Admission to medical school is a matter of inside versus outside
Graphic and text and links at
http://www.unmc.edu/Community/ruralmeded/changes_in_admissions.htm

The percentage of total medical students was compared to the percentage of
the US population for each 5 year period using the AMA Masterfile, AAMC
data, and census data. About 95% of US MD Grads have birth origins and
about 70% of osteopathic graduates, a much smaller or tiny group compared
to US MD Grads across this time span from 1941 to the present.

Asian admissions are about 22 - 23% (17% now for osteopathic) compared to
4% of the US population. White admissions are about the same as white
population at 100% although different segments have higher and lower
admission.

Large rural or micropolitan born admissions have decline slowly to 80% but
again large rural areas with major universities, medical schools, and
federal facilities have top levels of admission in the nation.

Rural admissions have declined faster than rural population decline
resulting in 50% admission levels and down to 25% for lower income rural
born children. Black admissions have increased with social organization
efforts abruptly to levels of rural born admissions and have remained
similar in recent years. Mexican American and Hispanic admissions also
improved with Civil Rights and the opportunity to gain admission to any
medical school but have also stagnated in recent years with similar
admission compared to lower income rural.

The past decade has involved more changes within race and ethnicity and
origins compared to changes in the various groups themselves. About 3000
more highest income medical students have replaced 1500 lowest income and
1500 middle income US MD students by 2004 compared to a more balanced
admission in 1997. 3000 of those least likely to choose family medicine,
primary care, rural, and underserved careers have replaced those most
likely to choose such careers.

About 70% of US MD Grads now arise from the top 20% in parent income in the
US, an increase from 60% in the past 10 years. 60% has been the level for
decades prior to this time. Declines have been greatest in those of lower
income and status in all races, ethnicities, and populations, including
rural. Rural born admissions have decreased below 10% despite 20% of the
population in rural areas. Rural physician levels are also 10% of total
physician workforce.

Underserved areas are also about 20% of the population and about 8% of
admissions and about 8% of the total physician workforce of the nation.
This includes urban underserved and rural underserved, each at about 4% of
US physicians.

The same forces that shape education, opportunity, admission to college,
admission to medical school, training, and policies impacting all these
areas also appear to shape physician distribution. There are consistent
matches all across the income, population density, and social organization
spectrum. Those least likely to gain admission are most likely to
distribute to family medicine, primary care, rural, and underserved areas.
Then there is a small percentage of neutral ground with average admission
and average distribution. Then there is the great majority of top status
origins, those most connected to major medical center locations for the
first 30 years of life in the United States or in other nations. These are
children that become the physicians least likely to be found in family
medicine, primary care, rural, and underserved careers for the 1987 - 2000
graduates (n = 316,000)

The variables can involve children of professionals, MCAT scores, county
birth origins, population density, social organization, county economics,
geographic coding, race and ethnicity - with one major requirement. One
must understand the factors involved. For example one must understand that
Asian populations in the United States have higher levels of income,
education, professional degree, urban origin, and closest proximity to
major universities and medical schools in a number of dimensions. Greater
numbers of whites share the same high status origins as Asian populations
but also have a wide range of lower and middle income origins. Studies of
the top 51 income counties that have a medical school in their city or
county can be revealing. This 1% of the land area has 20% of the population
of the US, 47% of Asians, 32% of Hispanics, 22% of African American, 17% of
White, and less than 0.5% of Native population.

In correlations with medical school admission at the county level, % of
professionals, birth in a county with a medical school, income, population
density, college education % are all important.    Geographic proximity
remains a major variable in linear regression along with percentages of
professionals and population density.   Indicators of extremes of poverty
(whole county shortage areas, predominantly minority) also contributed.

Those geographically and socially isolated are admitted at the lowest
levels, typically a bottom threshold of 4 admissions per 100,000 birth
population per class year. They also have the top choice of rural,
underserved, family medicine, and primary care careers at 2 - 4 times other
physicians.

Average admissions are 7 - 9 per 100,000 (9 if including the 16% who are
foreign born US MD Grads) using 1970s birth county population as a
denominator. Those with average admission levels have average to slightly
greater choice of family medicine, primary care, rural (if rural born), and
underserved (rural or urban depending upon birth origin) careers.

Those most connected to concentrations of professionals, income, people,
education, medical schools, and health facilities after 30 years from birth
to admission are least likely to depart major medical center locations (75
or more physicians) and are least likely to be found in family medicine,
primary care, rural, or underserved careers. Only family medicine choice in
this group increases rural or underserved location rates above national
averages. Temporary obligations can force these careers temporarily but do
not appear to be required with medical students from ordinary populations
and ordinary medical schools. Only exclusive origins, exclusive medical
schools, and exclusive health policies limit physician distribution.

With 70% exclusive admissions, a focus on 100% major medical center
training, and health policy that sends the most lines of reimbursement and
the highest levels of reimbursement to major medical center locations,
distribution of physicians and economics and health resources outside of
major medical centers is difficult.

For specialists, about 50% are crowded into 1% of the land area with 200
physicians at a zip code and 80% are found in 3% of the land area in major
medical centers with 75 or more physicians, usually competing head to head
in the same blocks or adjacent zip codes. This makes access to specialists
costly, difficult, time consuming, and even deadly for those who have to
travel and those who cannot travel but need to do so.

Robert C. Bowman, M.D.
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