Well, we seem to be going round and round about Asian being admitted to
medical school more as if entering into the profession of medicine is so
much more superior than any other professions. There are a lot of other
honorable professions such as nursing (which we have a shortage as
well), social work, psychiatry, manial, engineering, farming,
homemaking, trades etc, and etc. May be we ought to just treat medicine
as any other professions. I digress. I think the real question is not
how many get admitted to medical school and why (although it is
important if we have the shortage), but how many of those admitted
practice in rural or low income areas. And the next question is how do
we change this perception of the superiority of the medical field. One
way as an incentive which many had talked about with shortage of
physicians in low income and rural areas is to provide scholarship or
free medical education with graduates practicing in these areas in
return. I think that totally make sense and can help solve the issues
of only higher income families can afford sending their children to
medical schools. Last time that I checked, going to medical school is
not cheap, and the enormous debt that physicians have from their
educations may also be one of the reason why our health care cost is so
high.
>>> Robert C Bowman <[log in to unmask]> 02/16/07 11:05 AM >>>
My apologies about the wonderful protection provided by encryption of
sensitive patient information, which is never enclosed of course.
It is uncanny how multiplier effects work all the way from the extremes
of
concentrations, the worst health stats to the best, and the worst
behavioral or education outcomes to the "best"
Those most likely to gain admission to medical schools in the US are
Asian
with 3 times higher levels of admission (higher now with 23% admitted
and
4.3% Asian). Asian Indian admissions are actually 10 times higher (not
quite 1% of the US pop, 7% of admissions), a reflection of even
greater
concentration of status factors for this particular group in America.
Averages for whites, urban origin, and other foreign born not Asian
are
about 1 in 200 who are medical school age. Averages for whites or any
group
with the same elite status factors are as high as Asian populations.
Since
we fail to distribute information about social class and income well,
ethnicity and race ends up being the marker used.
Progressively lower levels of admission: rural born 1 in 360, Black 1
in
400, low income rural 1 in 750, Hispanic 1 in 700 - 1200, and lowest
income
of all at 1 in 2000. again these are comparisons to medical school age
populations. The range is 10 times higher to 10 times lower, but for
most
purposes, 3 times higher to 4 times lower is the range - about 7 times
Another calculation based on entire population (not just medical
school
age) by state or county finds Florida near the bottom again, with very
little chance of those most socially distant or those most
geographically
distant gaining admission. The company kept at the bottom reflects
serious
problems for a state that has relatively great wealth.
Family medicine appears to be a relative constant in admissions dating
back
to the class years of 1975. Once the nation had established Medicare,
Medicaid, and family medicine, the levels found in family medicine
have
stabilized and remained. Clearly the rates of FP choice have increased
and
decreased with health policy, but using a relatively neutral period can
be
helpful. Using Masterfile data and census data on birth county of
physicians with US birth and med school graduation 1987 - 1996:
About 1 born to each 100,000 gain admission from normally distributed
populations and eventually become family physicians. This is no mean
task
for those born in lower income or rural areas as only about 4 per
100,000
gain admission. It is rare to see less than this level.
Total admissions from a county or group for 1987 - 1996 class years *
100000 / population of county or group in 1970 / 10 (ten class
years)
Repeat for those choosing FM to get FM per 100000 per year
In the highest status populations the single future family physician
is
joined by about 8 - 10 others. The average for the nation for those
born in
the US is about 6 - 7 per 100,000 per year and this does not include
foreign born. Including foreign born increases the level to 9 per
100,000
for US MD Grads.
For the US born population alone, this translates to a maximum of about
1
in 4 or 25% choosing family medicine for the most disadvantaged or
distant
(usually both) populations. The minimum is about 6 or 7% or about 1 in
12 -
14.
To get more than 25% choice of family medicine it appears that you have
to
do work, you have to select very carefully beyond rural origins or
lower
income origins. One result from these findings: Generic approaches for
just
rural origin or for just lower income origin are not likely to work to
increase FP, since those admitted are more likely not to choose FP.
To get specific concentrations of FPs beyond 25% you have to
identify
characteristics that are specific for FP and not just rural or low
income.
Those who have done so have focused on areas such as people skills,
service
orientation, specific focus on family medicine. In the schools that
specifically select for family medicine and rural interest and
background,
the maximum appears to be 50% as in Duluth, using a variety of areas
such
as overcoming obstacles, time spent in rural areas, specific FP
interest,
service orientation, but higher may be possible since there is still a
generic push for rural involved. The rural push is good for rural
specialists by the way, which are needed perhaps more than FP in many
areas, so no problem here.
To get less than 6% FP in a medical school or state, you have to work
very
hard to exclude those who are trying very hard to become physicians
and
family physicians. Remember that they manage to gain admission even
from
the most difficult origins, even if they have to leave the country to
become a physician. Currently about 3 medical schools each year
graduate no
family physicians and this will likely grow. Of course 1 - 2
eventually
become family physicians (their exclusion comes after medical school
instead of before) Still this is less than 6%. Now to be fair, we have
entered a new era in health policy where FP choice for all populations
is
dimenishing. Seems that a certain level of primary care support,
support
for those outside of major medical centers is required and we have
sunk
below 1965 levels. (five periods of health policy)
Somehow the process of preparation, admission, and training manages to
extinguish family medicine in the narrowing process in some areas,
schools,
and states.
Anyway it is very hard to suppress family medicine. In recent decades
US
born types have even escaped to Caribbean schools and higher
percentages
become FPs than about 60% of US medical schools.
These are the areas of the nation that have been excluded so much that
they
have the lowest levels of admission. In the most severe cases, they
have
even managed to inhibit family physician production.
counties Admit Admit FM FM ratio
1987-96 87t96
Commuting Counties 381 1.28 0.29 22.6%
4 Adjacent Less Than 123 1.71 0.32 18.8%
10000
Whole County PC Shortage 784 2.03 0.43 21.1%
6 Adj Small Metro < 10000 626 2.08 0.46 22.2%
9 Not Adj Less Than 2500 511 2.16 0.59 27.1%
Retirement Counties 189 2.32 0.40 17.4%
Federal Fund Counties 381 2.62 0.56 21.4%
Over 20% Over Age 65 388 2.71 0.59 21.6%
Poverty Counties 535 2.84 0.59 20.9%
Manufacturing County 506 2.91 0.60 20.8%
Farming Dependent County 555 3.09 0.80 25.9%
Predominantly Black Rural 88 3.10 0.54 17.4%
NH - no public school 10 3.12 0.39 12.6%
8 Not Adjacent 2500 - 547 3.19 0.79 24.9%
10000
ME - no public school 16 3.25 0.46 14.3%
FL 67 3.45 0.40 11.5%
Numbers with descriptions are parker and ghelfi Urban Influence code
groupings from 1993, 8 and 9 are most distant, 4 and 6 are adjacent
and
lower income
The most distant and dependent counties have the most difficulty with
admissions. Some are "sucked dry" by adjacent areas. Whole county
primary
care shortage areas are concentrations of poverty, low education, and
poor
economics and often involve socially distant populations or those
where
patients are sucked into larger nearby urban areas. Not all of the
counties
are linked to high levels of minorities. The most rural and distant
ones
geographically are 85 - 90% white as are certain states. About 6
million
live in predominantly Black, Native, or Hispanic rural counties.
New Hampshire and Maine are rare states that have no public medical
school,
clearly impacting admissions. Dartmouth is private. Maine has only
recently
had an osteopathic school, but not one of the 6 public osteopathic
schools
that have the highest rates of FP, primary care, rural, and underserved
in
the nation.
Florida does have public medical schools and has created a new one and
more
may be on the way, but graduating family physicians, geriatric
physicians,
and physicians for Black and Hispanic populations will be a problem
for
Florida State which has promised to deliver in these areas. The fault
may
not entirely be FSU, given the environment. Retirement counties and a
retirement state may not be the best location for children - a lesson I
was
barely able to get across to my daughter and her grandchild. Of course
Nebraska responded with one of the longest coldest periods in recent
history.
It is very, very hard to suppress FM choice, but some manage to do so.
FM
as represented here does not appear to be a specialty so much as it is
a
collection of those different, diverse, older at admission, inner
city,
rural born, middle income, not born to professionals, and excluded.
they
are the most likely to arise from areas outside of major medical
centers
and the most likely to be found outside MMCs in practice.
We make decisions at the local, state, and federal level that result
in
these situations and exclusions.
For a review of what is coming, or not coming so to speak, Educational
Testing Service did a report on America's Perfect Storm at
http://www.ets.org/Media/Education_Topics/pdf/AmericasPerfectStorm.pdf
there are nice tables about various differences in student performance.
The
interesting thing about the report is that it never mentions rural or
nonmetropolitan once, nada. If they divided out the rural white
population
or the lower income white population, the distances would be even more
remarkable, even among different types of whites. By my calculations
the
levels of urban whites at the highest levels of literacy (4 and 5)
would
increase from 17 to 19 or 20% for urban whites compared to rural. This
is a
major omission since 50 million are white and rural, since 69% of the
poverty population of the nation is white, since child poverty rates
are
rising rapidly in most lower and middle class groups, and since the
major
points involved divisions and interactions between education and
class,
race, and ethnicity. The literacy data does not treat Asians well since
90%
of Asians are foreign born or have a parent who is and various science
and
math measurements would have had different results.
Rural areas being forgotten is also in the Wall Street Journal, where
loopholes allow foreign born physicians to bypass rural areas for the
urban
and academic locations that they most desire. Seems like someone would
figure out that 24% rural location from family physicians looks better
than
special legislation.
Quotes from this ETS report and from the education pipeline and useful
references at http://www.unmc.edu/Community/ruralmeded/education.htm If
you
have suggestions for additions or publication, please send.
Most total admissions in the nation - hope this works in email, last
one
did
County (City) | | Number in | Total | %
Family
| | Family | Graduates |
Medicine
| | Medicine | |
-------------------------------+------+-----------+------------+----------
San Francisco | CA | 133 | 1046 |
12.7%
-------------------------------+------+-----------+------------+----------
Hamilton (Cincinnati) | OH | 151 | 1056 |
14.3%
-------------------------------+------+-----------+------------+----------
Hennepin (Minneapolis) | MN | 190 | 1144 |
16.6%
-------------------------------+------+-----------+------------+----------
Erie (Buffalo) | NY | 112 | 1159 |
9.7%
-------------------------------+------+-----------+------------+----------
Milwaukee | WI | 154 | 1160 |
13.3%
-------------------------------+------+-----------+------------+----------
Orleans (New Orleans) | LA | 75 | 1169 |
6.4%
-------------------------------+------+-----------+------------+----------
Harris (Houston) | TX | 168 | 1181 |
14.2%
-------------------------------+------+-----------+------------+----------
Essex (Newark) | NJ | 106 | 1201 |
8.8%
-------------------------------+------+-----------+------------+----------
Baltimore City and County | MD | 128 | 1294 |
9.9%
-------------------------------+------+-----------+------------+----------
San Juan Municipio | PR | 110 | 1276 |
8.6%
-------------------------------+------+-----------+------------+----------
St. Louis City and County | MO | 179 | 1524 |
11.7%
-------------------------------+------+-----------+------------+----------
Allegheny (Pittsburgh) | PA | 201 | 1670 |
12.0%
-------------------------------+------+-----------+------------+----------
Suffolk (Boston) | MA | 168 | 1902 |
8.8%
-------------------------------+------+-----------+------------+----------
Cuyahoga (Cleveland) | OH | 252 | 2019 |
12.5%
-------------------------------+------+-----------+------------+----------
District Of Columbia | DC | 207 | 2129 |
9.7%
-------------------------------+------+-----------+------------+----------
Philadelphia | PA | 367 | 3005 |
12.2%
-------------------------------+------+-----------+------------+----------
Wayne (Detroit) | MI | 406 | 3109 |
13.1%
-------------------------------+------+-----------+------------+----------
Los Angeles | CA | 751 | 5369 |
14.0%
-------------------------------+------+-----------+------------+----------
Cook (Chicago) | IL | 713 | 5546 |
12.9%
-------------------------------+------+-----------+------------+----------
New York (11 Counties) | NY | 1404 | 18690 |
7.5%
Numerous variations in the nomenclature for birth city and state for
New
York City in the Masterfile (NY, NYC, New York, boroughs, spelling
errors)
make this city the most difficult to code. The 11 county area used
minimizes error and maintains similar admissions ratios and family
medicine
choice. What is found in the Masterfile as Washington DC birth could
also
be subject to actual birth in nearby counties. Considering DC and
surrounding counties as an area does dilute admissions ratios, but not
by a
great margin. Birth in Washington DC is an entirely different world
with 2
FPs and 22 admits per 100,000, both the highest in the nation and
complete
outliers. Those born in Washington DC becoming FPs did not stay in the
area
diffusing across then nation with college, medical school, training,
and
practice. They go to places with fewer in major medical centers and
better
distributions of education and income.
Readers are left to their own impressions as to whether variations in
FP
choice using birth origins are related to locations that distribute
income,
education, and opportunity at higher levels. Certain areas such as MN
continue to do well. CA, FL, NY, and other areas continue to do less
well.
This also includes the foreign born physicians in the US in % in
family
medicine, but my inexperience does not allow me to assess other nation
inequities and individual physician data would be needed and adjusted
for
status levels in previous nations.
For FM in the US, you will find consistently high correlations with
Gini
Indexes, income quintile ratios, and FP choice at all levels from
county,
to state, to medical schools. They also share the same correlations
with
MCAT scores, although again the individual MCAT scores, parent income,
and
parent occupation data are highly protected. They are consistently the
opposite from the top status populations and funding mechanisms.
Family medicine choice increases with broad measures such as high
school
graduation rates, and has less increase or even decrease with
increased
rates of college educated or professionals.
Given the doubling or tripling rate for distribution for family
physicians
for all areas outside of major medical centers, given the admissions
relationships, given the origins and locations, family medicine appears
to
be an excellent marker for further study regarding distributions.
It is also nice to have birth to practice data on US physicians and
career
choices using these markers for 93% of US MD Grads.
Robert C. Bowman, M.D.
[log in to unmask]
www.ruralmedicaleducation.org
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