Sent a response to a question about whether there were changes in lower
income types and scores involving the MCAT test. With costs of applications
and test and college up, there are concerns. This was my response.

Standardized test scores are a measure of what is being tested and who is
taking the test. Ellen and AAMC would know this best. What has been
frustrating to AAMC and others over the years is how the test is used in
admissions or by those who have an agenda within medical schools and across
the nation.

Increases in the MCAT in all areas for accepted medical students but
particularly in the biosciences (about 0.1 unit per year x 14 years) may
well indicate a narrowing group. This is also noted in income changes with
increases in students from families making over $100,000 increasing by over
3000 a year from 1997 - 2004 and replacing 1500 students from less than
$40,000 income and another 1500 middle income types. The nation has 3000
fewer students who represent about 70% of the population. The nation has
3000 more students who represent the top 30% in income and status and urban
origins. The bulk of this group was born or raised in a county with a
medical school, which also tells you where they will be locating in the
future since this group is found in major medical centers (med schools or
zip codes with 75 or more doctors) at nearly 80% levels.

Race and ethnicity are important, but socioeconomics are more important.
Mexican American highest income origin students increased by 133% from 1997
- 2004 and white increases were over 80%. Asian increases were the lowest
at 60% and this may be a leveling out. Asian medical students are already
selected at over 4 times their representation in the population, a function
of highest income, most college grad parents, most professional parents
especially moms, top college prep, (AAMC Minority in Medicine reports) and
closest proximity to medical schools. (Birth origins from Masterfile, and
census) White medical students, especially from rural areas and lower
income groups, are declining the most in the past 25 years and occupy
counties with lower income levels and counties more distant from medical
schools. 71% of the most urban populations are white yet this increases to
90% in rural America. All other populations concentrate in the most urban
areas. The concentration of Asians in counties with medical schools is by
far the greatest. At the other end of the spectrum with rural and lowest
income and minority there are 3 million in predominantly black, 3 million
in border Hispanic, and 500,000 in Native dominant counties. These are
counties least likely to birth physicians and the least likely to have
physicians in 2005

Income, education, college graduates, and professionals decrease with
population density. Choice of family medicine increases opposite to these
factors and family physicians also distribute in higher levels as counties
decreases in income, education, populations, facilities, and physicians. FP
increases with increased high school graduation rates. Populations that are
left behind at high school or before mean lower rates of FPs and are likely
to mean fewer service oriented professionals of all types: teachers, public
servants, counselors, and nurses. Taking their place are increasing rates
of prison, welfare, unemployment, and health care costs.

FPs are 30% of rural docs and 58% of docs in isolated rural areas and 61%
of rural CHC docs and 67% in isolated rural and underserved low income
areas. Without broader education, broader admissions, and the specialty
that spreads broadly across socioeconomics and geography, the nation will
have rapidly worsening health access problems. Temporary doctors are not
the solution. Better education and child development is the solution, for
all of these areas.

Physicians born in counties now considered whole county primary care
shortage areas were 1.3% of US MD Grads. This group had origins in counties
with 4.6% of the United States population, counties with the lowest levels
of physicians, income, and education. As physicians this group is found in
rural locations at 24% (11% avg), family medicine at 21% (11% for FP),
underserved locations at 15.4% or 2.5 times the national average, rural
plus underserved location at 4 times the national average of 2.6%, and
whole county shortage area practices at 7% compared to only 0.8% of all US
MD Grads. Those returning to whole county shortage areas similar to their
birth include 4% who trained in obstetrics, 5% in pediatrics, 6.5% in
internal medicine and 15% in family practice. Those captured in major
medical centers are not going to distribute.

Few have the challenges of Native American females born in rural areas and
those choosing family medicine are even more humble origin. This is a
combination of rural birth, lower income, different language and culture,
different age, different education, much different life experience. There
is no standardized test that can reconcile the differences between
Asian/white/highest income types that are 70% of US medical students and
the Native combination of major differences. By the way, Native rural males
doing FP have been eliminated from the pipeline, the first to go with
others to come. The barriers of income and education and college and
medical school and choice of family medicine are too much. Urbanize male
Natives remain but have lower distributional choices.

According to my understanding the MCAT is a power test. The MCAT is
designed right on the edge of speeded bias, as noted in recent years when
it was changed (likely not for gender for those taking the test now
however). Anyone with multiple socioeconomic and background differences
will 1) not be taking the test 2) will have speeded bias. For example a
rural born child is not just rural born only. He or she is rural, lower
income origin, lowest levels of college prep, different in culture, and
usually a bit older also. All are factors in different scores. All are
factors improving distribution probability. Gender on race bias is severe
for all lower income groups as indicated in black males, rural males, and
Native American males.

When considering the past 60 years of admissions by income, geographic
origin, ethnicity, and race there are similarities in certain low
probability admission groups. Admissions probabilities for Mexican
Americans are the same as those from lower income less organized rural
areas at about 20 - 30% compared to population levels. Admissions
probabilities for Blacks are the same as for students born in middle income
rural areas at about 50% of population levels. Higher income rural birth
and likely higher income of any group is 80 - 110% of the national average.
(power point slides available)

Those above average in admissions probability (Asian, foreign born, top
income quintile, most urban, born in a medical school county) are found in
rural areas, underserved locations, family medicine, and primary care at
the lowest levels as noted in 1987 - 1999 graduates currently in 2005
careers and locations in the Masterfile. Expansion of medical students
involving non-distributional populations will not distribute physicians or
restore some balance in primary care, currently at record low levels.

Family medicine choice is essential to distribution. FP has 57% of
physicians outside of major medical centers and this increases to 70% with
the removal of those not in direct patient care. Every other specialty has
69 - 90% concentrations inside major medical centers which are zip codes
with 75 or more physicians or medical school zip codes.

Birth origins with increasing socioeconomic and geographic distance from
medical schools and major medical centers, choice of FP, and health policy
that encourages choice of FP and physician distribribution (funding to
lower and middle income health care) are essential for health care access
outside of major medical centers across the nation where 71% of physicians
concentrate.

74% of the top 146 college positions are held by top income quartile
students, a fact I picked up from the Amherst article regarding Carolyn's
President http://www.businessweek.com/magazine/content/06_09/b3973087.htm
which I consider one of the finest examples of hope for narrowing education
and income gaps in the nation. Somehow we must admit lower and middle
income kids and keep the professional parents and alumni happy. No easy
task. Tax revolts and reversals of affirmative action are just a few of the
national problems stirred by these groups and the local impacts in
professional schools have been even more significant.

Powerful parents who mostly pay the way for their own children in private
schools and top colleges and vote in the highest levels and influence
voting at the highest levels fail to see the wisdom of investing in lower
and middle income peoples and children.

Other Indicators of poor progress

Higher income children gaining benefits for college funding, but not lower
or middle income types (also from the above) and more at source document at
the Century Foundation site (Kahlenburg) at
http://www.tcf.org/list.asp?type=PB&sort=date&topic=3

or one of the key chapters (SOCIOECONOMIC STATUS, RACE/ETHNICITY, AND
SELECTIVE COLLEGE ADMISSIONS at
http://www.tcf.org/Publications/Education/carnrose.pdf

Whitcomb noted that the nation was in danger of admitting only rich
students recently in Academic Medicine in comments regarding debt and
tuition. The impacts were noted to be all along the pipeline. This was
another bad year for the pipeline since 30,000 fewer poor children took the
SAT test this year, attributed to the increased cost of the test - (recent
Chronicle of Higher Education)    Despite this the SAT scores went down,
not up - actually a chilling indicator. ACT scores went up very slightly.
The state of Washington indicated it was puzzled with declines in certain
age groups (Seattle Sun Times 9/11/2006)    Until the nation has a grip on
child development, early education up to age 8, and a better balance
regarding education and income and health access (and housing, security,
opportunity, economics) there will be more puzzling declines.

Worth reading is the division of the nation into 8 socioeconomic and racial
groups based on health status. You will also find the same types of data as
I noted above about medical students and college access.
http://www.washingtonpost.com/wp-dyn/content/article/2006/09/11/AR2006091101297_pf.html

Wide Gaps Found In Mortality Rates Among U.S. Groups  By David Brown
Washington Post Staff Writer    Tuesday, September 12, 2006; A01

won't repeat this except the end:

Richard Cooper, chairman of preventive medicine at Loyola University School
of Medicine, said that "the problem with these sorts of analyses is that
they don't tell you anything very illuminating about the underlying social
process" that leads to differences in life expectancy.

End of text quote

Perhaps the most difficult problem in health, education, and medical
education is that few have the perspective to grasp what is going on in
America. To really understand such a situation, you have to fully
understand what it is like to live in lower and middle income groups. Then
you have to overcome the obstacles of income and education and retain these
experiences to write them in ways that finally have impact upon those who
were academic since birth.

Somehow we must learn to repair, renew, and rebuild the constantly changing
types of infrastructures that will meet the needs of the nation, all of the
nation. We will also need to teach this to the world. Otherwise we will
have states that steal infrastructure from other states and from the world,
and a much more unstable situation that is ever more costly, and in much
more than just dollars.

Robert C. Bowman, M.D.
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