Who should we take in medical school? What should be the criteria? Who will be a good doctor?

There are many serious inequities in our society, and they tend to build upon one another. People with more advantages have more opportunities to do well themselves, and those with fewer have less. Those advantages (or, conversely, disadvantages) include wealth, white race, male  gender, suburban or urban (but not poor areas) location, and education. All these feed one another. For example, coming from a well-to-do family and being white dramatically increase the odds of success in a chosen field. Even if there were no discrimination against people based on race and color (and this is a long way from being true), there is still the fact that people of color are grossly over-represented in low-income communities and families. This is a clear example of structural racism, so that effective discrimination based on class disproportionately falls on people of color.

An important manifestation of this exists in healthcare, and in particular the production of healthcare professionals (but also in other professional fields). In medicine specifically, we have a physician workforce that does not reflect the population of the US in terms of class (or family income), race, gender (although this is the area in which the greatest progress has been and continues to be made), geographic location (rural vs. urban), and specialty choice. Our doctors overwhelmingly are from upper-middle-class backgrounds, are white, are from suburban (or well-to-do urban) communities, and largely male. They practice in urban and suburban areas in even greater proportion than they come from them, in part because they also practice in specialties and subspecialties that cannot survive in smaller communities, rather than in family medicine and other primary care specialties that are in shortage. This exacerbates the other inequities by making healthcare something that is less accessible to many Americans based on geography (where are the doctors located?) and culture, as well as because of cost, the absence of a universal affordable healthcare system being an almost uniquely American phenomenon.

Not having a medical workforce that looks like America, or practicing in the areas and specialties where there is most need, goes beyond the admissions process to medical school. It is impacted by the curriculum (both formal and informal, or “hidden”) in medical school, by role models and mentors, and very much by the potential income from practice. The systemic characteristics of society greatly influence who is considered a “good” candidate for medical school, and even who applies. These are considerations addressed in a recent blog post on LinkedIn®, a professional networking site, by Dr. Heidi Chumley, dean of the Ross University School of Medicine (RUSM). Dr. Chumley focuses on the challenges faced by students from backgrounds underrepresented in medicine (URiM), and in particular on the emphasis on performance on the Medical College Admission Test (MCAT) for deciding who gets into medical school, since URiM students perform less well on that test. She notes that what seems like a small difference in scores makes a significant difference in admission: “There remains an unexplained gap in average MCAT scores between White (503.1), Black (494.9), and LatinX (497.1) test-takers. This gap matters as 29% of applicants with a score of 502-505 are accepted compared to 10% with a score of 494-49.”

Dr. Chumley also address two other critical points. First, that the lower MCAT scores are likely tied to many of the social and educational disadvantages faced by URiM students, thus reflecting, and compounding, the other factors that these students have to overcome. Second, that efforts implemented by many medical schools (and endorsed by the Association of American Medical Colleges, AAMC) to have a more “holistic” admissions process mostly changes the selection of which high-scoring students are admitted. Yes, it is great that students who have a social conscience and have done volunteer work in the US and abroad are selected over those who are selfish and not so involved, but this rubric, as she points out, ignores the fact that many lower-income (and URiM) students need to work at paying jobs to support themselves (and often their families), and devalues such employment in comparison to the voluntarism that is more accessible to those from privileged backgrounds.

Added to this is the financial component of the cost of medical school itself, which, in the US and in the US (and Canadian) serving Caribbean medical schools (of which Ross is one of the largest and most prominent), is staggering. Students typically graduate from medical schools with debt loads of $250,000 or more. In addition to being outrageous to start with, add the fact that compound and accrued interest makes the total to be repaid much higher, and this encourages students to choose higher-paid specialties even when that is not where the greatest need is (you may make, over a lifetime, $7M more practicing as, say, an anesthesiologist compared to a primary care doctor) or even where the student’s personal interest lies.

Dr. Chumley describes some of the efforts to increase access for URiM students at RUSM, and they are indeed impressive. They include “pipeline” relationships with HBCUs (Historically Black Colleges and Universities) and HSIs (Hispanic-Serving Institutions) and  re-thinking what criteria for admission are essential, valuing the life experience (including work experience) of applicants and putting less emphasis on the absolute score students get on the MCATs. As she points out, the MCAT predicts performance on similar multiple-choice tests of knowledge including most “pre-clinical” tests in medical school, and the licensing exam, the USMLE (particularly Part I, which covers basic science). It definitely does not predict performance as a good or excellent clinician. Also, while there are significant differences in the first-time pass rates on USMLE in those who score “over-500” (> 95%) and “just under 500” (> 80%) groups on the MCAT, the medical school curriculum should be addressing those differences.

The two points I would like to emphasize are the criteria for who is likely to become a good doctor (and thus should preferentially be admitted to medical school) and the enormous cost burden on medical students that obviously falls hardest on those with the least wealth. As I have said before (The high cost of medical education: Who should be trained to become doctors?, Dec 10, 2019; Free tuition in medical school is only one step toward producing the doctors America needs, Aug 26, 2018), those who should be given the opportunity to become doctors (ie., be admitted to medical school) should be those most likely to make a positive difference in the health of our population. This includes a sense of community over self, a willingness to serve where needed, and interest in (preferably commitment to) practicing the specialties most in need in the areas most in need of them. Since URiM doctors are more likely to practice with patients from similar backgrounds (and those patients are often more comfortable seeing them), and a comparable correlation exists with those from rural backgrounds, these characteristics should be very important criteria. As should coming from a family with lower than average wealth and income, which requires addressing the second point. Higher income does correlate with better education and higher MCAT scores, and maybe higher scores on basic science tests in medical school (which are very like undergraduate science tests) and USMLE Part I scores, but not (and almost inversely) with practicing the specialties most needed and caring for the people most in need. So this should at best be a neutral, not positive, criterion.

And the money is a big one. You can admit a student from a low-income family who will be a great doctor, but they should not have to go into absolutely crushing debt and certainly not to enter the highest-income specialties to pay it off. This can partially be addressed by medical schools offering scholarships and states and localities offering loan-repayment programs, but it would be most effective if the federal government could subsidize the cost to make it far lower, and in conjunction with requirements that schools (state or private, stateside or Caribbean) to produce the physicians America needs.

Of course, as well, and even more important for all our people, to have a free or very low cost universal health system.

 

Disclosure: Dr. Chumley and I have known each other for many years and previously worked together.

The high cost of medical education: Who should be trained to become doctors?

Medical school is expensive. College, for that matter, is expensive, but medical school is more expensive. According to a consultant website, based on data from the Association of American Medical Colleges,

On average, medical school tuition, fees, and health insurance during the 2019-2020 academic year ranges from $37,556 (public, in-state) to $62,194 (public, out-of-state). Average private school figures come in just below public schools for in-state and out-of-state students, at $60,665 and $62,111, respectively.

That is a lot of money. Per year. Multiply by 4 years. Add books, living expenses (you know, food, rent, like that), and miscellaneous other costs, and it is not surprising that the average medical student graduates a quarter-million dollars in debt.

Of course, if your family is very wealthy, it is not a problem. But given that the mean household income in 2019 was about $63,000, just about a year’s tuition in many of these schools, it would be a stretch for those families to pay such expenses. Indeed, at the 75^th%ile ($113,000) it would be more than half of gross income, and I doubt that even those at the 90^th%ile ($184,000) would find it easy to support a medical student. As medical schools (hopefully) strive for increasing diversity, by income of family of origin, race and ethnicity, and geography (rural vs. urban), this cost becomes a bigger and bigger issue, much more than when only children of the elite (including physicians) attended medical school.

Of course, these students are going to be doctors, on average the highest-paid profession in America. According to most sources, including this one based on a survey on the doctor site “Medscape”, even the lowest-income medical specialties would be easily in the top 10% of income, and several way into the 1% ($475K). (Indeed, the income for those highest-paid specialties seems to be lower than those I have known, who not uncommonly make over $1M.) But even using those numbers, there is a several-fold difference in being in, say, Pediatrics ($212K) or Family Medicine ($219K), and Orthopedics or Plastic Surgery ($500K). It is certainly understandable that, at such high debt loads, the greater income of a high-paid specialty seems more attractive, and may further decrease student choice of primary care (lower paid) specialties. (At a difference of almost $300K a year, a plastic surgeon could expect, over a 30 year career, to earn almost $9M more than a pediatrician! That is real money!)

In addition to their own cost of living, often having to help support, rather than be supported by, a family, is another reality for those who are in medical school and later in residency training. This is a major focus of an important NY Times article on the topic published November 26, 2019, “I have a PhD in not having money”, about the challenges that low-income medical students have, and by extension the challenges for medical schools that really might wish to have a diverse class. The challenge is not only for minority students, who on average come from families with significantly less wealth and income, but across-the-board for students from families with incomes that are not in the higher ranges. It includes most students from rural areas.

In fact, there is an enormously close correlation between students from areas and population groups which are most needed in medicine and those most poorly represented in medical school. In some ways this is a tautology; since doctors are likely to practice in communities like those in which they grew up, poor, minority, and rural communities which are dramatically underrepresented in medical school are the least served. Also, the higher income earned by subspecialists (and, let us not forget, the explicit and implicit encouragement by faculty for students to enter these fields) means that they can practice only in “major medical centers”, places with populations big enough to support a need for that specialty and with hospitals that can provide them a place to practice. Thus, fewer medical students train to be family doctors, who can practice in and are much needed in rural areas, exacerbating the existing reticence of students brought up in cities and suburbs to relocate there.

The Times article is good, but it focuses almost entirely on the issue of paying for medical school. Clearly this is incredibly important. The students featured in it say things like “You have to decide, do you use your loans for a study aid or for a rainy-day fund in case someone at home gets sick?...I haven’t had dental insurance in two years. When tuna is on sale for 80 cents a can, I go buy 30 at CVS,” and “There’s this idea that because we’ll all be doctors one day, the loans don’t matter and it’ll all even out. But that doesn’t account for day-to-day expenses now, like if my mom texts me asking for help.” This begins to get at the larger issues, that it is not only the question of how to pay for medical school, but a variety of related things that characterize students from lower-income backgrounds.

Students from poor families tend to live in poor neighborhoods. Because of the US’ regressive system of financing public education, which depends a great deal on local funds, the quality of the education is likely to not be as good. I refer not to the skill or dedication of the teachers, but the resources to provide additional instruction, instructional support, and special classes such as Advanced Placement. Similar conditions apply in rural areas. Where the student from an upper-middle-class suburb may have many advanced placement classes, especially in sciences, by the time they graduate from high school, and have learned disciplined study habits and been given lots of role models, students from less-well-off school districts are much less likely to have. In a rural area, there may be one science teacher who is shared by more than one district. This gives the more privileged students a leg up before they even start college. Before they start high school. Before they start school altogether.

Then, disadvantaged students have to compete on academic criteria with those from wealthier backgrounds on Medical College Admissions Tests (MCATs), a type of test for which those others have been prepping for years. Medical school faculty on admissions committees often can’t – or don’t care to -- distinguish between the ability to perform well academically and the potential for becoming a good doctor if given the right support. A child of a well-to-do family who has had not only excellent schools but tutors and other support when needed, and who looks like the children of the MD and PhD faculty, might be “hitting on all cylinders” to do as well as they are, while the child of a farm worker or motel cleaner in a rural area may have unlimited untapped potential.

And, yet, it is still more. Producing more doctors from the top income levels means that the communities like those they come from, which already have enough or more than enough physicians, will become more overserved; that the specialties that exist in abundance in those locations will have more members. And lower income communities, rural communities, minority communities, communities that need primary care doctors, will remain underserved. And the health of the US population will be further jeopardized.

Some schools, like Mount Sinai in New York, have eliminated tuition. That is a good thing for the students who are admitted, especially for those who are from low-income families, but it does not explicitly choose students from low-income families. That is a major flaw; it mostly serves to further advantage the most-highly-advantaged students who comprise the bulk of the class. To care for the American people, medical schools need to admit and train physicians who “look like America”, for real, not a few token students in a class mostly comprised of scions of the top 25% or even 10%. This means that the first pass for admission should be demographic – students who come from low-income, from rural, from minority communities, students who don’t look like most current students, students who don’t look like the children of medical school faculty and their neighbors. If there are to be some slots reserved for those who are from privileged backgrounds and overserved communities, they should be for those who are most likely to practice in areas and specialties unlike those in which they were raised, those who have a demonstrated history (not an essay expressing intent) of real service. Were they in the Peace Corps, or AmeriCorps, or Teach for America, or something that actually required extended work and sacrifice?

Those students who are admitted will need maximal financial help, scholarships as much as loans, and even more educational support, so that they can reach their full potential and be able to become the doctors who can help their communities if they choose to return (not all will but they are much more likely to than others). That is what medical school funds should be spent for.

And we need it to start soon. It will be 30 years before currently accepted medical students replace the existing doctors, and we shouldn’t have half-measures.