Sunday, December 14, 2008

Medical Student Selection

The US has great health disparities, and reducing them is a major component of the federal government’s Healthy People 2010 goals. We have spoken earlier about the fact that many people lack of access to quality care, most often because of lack of health insurance, adequate health insurance, or availability of health providers in their area. Doctors do not locate in areas that are already underserved, rural and inner city, but rather overwhelmingly choose to locate in already well-served areas, particularly in suburbs and the wealthier portions of cities. Julian Tudor Hart, the British physician and epidemiologist, called this the “inverse care rule”: the availability of health care is inversely proportional to the need for it.[1] The previous entry (Dec 11, 2008) addressed the issue of the need for a primary care infrastructure as the bedrock of any quality health system, and also noted that medical students are not entering the primary care specialties. Beyond the overall need for primary care in the society as a whole, it is obvious that rural areas require almost exclusively primary care, and primarily family medicine, physicians.

Given the decrease in interest among medical students in entering primary care careers, the existing health disparities are only likely to increase. I noted that the 20% of the US population that lives in rural areas has only 9% of physicians, but fewer than 3% of medical students are planning practice in rural areas. Even among the decreasing number of students entering primary care training, most come from the urban and suburban areas surrounding what Dr. Robert Bowman calls “major medical centers”, and are used to the life and lifestyle available in those settings. Moreover, even an individual student from a rural area who is otherwise interested in rural primary care practice, may find that the background or work requirements of their spouse or partner precludes a rural location.

The market affects specialty choice by medical students in terms of income; specialties with higher incomes are more in demand by students, increasingly so as medical student debt climbs to $200,000 or more. It is estimated that an anesthesiologist, for example, can (at current reimbursement rates) expect to make $7 million more in his/her career than a family physician, so we’re talking real money. The market is not so good, however, at diffusing physicians. More than for many professions, in medicine, and especially medical subspecialties, supply leads demand. Thus, while the suburbs of a large city may have plenty of X-ologists based on any estimate of need, one more is likely to do just fine financially, generating a comfortable standard of living for his/her family, pride from his/her parents, and maybe even great personal satisfaction; s/he will not, however, have a significant impact on overall population health, or make a dent in the health disparities that exist.

In any process of creating a product (and, with apologies, in this sense medical students can be seen as a “product”) the determinants of outcome (in this case which specialties students enter) will be affected by three variables: input variables (who we take into medical school), process variables (what is the curriculum, and the overall experience in medical school), and output variables (what is the practice environment like, especially reimbursement). If the latter is the most important, it is also the one that medical schools have the least control over. Changes certainly need to be made in the process, the experience in medical school, so that students do not hear messages that the more sub-specialized you are the “better” you are – or the ironic dual messages “You’re too smart to be a family doctor,” and “You have to know too much about too many things to be a generalist!”. But medical schools also need to look carefully at who is admitted. We actually know what characteristics are more associated with students entering primary care and underserved practice. These fall into demographic characteristics and individual characteristics.

Demographic characteristics distinguish between populations. The evidence is clear that students who enter primary care and underserved practice are more likely to be from rural areas, under-represented minority groups, and families with lower incomes, as well as to be older. They are also, unsurprisingly, as a group likely to have lower grades, come from “lower status” colleges, and have lower scores on the Medical College Admission Test (MCAT). Thus, using MCAT scores and grades as the main criteria for the selection of medical students will select a cohort of students less likely to practice in the sorts of specialties and areas where there is the most need. I would argue that schools should identify a threshold level of MCAT score above which students rarely if ever fail out of medical school, accept students with scores above that, but not otherwise use it for ranking (i.e., if the cutoff is, say 28, then 32 is not “better” than 30, in terms of making admissions decisions).

There are, of course, individual characteristics as well. Some students from wealthy families, from majority groups, from the suburbs, with high grades, will become primary care physicians and care for the underserved. But, in entering medical school, this cannot be assessed by an essay, or even an interview. The most reliable indicator of future behavior is past behavior; the student who says s/he wants to care for the underserved needs to demonstrate a past history of action; if they have been in the Peace Corps, or VISTA, or Teach for America, or helped start a free clinic or a rape crisis center in college, they are much more likely to actually serve the underserved in the future.

Of course, there is resistance to changing admissions criteria. Many say that it is “lowering standards”. This is only true if one assumes that grades and scores on tests such as the MCAT are the best measure of who will become the best doctor. They are not. In addition to not predicting who will meet society’s needs, they do not even predict performance in the clinical curriculum. (They do better in predicting performance in the pre-clinical, or basic science curriculum, where students mainly sit in class and are assessed by short answer tests measuring recall of facts. Surprise.)

In fact, if we continue to use the same criteria to accept students that we always have, we are likely to continue to produce the same doctors that we always have: smart, competent, and not practicing in the areas of greatest need and thus not likely to reduce health disparities. Paul Bataldan has famously said “Every system is perfectly designed to get the results that it gets,” and we know what the results that we get from our current selection system are. Albert Einstein is credited with saying “The definition of insanity is doing the same thing over and over again and expecting different results.”

Let us not be insane, and do what is needed to be done to meet the health care needs of all of our people.

[1] Tudor Hart, Julian, “Three decades of the inverse care law”, Br Med J, 2000 Jan 1;320(7226):15-8.

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