In
his JAMA “Viewpoint” article, “Social Mission in Health Professions
Education: Beyond Flexner”,[1] June 17, 2017,
Fitzhugh Mullan makes a convincing case for medical schools to be committed to
their social mission. He takes his definition from the “Beyond Flexner” website
(www.beyondflexner.org), which says
“Social mission is about making health not only better but fairer—more just,
reliable, and universal”. He details what this means in terms of commitment to
reducing health disparities, increasing access to healthcare in both rural and
urban underserved communities, increasing diversity within the health
professions. These serious issues have been identified for decades, but in fact
the trend may be toward getting worse instead of better.
Mullan
cites some examples of medical schools, primarily newer and “community based”
schools, that are working toward these goals. These include Morehouse and
Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982
respectively), those of a more recent expansion in the 2000s (Florida
International University and the AT Still Mesa Campus), and those yet to come
(the merger of Geisinger Health System and Commonwealth University, Kaiser
Permanente School). But he also talks about “mainstreaming”, the need for
consciousness about, and implementation of, social mission to be a
characteristic of all medical schools.
I
believe that the most important measures of a health professions school’s
social mission are its outputs. Using the 3 criteria identified by Mullan and
colleagues in their seminal 2010 Annals
of Internal Medicine article “The social mission of medical education:
ranking the schools”,[2] we need
to look at whether its graduates are more diverse, whether they practice in
underserved areas, and whether they are more likely to be in primary care
specialties. The 2010 article showed that some schools do better -- more often
those that are public, newer, and not in the Northeast -- but the fact is that
none is doing all that well.
The
number of students entering primary care is a critical indicator because, based
on national and international comparisons, a well-functioning health system
should have 40-50% of physicians should be in primary care; the US is well
below 30% and going down. Family medicine match rates are the most sensitive
indicators of primary care production, because unlike internal medicine virtually
all family physicians practice primary care, so a choice of this specialty
means a commitment to primary care. In addition, it is the specialty most
suited for practice in rural areas. Even if all schools consistently produced
50% primary care physicians, it would take at least a generation to get to that
number for all physicians in practice, and we are far, far from this.
In
2012 John Delzell and I looked at 10 years of data (2002-2011) published
annually on the family medicine match by the American Academy of Family
Physicians (AAFP) documenting the number and percent of students from each
medical school entering family medicine.[3] We found
only a few schools that were relatively high in both number and percent, with
the University of Minnesota and the University of Kansas far ahead of the rest.
And yet even those schools do not produce primary care physicians at the 50%
rate. In the most recent AAFP report, on 2015 graduates,[4] even the
“socially conscious” schools cited by Mullan did not have very high numbers
matching in family medicine: Morehouse 8
(12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the
largest number in the nation, but still had 20 fewer than it did in 1999! In
1994, the Association of American Medical Colleges (AAMC) announced Project
3000 by 2000, aiming for 3000 minority medical students into US schools by the
year 2000[5]. It
failed. Today, in 2016-17, we are not only far from that number, but the
percent of many minorities (especially African-American men) continues to drop.[6]
As
in any process, the results of medical (and all health professions) education
are affected by 3 sets of variables. Input
variables are the students enrolled,
process variables include the curriculum and overall experience of students
during their education, and output
variables are the expectations of what the income and life experience of a
graduate is likely to be. While the last is probably the most important
determinant, especially given the degree of debt with which students are
graduating and the fact that many specialists can earn 2-3 (or more) times as
much as a primary care physician, it is also the area that schools have the
least ability to influence. As Mullan and colleagues have emphasized, medical
schools can influence the process variables, including the school’s vision and
mission, the teaching of social mission, determinants of health, disparities,
and other areas in their classrooms and clinics, experiences for students to
serve such as free clinics, and mentoring and role modeling by faculty.
However, making these changes seem to be insufficient to overcome the negative
influence of the output variables in terms of students choosing primary care
and practice in underserved areas. At least for most of the students currently
in medical school.
Which
brings us to the input variable: who is admitted? Clearly, from the data cited
above, medical schools are not taking appreciable numbers of students from underrepresented
minority groups, from rural areas, or from lower socioeconomic groups, at least
not in anything close to the proportion in the population. They take, on the
whole, white (and Asian) students from well-to-do suburbs of large cities who,
not coincidentally, went to the “best” public and private schools and have the
highest grades and Medical College Admissions Test (MCAT) scores. The problem
for the health of the American people is that the strongest predictor of where
a medical student will practice is where they come from; minority students are
far more likely to practice in minority neighborhoods, rural students are far
more likely to practice in rural areas, and white upper middle class students
from the suburbs are more likely to practice in the suburbs. These are the
areas that already have enough physicians (and sometimes too many). In a real
sense, a physician who enters practice in a non-underserved area in a
non-shortage specialty is contributing little marginal benefit to the health of
the American people. The imbalance of physicians practicing in health
professions shortage areas (HPSAs) vs other areas is demonstrated in the
attached table from Zhang, et al.[7]
And,
most importantly, these changes and programs must happen at all medical schools
and for the bulk of the classes. The time for experiments and pilot programs is
done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”.
And now is not too soon.
[1]
Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286
[2] Mullan F, Chen
C, Petterson S, Kolsky G, Spagnola
M. The social mission of medical
education: ranking the schools. Ann
Intern Med. 2010;152(12):804-811
[3] Freeman J, Delzell J, Medical School
Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med
2012;44(9):613-4.
[4]
Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School
Graduates Into Family Medicine Residencies: 2015–2016, Fam Med
2016;48(9):688-95, (online Table A).
[5]
Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic
Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18,
1994DOI: 10.1056/NEJM199408183310712
[6] https://www.aamc.org/data/facts/
[7]
Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA,
Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008
May 15;77(10):1378.