Admissions Ratios, Changing Admissions, and Physician Distribution

Robert C. Bowman, M.D.

Seven years of recent graduates of allopathic medical schools in the United States from 1994 to 2000 were compared to the seven years of population who were 18 to 24 year olds in the 2000 census. This was a group approximately the same age as medical students. The study gives a population-based estimate of access to education and medical education in the United States. The student types were ranked from highest to lowest levels of admission with the average being about one allopathic medical student for every 200 citizens or residents in the population at large.

Family medicine choice for the same class years was compared to the total medical students. The choice of family medicine at this time period was maximal as influenced by managed care and health reform. (managed care) Choice of family medicine has declined by 50% compared to these years. Recent trends in admission were included for comparison purposes.

Shaded cells indicate groups with the highest levels of distribution to rural or to underserved areas, those with lower probability of admission and stable or declining admissions. The data on medical students by ethnicity and race is from Association of American Medical Colleges matriculants.  All other data is from the Birth Origins database derived from the American Medical Association Masterfile. Income quintile choice of family medicine was estimated using birth county income and population density levels divided into 5 equal segments.

Those most likely to gain admission are the medical students with the most urban origins born to families with the highest levels of income, education, and professional degree. Those most likely to choose family medicine and to distribute where they are most needed are being steadily replaced by those least likely in a process lasting over 20 years with dramatic changes from 1997 - 2001.

Family medicine is a choice of lower and middle income students and those who are first generation in their family to college. Family medicine is a less likely choice for graduates of the most eastern schools and older medical schools and those with the most non-distributional medical students. Elite students are the youngest and most urban students and have parents with the highest levels of income, college education, or professional degree. Elite students have consistently the highest standardized test scores at all levels of education. These do reflect academics but also are a reflection of socioeconomics, urban origin, education access, and advantages in verbal ability from the earliest ages. Humble origin students depend upon state and local education and most had to overcome significant obstacles of income and education and other differences to gain admission. The losses of humble origin students indicate major education problems in the nation and indicate increasing inequities in education and health access in the future. States and cities that concentrate income and education deny education access to the most likely to choose careers as serving professionals and tend to maximize admissions of the most elite. (Bright Future Rankings)

The medical schools with the highest Medical College Admission Test scores are the ones that have the fewest different or humble origins types of students, those who are lower and middle income, older, or rural born. They graduate few family physicians, rural physicians, or physicians that locate in underserved areas. (Distributional Medical Schools) Over 80% of elite students by origins, youngest age, or type of medical school practice in major medical centers locations just like the locations where they were born, raised, educated, and trained. The distribution in this group will remain minimal. Populations with more humble origin student types have the least major medical center origins and become physicians that tend to avoid major medical centers in career and location choice however their greater geographic, cultural, and socioeconomic distance from medical schools is punishing in terms of access to education, college, and medical education.

The task of distribution is made easier by education investment sufficient to present admissions committees with a significant number of dedicated, mature, and qualified candidates that are also of all income origins that also have interest in family medicine, and that also have plans to distribute to locations and populations where physicians are most needed. The task of admission for distribution is made more difficult by

1. Poor quality education and poor distribution of education resources to lower and middle income populations
2. Poor public support of college positions, funding, and college student funding
3. Inappropriate uses of standardized tests without consideration of all of the various differences measured
4. States and medical schools that have few available public supported or instate medical school positions
5. Policies that favor admissions of the students of professionals or alumni
6. Standardized tests and test preparation that favor students who have the most exposure to computers and technology and the most income
7. Poor cooperation between medical schools, education, and colleges at the state and federal levels
8. Medical schools admitting more out of state or foreign born students rather than working to stimulate better education and preparation within their states.
9. Poor emphasis on family medicine in medical education
10. Poor health care coverage of the middle and lower income patients cared for by family physicians

Changes in admissions and changes in health policy do not favor the distribution of physicians in the United States in coming years. Health policy makes it difficult to retain any in primary care in careers favorable to rural and underserved location. (Primary Care Retention, Managed Care and Choice of FP, Managed Care Comparison Table,  Distributional Medical Schools) Increases in student urban and foreign born origins, student income levels, and school MCAT scores predict declining choice of rural and underserved practice. Changes in Admissions

The studies that demonstrate that medical school expansions will improve economics are certainly correct, however most of the nation beyond major medical centers will be left out of this impact. The current expansion will also bypass the medical students most needed for distribution. In the past expansion the most urban born students increased with little change in rural born, lower income, and minority student admissions. Medical students who were born, raised, educated, and trained in or near major medical centers have parents who build their pipeline to a medical career. Not surprisingly these origins drive the students to choose subspecialty careers and return to major medical center locations. The pipeline for the distributional students is public education and state support for college and medical school. Expansion without prior investment in education and health policy will only concentrate physicians in high income urban areas and major medical centers.

Distribution of physicians and other professionals will require a different approach to education, to college, to admissions, to training, and to health policy. Most of all it will require the participation of the American people, all of the American people.  

Physician Workforce Studies

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