Robert C. Bowman, M.D.
Abstract
The characteristics of physicians graduating from medical school are important for the nation. Medical schools represent a wide variety of locations, missions, and other characteristics. These characteristics can be used to predict workforce. The specialty, location, and career choices of physicians graduating from medical schools can be predicted based upon characteristics known at admissions and before. Some of the workforce outcomes most predictable include careers in research, choice of family medicine and general practice, and choice of rural location. Medical schools must work harder to understand the origins of students and the many influences prior to admissions so that they can understand the career decisions of their graduates.
See summarized predictors at FPs Are Different Table
Introduction
Many studies have involved predictions of US physician workforce. Most have concentrated on medical school curricula and environments. Major concerns have been raised about practice and reimbursement issues. Much less is known about the influences before medical school leading up to admissions.
Previous studies by the author have involved birth origin studies using the AMA masterfile Variables in the Medical School Database, probability of admission based on rural or urban origin Probability of admission tables, and the choice of family medicine and primary care using linear regressions. Choice of Family Medicine: Past, Present, Future
There are clear associations between characteristics of students and the graduation of certain types of physicians.
Methods
The AMA masterfile involves a variety of characteristics that are relevant to admissions committees that are readily available. These include age and birth origin. Other characteristics such as longitude, state education influences, instate admissions, and ethnicity can be important.
Population: Typical Allopathic US medical schools
Atypical allopathic medical schools were excluded, leaving 113. Atypical medical schools included schools in Puerto Rico, the military school, osteopathic schools (incomplete data on primary care choice), schools with mergers, schools too new for graduates, schools with an atypical mission (Howard, Meharry, Morehouse, Drew, Duluth, Mercer), and those impacted by atypical mission or design (U of MN impacted by Duluth and 6 year design of U of MO Kansas City).
The regression was weighted by % non-metro pop of the state and analyzed with SPSS 12.
Dependent variables
The percentage of each medical school graduating in each major specialty was ascertained from the AMA Masterfile for 1994 -2000 graduates.
Results
Discussion
This study is not about individual physician decisions. It is about the "decisions" of medical schools in a number of areas over many years and involving many characteristics. These result in variation in the graduates.
The most pressing application of this research involves the tendency in our medical schools to believe that they are the "cause" of physician choices, through brief influences in medical school. Certainly there are many specialties that show little impact of pre-admission characteristics, but there are clearly some careers that are impacted.
As Flexner noted before, the qualities of those entering medical school resulted in qualities of the physicians graduated. The primary concern of medical education 100 years ago was improving the quality of physicians, particularly their academic preparation. The primary concern of medical educators today remains the quality of medical education, but there is evidence that a focus on academics, and particularly speeded intellect testing, is distorting US workforce toward certain specialties and research and away from primary care and family medicine. Numerous challenges regarding the quality of teaching may also drive students away from the more complex and challenging specialties, such as primary care, psychiatry, and obstetrics. This is a serious problem for the nation given numerous studies linking primary care and family medicine to cost, quality, and access.
The same trends toward admissions of more with speeded intellect, less age, more urban sophistication, and higher social status may conspire to reduce the numbers and distribution of physicians most responsible for access to prenatal care and mental health care and care to underserved populations. Older students and rural students are admitted in lower ratios for a variety of reasons, including slightly lower MCAT scores. This should be reconsidered by a nation in need of physicians for the front lines.
Family medicine appears to be uniquely associated with a variety of characteristics that are lower priority for admissions, including MCAT scores, those born rural, those born instate, and those not Asian or urban. The MCAT bioscience score is up 1 point in the past decade, rural born students are down 47% in the past 20 years, instate born admissions are down 17% in 20 years, and the increasing numbers of Asian students (from 400 to 40000) choose FP at 3 - 5 % rates. This is more than enough to explain a declining match without the contributions of longitude (fewer FP in the east), and state education (more FP from states with higher state college continuation rates). See predictions of FP "match" based on background and ethnicity (social status)
The strength of this study is its national scope and the unique application of birth origin data.
The limitations of this study are great and involve the use of data not involving the 1994 - 2000 cohort. Because of this, the relevance to individual schools is limited.
The best application of this research is for medical schools to internally and externally evaluate themselves. This should include much more emphasis on the environments of their students before admission and the choices of their physicians after graduation.
Medical school expansions based on the current admissions priorities will only distort physician workforce further. Admissions during medical school expansion were students born in the most urban codes 1 and 2 in the nation.
Medical school expansions that "remedy" the defects of current admissions would be the only acceptable method of expansion. Expansions should involve replications of proven models that have been ignored and can assure national leaders that we can meet the needs of the nation and underserved areas.
Emphasis on education would likely also increase the choice of primary care and also improve the graduation rate of researchers.
Emphasis on older student admissions could improve the physicians serving on important front lines in health care, including psychiatry, family medicine, and emergency medicine.
The tendencies of older students to choose specialties that involve a more complex integration of behavioral, social, and science should be noted. It may be that maturation and versatility are key characteristics that allow medical students to pursue specialties that challenge in multiple dimensions. This may also be true in the financial and legal aspects of medicine, where multidimensional problem solving is greatly needed.
For an excellent discussion of 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
Side Effects of Selecting for Family Medicine
Medicine, Education, and Social Status
