997, changes in Admission of Minorities and declines in minority choice of FP may also reflect social status changes in admissions.

Please notify me if you want any of your emails posted to the group on Admissions or RME group    Thanks.

Admissions and ORIGIN

Admissions Package

Admissions Summary

When "Weaker" Is Better

www.ruralmedicaleducation.org

A Response from Australia

How very interesting to see your medical school stats.  We show very similar student demographics in Western Australia, though socioeconomic status, farming or rural background and taxable incomes of farmers are a very thorny issue round here!  Interestingly, local research shows that students in the earliest years of medical school show the least amounts of prejudice against aboriginal and disadvantaged patients, and seem to become progressively more prejudiced and occasionally snobby as the years in the teaching hospitals go on. Thank God for GP placements, I say!  Keep them all human!

In Western Australia, about 40% the medical school population is of Asian origin, mostly south-east Asian [Chinese, Indonesian, Malay, Singaporean] This has made for interesting cultural diversity at med school, though the Asian students are also mostly in the higher tiers of the SES ladder. However, their backgrounds are overwhelmingly urban, and we have only small numbers interested in rural careers, or indeed in GP careers.  Very status-conscious, and incredibly sensible of the honourable profession of medicine.  Huge family pressures.  [Being married to a Singaporean who is sensibly NOT a doctor, I can tell you that one of the most telling reason for the acceptant of a non-Chinese girl into the family was that I was a doctor.  At least it guaranteed a gold star from the grandmother!]

One of the reasons our aboriginal people find it hard to do well at school and get into professional careers is also socioeconomic status.  They are really behind the 8-ball, often poor, chronically ill, unsettled, with loads of relatives arriving and needing care and food and a bed every time they think they can get ahead.  The kids are especially prone to ear disease, and if they can't hear they can't learn.  There is usually a lot of noise and laughter [and occasionally a lot of screaming and violence] in the home, with nowhere to study and no great value placed on book learning.  It will take Australia another 5 generations to bridge some of these gaps and for aboriginal people to be visible in all strata of life and in all professions at all levels.

Mind you, the med school now makes life financially easier for rural students, so perhaps there will be some assistance for the struggling ones as well.  Rural students have access to scholarships and grants and subsidies that the urban poor can only dream of.  I certainly remember the med school assuming things like access to a car [had a pushbike] and ability to get round to various hospitals and clinics as much as 30km away from each other, within an hour.  And then be presentable to see patients.  I remember having to sell treasured jewelry to pay for a stethoscope.  And having to write IOUs to my pensioner parents for book bills at the start of the year. Not having the $10 to join a student club.  not being able to go to the end-of-uni camp because I couldn't afford the $40 deposit, let alone the $200 fee.  there must be loads of students out there with problems like this, only they often don't get seen.  How can the university identify them if it doesn't even consider that they might exist?

Some of us are keeping an eye out for them.  They can be spotted, usually because of the late hours they keep working at one or even 2 jobs to keep on keeping on.  In a car-friendly place like WA, they get off the bus or the bike.  They need some encouragement.  Or we'll end up with a med school full of the western suburbs types who are the children of medics and our gene pool is going to become....

I am pleased to report that I'm just as poor, but now it's due to the fact that I own an elderly and tax-deductible aeroplane and spend my time doing rural clinics.  Better than the pushbike any day.  i don't live in the western suburbs.  [In WA, this is the desirable coastal strip.  But way too far from the airport]

Cheers,

Olga Ward

Western Australia