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
The following study by Madison gives an inkling of what could happen if a school made such a determination.
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:
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 GQ 1995, data comparing rural interested students vs their peers).
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
Mother Theresa Servant to the Underserved
Back to main rural med ed web site
From the perspective of service to the underserved, it would be preferable to admit minorities generally, as they are 4 times more likely to choose underserved locations. This is clearly a good choice for inner city poverty locations. Minorities except for blacks are far less likely to choose rural locations. From a rural underserved standpoint, few Asians and Hispanics choose such locations. It is clear that there are successful programs that will allow more minorities and rural people to be admitted, but these programs do not have the support that they need. Preparing Underrepresented Minorities for Rural Health Careers 2001 http://www.nrharural.org/dc/issuepapers/ipaper18.html
One of the reasons for the Title VII (federal primary care med ed funding) debates is the lack of demonstrated success in graduating physicians that will serve underserved areas. See Title VII concerns also Title VII Funding Caution
