See also Medicine, Education, and Social Status for more data and tables and graphics
Also Side Effects of Selecting for Family Medicine
The last year has been a journey for family medicine as a discipline, and for me in a personal 1600 hour obsession with choice of physicians for underserved areas. This started with rural areas, moved to family medicine, and now extends to primary care and all underserved areas and populations.
The focus of this page is family medicine. We are bombarded by a variety of concerns regarding family medicine. We have begun to organize responses. Recent efforts have focused on how to "market" family medicine. We have also continued to attempt to explain to the nation, to medical schools, and to government why we are important to the nation, in care, in outcomes, and in distribution. Graham Center Articles and One Pagers. However we tend to neglect the major difference that we have with other physicians and most other providers. This should be clear in our name itself, which speaks volumes about the "family" role that we often provide to patients. This is not understanding and applying family systems, but in a sense "becoming" a part of the family, limited by time and
Family medicine is not what we practice, but who we are, and this makes all the difference.
I. Family physicians are definitely not as young as medical students go.
The percentage of students choosing family medicine increases with every year of increase in age at the time of graduation from medical school. Only 10% of medical students graduating at age 25 chose family medicine, age 28 at 15%, age 32 at 20% and maxing out at 36 % of those graduating in their 40s.
Is this maturity? Does this mean those who approach medicine as a second career choose family medicine because of what they have experienced in life? Do older students represent those who have overcome adversity in income, education, status, and more, and therefore are students who are different and make different choices? Likely all of the above and more. Why would students later in life choose a medical career that results in the least income, when they have debts and families and a shorter medical career? Call it character, term it "a calling," or perhaps family medicine merely is an extension of who FP docs are as people and what they want to accomplish. In just about every nation except America, older is associated with respect and wisdom, why not America?
There are only two other groups that have similar older statistics and these are psychiatry and emergency medicine, and both share the front lines in patient care. More versatility needed perhaps, more willingness to deal with uncertainty, more confidence? Surgery, surgery subspecialties, and medicine subspecialties tend to attract students who are younger at graduation. See tables on age and specialty choice with linked version.
II. Family physicians do tend to come from "different" locations.
Most understand the connections between rural origin and FP. Some do not realize this extends to those not born in the most urban areas of the nation. See Rural Birth Origin tables. Family physicians have different characteristics that are available to admissions committees. Career Predictors Table
Family physicians also don't tend to come from out of state locations. Those who were born in the same state as the medical school they attend choose family medicine 17% as compared to 11%, instate rates by school are 30 - 70% higher than those from out of state. It might be that they are "connected" and this connectedness defines who they are, what they will choose, what kind of medicine they will practice, and where they will locate - and what kind of value that they can return to a state or communities in most need of economics, services, health access and support of health facilities and systems. Students facing challenging education and lack of social status may be particularly punished by lack of instate admission opportunities. This can be made worse by education declines decades old in this nation, particularly in low income areas. Why should students be punished just because of where they were born and who their parents were? More importantly why do leaders in state government tolerate the continual growth in numbers and percentage of out of state students? Why do state and national leaders fail to mobilize the Full Potential of Osteopathic Schools with Instate Admissions, with the only growth associated with out of state status? Only two types of schools come close to 50% family medicine graduation rates. These include the Duluth two year model with entirely rural FP admissions and the public osteopathic medical schools. Where are our wise leaders, the ones who are looking for solutions to maldistribution of health and education resources?
III. Family physicians are definitely not "high society."
Family physicians are not high socioeconomic status in education and parent. They are less likely to be children of professional, high income, and highly educated parents. They have origins just like the regular people that they serve. They are from a broader range of people types, as a result they understand the people and their needs, and they serve the people. Service-orientation is also a part of who they are. Take your pick, rural, older, instate, inner city, lower performing in tests, family medicine is just more connected to a broader range of status types in the nation, whether that is socioeconomic status, health status, or education. Perhaps more importantly for states and the nation, this means they choose to serve underserved, rural, and lower status populations in far greater numbers. This is not a matter of choice, it is who family physicians are and where they came from, and perhaps more importantly, what they have learned long before they were called "medical student." Those consistently most educated and highest income in origin, choose family medicine at the lowest levels (Asian, professional family, most urban, highest educated). This is also the group that is most likely to be admitted to medical school in the US, in Canada, and in Great Britain. Admissions and Social Status Barriers To Entry There is, however a problem. Since family medicine has a different emphasis, often those of higher status do not seem to understand this or why family medicine is important. Sadly this often includes leaders in medical education who could be far more effective if they did more than "tolerate" this critically important discipline. This prevents the fulfillment of family medicine, and effective and efficient and better distributed health care.
"And now they've raised five children/One winter they lost a son/But the pain didn’t leave them crippled/And the scars have made them strong/Never picture perfect/Just a plain man and his Wife/Who somehow knew the value/Of hard work good love and real life." Rich Mullins
IV. No other discipline is so dependent upon state and government efforts, and not only in health, but also in education.
The lower status, rural, and inner city origins of Family Physicians makes them dependent on state education, particularly in such locations. In more recent years these education areas have had the most difficult challenges. Family medicine origins involve students of low status, those of humble family origins rising up in status, and those who have seen the abuses of status and intolerance and want to make a difference. The educational influences on all of these groups are significant. States with better state education opportunity graduate more family physicians. This is not just high school graduation, it takes higher college continuation rates. It is not emphasis on the gifted that matters, it is a broader education approach. It is not just suburbs, but inner city and rural education and those with lower socioeconomic origins, all major sources of family physicians. With better education breadth, better graduation rates, and better investment in education then a state does graduate more family physicians. In other words, better state education opportunity means more family physicians, and of course much more than family medicine outcomes for a state as well, including lower health care and legal costs, better access, more prevention of health care problems. If schools do poorly, there is also impact on those of higher status and income. Those with means take their kids out of the wealth of experiences that would provide critical development to those who have access to anything that they want. The relationship between health and education and family medicine can result in accelerating cycles of improvement or decline. If health care costs go up and erode state education, then there are less family physicians and higher health care costs and …. If states invest in education, there are more family physicians and lower health care costs, for a variety of reasons related to education and family medicine. No state (or nation) can sit this fence, they move one way or another, and faster and faster over time. See also Segment on Priority on Education
"You can bend the rules plenty once you get upstairs but not while you're trying to get there and if you're someone like me you can't get there without bending the rules." Tess McGill played by Melanie Griffith, Screenplay by Kevin Wade, Directed by Mike Nichols. Promotional Line for the movie: "For anyone who's ever won. For anyone who's ever lost. And for everyone who's still in there trying."
V. MCAT and Family Medicine
Now since we know about the education, rural, and status connections, perhaps it is time to deal with a major societal indicator of education, family origin, and urban location, the Medical College Admission test. See MCAT Correlations at links. Family physicians are less likely to be the students with the highest Medical College Admission Test scores. No one gets into medical school that anyone would consider dumb, however family physicians (and primary care physicians) do not perform as well on the speeded intellect test that is the primary determinant of who gets an interview and most importantly, who is admitted. This may be that the FP type has a bit less test taking ability or it might just be the way FPs are wired. This may have more to do with breadth and relationships as compared to fast multiple choice answers. In any case, emphasis shifted away from the MCAT test means more family physicians, and office based internal medicine, and ob-gyn. This shift also usually results in a physician, FP or not, who is more versatile, practical, and patient-oriented and may just be more oriented toward medical teaching. Such a physician is less disease and cure-oriented, and more likely to be team- and process-oriented. Oh, how the nation needs even a few more of these in today's patient care. Test taking is connected to education, parent, and urban origin in many studies. As we rank students more and more based on the MCAT test and past attendance at elite colleges, it is not a surprise that we get fewer family physicians and more physicians who put a priority on intellect and disease, ones who grow frustrated with any patient or condition that does not fit with their "speeded" decision-making. Choice of Family Medicine: Past, Present, Future
Cohen Encourages Admissions to Look Beyond MCAT
The value of these "differences" is also difficult to measure.
Because family physicians are different, they also vary greatly from each other. Often family physicians have a position between cultures, languages, disciplines, and approaches to health, such as behavioral vs biomedical, or relationship vs procedural. Who else encompasses such a diversity of issues from access to abortions (and the opposing view) to the dignity of death. These differences are developed by the right kinds of medical education and health care experiences. This multiplies the utility of the backgrounds, the cultural origins, and the experiences to make family physicians so valuable in health care, planning, community development, education, and health systems. When medical education is retarded, then so is the development of these differences. See Medical Education Retardation The stellar outcomes of the Accelerated Family Medicine Training Programs is a direct result of addressing this medical education delay and "wimpiness." There are those who would try to convince us that it is the medical students who are growing more lifestyle oriented. However the evidence is just as great and growing, that the "lifestyle" career choices are the ones that students choose when they are not well oriented, prepared, or trained to the more intensive careers. Declines in teaching role, numbers of procedures, and a general loss of the sense of being a physician while in training as a student, resident, or even a fellow is a major problem.
Sadly for the nation and for the world, "different" is not popular with medical school admissions committees. Even with the proven potential of Superselection that allows admissions committees to shape the workforce of an entire state, "different" does not seem to matter. Rural, instate, lower status, and older are all admitted in less numbers and in lower ratios in relation to who applies. Even worse, the situation is about to deteriorate even more rapidly in any kind of expansion, without better education and admissions. Even the expansionists agree to the need for better K-12 in studies of workforce and in presentations (Cohen, Cooper, and Salzberg). Even though "different" is not popular now, it was even less popular in the US during the previous medical school expansion years impacting the graduates of 1970 - 1981. Probability of admission tables There is reason to believe that "different" students will be left behind again in any sort of rapid expansion of medical school positions. After all, K-12 education, small and community colleges, and students of less status have not had time to gear up for such an opportunity. There have been no changes in the cost of preparation, tuition, or support. In the past expansion, rural born students had even less probability of admission, moving from 70% chance compared to urban to less than 50% chance. In any coming rapid expansion without discipline, planning, and changes in national priorities, rural students could have even lower probability, moving from half the chance of admission to medical school compared to urban students to a third or lower. This is just as likely from lower economic status students. Even underrepresented minority students were left in the dust with the last expansion, with no improvements in numbers until they became a major national focus, and after the nation had reached current graduation numbers. This means they roughly had a 50% decline in admissions from 1970 - 1981 as well. Cost, Quality, Access, and Physician Workforce Expansion Don't believe that rural, older, and "different" students can respond, well they did in the post expansion years. Also you might remember what happened when elementary school students in inner city New York were guaranteed admission to college. If not, perhaps you need to read about teacher expectations less for black and Hispanic students, even when studies show black parents have some of the highest expectations of their kids in the land….. also you might study what family medicine graduates can achieve when they are accelerated in learning, regardless of origins or practice preferences. Success in Harlem
Family medicine is much more than a medical discipline. It is a way of life. It is about people of a certain set of characteristics that coalesce around fulfilling the potential of people,
It is no wonder that the bulk of medical students admitted, those who are less comfortable with "different," choose other careers. Until
Until then, we don't deserve family medicine.
Those who truly understand health care for a state or nation or continent, know we must do better in education, community health, public health, patient education, and more access to basic health services for those without. The service orientation, the character, the origins, the lack of sophistication, and the very being of family physicians makes FP the right choice until education is distributed so well that an entire population can integrate these critical lessons. Even then, patients will need someone that relates to them.
In summary, Family Physicians Are Not Better or Worse, at least in the way physicians are seen generally in the nation, but they are different. And for the United States and people across the planet, there is no other physician more needed, and therefore better for the Nation as a whole and particularly for those in most need of health care.
Right up there with schoolteachers and public servants, there are no better measures of the success of our nation in terms of education, social mobility, and reduction of hopelessness in our nation
than the choice of family physicians.
There is not a decline in family medicine because of politics, or medical school environments, or regulation. We have the selections, the models, the programs, the relationships, and the practices that can indeed make a difference, yet they are ignored. We have a decline of family medicine because we have had a decline as a nation. It will take the efforts of the nation, and states, to restore both, but again that is OK with us in FP, because of one reason. It is what we are all about: the process of facilitation and restoration. Just like our practitioners, we are in it for the long term and we are 100% for what is best for the nation.
We can choose different and help heal the nation and beyond, the question is, will we.
See also Medicine, Education, and Social Status for more data and tables and graphics
Robert C. Bowman, M.D.
Gender and Ethnicity in FP Graduates 1997 - 2003 grads
Increasing International FP Graduates
What is happening to key factors in admissions, older, rural, instate? See FPs Are Different Table
Can you predict the FP match with data from medical school matriculants, 4 years before the match?
Yes you can.
Except for 1994 - 2000, you can predict the match
Never, for exclusions based on status would be as intolerant as the current regime is ignorant.
Here is an example:
When a student comes in with incredible MCAT scores, admissions interviews center around the ability of students to relate to others. There should be no difference in the approach to those with high MCAT status as compared to those who have high social status. Do they relate well to others or has their status and upbringing hindered their development. At the heart of quality of care is the ability to care for others in the same way that you would desire to be treated. At the heart of being a top physician is being able to provide care with little or no regard to your own needs or situation, and total focus on what is best for the patient. Those students, high status or not, who have demonstrated that they can provide this kind of focus, this kind of versatility, this kind of willingness to develop in more than academics, is the kind of physician that we most need.
The same goes for admissions committees and chairs. They must strive, above all, to find these students. This is often difficult, since it often involves students who may be very different from them, and from very different origins.
Students of high status who have this versatility can add much to medical education and medicine. They often have leadership training and understand how to manage resources. They also have contacts that can facilitate much needed efforts in medicine, education, and other areas. Some of our best national leaders have been those of high social standing who had this versatility and devotion. Such leaders command respect from associations, groups, and nations.
A Century of Reform if this is what AAMC wants, then need to take care to admit the physicians that can actualize this plan.
Medical Schools and Restoration
Community Driven Approach: Linking Resources with True Needs