Hall, Frances R.; Mikesell, Collins; Cranston, Pamela PhD; Julian, Ellen PhD; Elam, Carol EdD
Since 1974, the number of applicants to U.S. medical schools has fluctuated significantly. From 42,624 applicants in 1974, the number of students in the applicant pool fell to a low of 26,721 in 1988 and then rose to a new high of 46,968 in 1996. Since 1996, the applicant pool has declined again.
During the last half of the 1960s and the early 1970s, the number of applicants to U.S. medical schools soared, reaching its peak in 1974. Singer1 found that because of the draft policies during the Vietnam War, men enrolled in college at a rate greater than predictions based on the size of the age cohort. The number of bachelor's degrees awarded to men, which began to rise more sharply in 1967, peaked in 1974. More specifically, the number of men receiving bachelor's degrees in the biological or life sciences [described by the National Center for Education Services (NCES) as biology, biochemistry, biophysics, botany, cell and molecular biology, microbiology or bacteriology, zoology, and other biological science] peaked in 1976 at 35,520 and had dropped to 19,993 by 1986. The pattern differed for women. The number of bachelor's degrees for women in the biological or life sciences peaked in 1978 at 19,797 and dropped only slightly to 18,531 by 1986.
In 1975, however, the number of students in the applicant pool began to fall, reaching 26,721 applicants in 1988, which concerned medical schools.2 Eisenberg3 showed that, without the increased number of women applicants, medical schools would have experienced difficulty maintaining quality in their entering classes. Barzansky4 reports that, while women were more represented in medical schools at the beginning of the 20th century than in the next two decades, the significant growth in the enrollment of women occurred during the 1970s and 1980s. Enrollment of women rose from 8.77% of all medical students in 1968 to 35.1% in 1988.
To help explain the falling numbers of medical school applicants, Barondess and Glaser5 found that the job satisfaction of practicing physicians was an important factor in medical students' choices of medicine as a career. Further, Colquitt and Killian6 reported that students might decide against medicine because of financial concerns, being discouraged by practicing physicians, and finding other fields to satisfy their interests. Kassebaum and Szenas7 postulated that changes in the applicant pool between 1984 and 1994 were related to the number and pattern of undergraduate majors and to changes in the employment conditions for college graduates. In addition, Kassebaum and Szenas found that a significant part of the decline between 1984 and 1988 was related to a decline in the number of repeat applicants, while between 1988 and 1994 a sizeable proportion of the increase in medical school applicants could be attributed to the increased number of reapplicants.
Due to the significant fluctuations in the applicant pool for allopathic medical schools from 1974 to 1999, we designed a study to identify more specific trends. We examined what factors (such as numbers of biological or life sciences majors in the United States, numbers of MCAT examinees, and U.S. unemployment rates) might be related to the changes in the size and makeup of the applicant pool, and if there were any, the natures of the relationships. We also looked at how the characteristics of the applicant pool (such as age, race/ethnicity, state of legal residence, and gender) changed over the study period.
We collected descriptive data for medical school applicants for 1974–1999 from three sources. The Association of American Medical Colleges' (AAMC's) Data Warehouse provided data on characteristics of the total applicant pool for the entering classes of all U.S. medical schools for the years 1974–1999. Variables were race/ethnicity [including underrepresented minority (URM) applicants, defined by the AAMC as African Americans, Mexican Americans, Mainland Puerto Ricans, and Native Americans, Native Alaskans, and Native Hawaiians], gender, first-time versus reapplicant status, age, and state of legal residence. Data describing the numbers of undergraduates receiving bachelor's degrees and national unemployment rates were obtained from the NCES and the U.S. Bureau of Labor Statistics, respectively.
Undergraduate Degrees in the Biological or Life Sciences
The numbers of applicants for the individual entering classes were compared with the numbers of undergraduates receiving bachelor's degrees in the biological or life sciences in the preceding academic year for 1974–1997. Although only approximately half the applicants to medical school were biological or life sciences majors, the numbers of graduates with bachelor's degrees in biological or life sciences paralleled the rise and fall in numbers of applicants until 1996.
When women and men applicants are examined independently, different patterns emerged that supported Singer's 1989 findings (see Figure 1). From 1974 to 1995, the number of women who earned undergraduate degrees in the biological or life sciences paralleled the number of women applying to medical school, increasing throughout the time period. Both the number of men earning undergraduate degrees in the biological or life sciences and the number of men applying to medical school declined from 1974 to 1988, and then the numbers of both cohorts began to increase.
The number of women applicants was numerically equal to 61% of women biological sciences majors. By contrast, the number of men applicants represented 97% of the biological science majors for the period. These comparisons suggested that medicine was a prime career field for men earning undergraduate degrees in the biological or life sciences, while some women choose other career fields or delayed their application to medical school.
Figure 2 shows the comparison of the numbers of applicants over the study period with the annual employment rates in the U.S. For each study year, the number of applicants was divided by the number of bachelor's degrees conferred in the same year to create a ratio that could be compared with the unemployment rate, which is also a ratio. For the period 1984 to 1992 the fall and rise in numbers of applicants paralleled the pattern of unemployment rates, which supports the conclusion of Kassebaum and Szenas,7 despite the use of different indicators of unemployment (the previous study used U.S. Department of Labor numbers of employed and unemployed college graduates and those not in the labor force). From 1992 until 1996, the numbers of medical school applicants increased while unemployment decreased.
Our data confirmed that reapplicants were a greater proportion of the applicant pool when the pool was high and a smaller proportion of the applicant pool when the pool was low, as reported by Kassebaum and Szenas7 (see Figure 3). Reapplicants represented 33% of the total applicant pool at its peak in 1996 and 24% at its low in 1988. The ebb and flow of the total pool were reflected in the pool of first-time applicants, but were exaggerated when reapplicants were included.
The number of women applicants increased from 8,712 in 1974 to 17,433 in 1999. The proportion of women in the applicant pool also increased over time. Women applicants increased from 20% of the total pool in 1974 to 38% of the pool in 1988 and to 45% of the pool in 1999. During the same period, men applicants decreased from 33,912 (80% of the total pool) to 21,096 (55% of the total pool, see Figure 4). Data published recently in The Chronicle of Higher Education8 indicate that the proportion of undergraduate college degrees awarded to men has been declining. In 1999, less than 45% of college undergraduates were men, compared with 55% in 1970.
In 1974, URM applicants represented 7% of the total applicant pool; in 1988, this proportion was 10.5% and in 1999, 10.9%. The use of proportions, however, masks the numeric increase in URM applicants, from 2,890 in 1974 to 2,813 in 1988 to 4,181 in 1999. In 1988 Asian/Pacific Islander applicants represented 12% of the total applicant pool; in 1999 Asian/Pacific Islanders were 20% of the pool. In 1988, white applicants comprised 71% of the total applicant pool, and in 1999 they were only 61% of the pool.
Interaction of Race/Ethnicity and Gender
The applicant pool did not grow evenly with respect to the interaction between race/ethnicity and gender combinations within the total applicant pool. Greater numeric increases were observed in the number of Asian/Pacific Islanders, both men and women, and in the number of women applicants of all racial/ethnic backgrounds. The increases in the number of women of all ethnic backgrounds and the number of Asian/Pacific applicants between 1988 and 1999 accounted for 80% of the numeric increase in all applicants (after correcting for double counting, see Figure 4).
URM women represented 6% of the applicant pool in 1988, and 7% in 1999. Since 1984, African American women have outnumbered African American men in the applicant pool. Of particular note is the fact that, in 1999, 67% of African American applicants were women. As a measure of comparison, in 1988, Asian/Pacific Islander women applicants represented 5% of all applicants, but they were 9% in 1999.
The applicant pool's changes based on gender and ethnicity are even more striking looking back to 1974. The number of white men applicants declined from 28,414 in 1974 to 13,517 in 1999, an overall decline of 52% (the low was 12,125 in 1988). The number of white women applicants increased from 6,797 in 1974 to 10,034 in 1999 (the high was 11,823 in 1996). The number of Asian/Pacific Islander applicants increased dramatically over the study period, from 986 to 7,622. The number of URM men applying to medical school dropped by 18% from 1974 to 1999, from 1,984 to 1,629. During the same time period, the number of URM women nearly tripled, from 906 to 2,552.
The relative proportion of applicants by age group did not change dramatically over the years studied, although modest shifts occurred between the 21–23- and 24–26-year-old applicants. The proportions of the other age groups remained relatively constant.
In most years, a rise or fall in the number of spring MCAT examinees preceded a rise or fall in the size of the applicant pool for the fall of the subsequent year. For example, the declines in the numbers of MCAT examinees in the spring administrations of the examination preceding the application years 1996 through 1998 correspond to the declines of the total applicant pools for those years.
Place of Origin
We observed a shift in the applicants' places of origin according to geographic region as defined by the AAMC. Since 1981, applicants whose legal residences were in the AAMC's southern region have outnumbered those from any other single region. Before 1981, the largest number of applicants came from the northeast (see Figure 5). This change has occurred at a time when the numbers of first-year seats in U.S. medical schools by region have remained relatively stable.
So, what does all this mean? Changes in the composition of the national applicant pool may result in changes in the demographic characteristics of entering classes, assuming that medical schools continue to select those students who are best qualified for the study and practice of medicine. A change in the size of the national applicant pool does not always have an impact on the size of the applicant pool at an individual school; however, when a national trend is clear, an individual school is wise to consider its potential impact on its own pool of applicants. The demographic profile and size of the national applicant pool helps to shape the profiles of entering classes when admission policies and practices are held constant.
The increase in the proportion of applicants who were women over the period of this study is striking, rising from 20% of the total pool in 1974 to 45% in 1999. This trend occurred at a time when the proportion of undergraduate degrees awarded to men was declining.8 Thus, it may be that the increase in the number of women in the applicant pool, and subsequently in medical school, reflects not only an increased interest in medicine by women, but also a shift in gender balance among those seeking postsecondary education. The fact that the number of women applicants continues to be related to the proportion of college biological science majors supports this position.
Over the same period, the number of men applicants dropped from 33,912 to 21,096, a reduction of 12,816 applicants, or a little more than half of the current pool of male applicants. Why the pool of men applicants, both for colleges and for medical schools, is declining and why men are not applying in the same numbers as before while the number of women applicants is increasing are important questions for future study.
Our study shows that virtually no progress has been made in expanding the pool of URM applicants. While the pool has increased nearly 50% since 1974, the total applicant pool has also increased, and URM applicants in 1999 represent only 10.9% of the applicant pool, an increase of only 0.4% since 1988. At the same time, the gender composition of the URM pool has shifted significantly to a preponderance of women; African American women now represent 67% of the pool of African American applicants. This is a rate of increase far greater than that for all women in the total pool. Without this sharp increase, the number of URM applicants would have declined dramatically during the period of the study. While the addition of significant numbers of African American women is a great gain for medicine, our belief is that this increase is more likely to be related to the overall increase in the number of women applicants than to reflect efforts to expand the URM pool. There has been a 33% decline in African American men applicants, and it is critical to understand the reasons for this decline before progress can be made to expand the URM pool.
The number of Asian/Pacific Islander applicants has increased significantly, rising nearly eightfold since 1974. Asian/Pacific Islander applicants now represent one fifth of all applicants. Within this group, the proportion of women applicants has risen at a rate more parallel to that of all women applicants, unlike the predominating number of women in the African American pool of applicants.
While the findings from this study suggest that the number of applicants relative to the number of bachelor's degrees conferred is comparable to the unemployment rate, more information is necessary. Studies should examine what fields of education and employment potential candidates for medical school pursue in periods of low numbers of applications to medical school. How is the size of the applicant pool associated with economic and job market factors that might be measured by such indicators as the Consumer Price Index? Similarly, during the periods of larger applicant pools in the 1990s, relatively larger numbers of applicants aged 24–26 decided to make medicine a career. What personal and economic factors, if any, influenced those decisions? Did they change careers, did they pursue advanced degrees, or were they reapplicants who stayed in the pool for several years?
Most admission directors know that the number of students sitting for the spring administration of the MCAT is an indicator of applicant pool size in the subsequent admission cycle. While this information is useful, it does not permit long-term planning for office staffing and support. In future studies, can a model be devised to study interactions across all factors reviewed in this report to determine other markers that will be helpful in planning strategically for the future?
The most important message of this study is that changes in the proportions of women applicants have been the driving force in the expansion of the applicant pool since 1974. Asian/Pacific Islander applicants have also contributed significantly to increases in the applicant pool. In the late 1970s and early 1980s, the increased number of women applicants helped to offset the decline in the number of male applicants, as reported by Eisenberg. This trend continued during the late 1980s and early 1990s, as reported here. Dramatic increases in the number of women applicants more than offset declines in male applicants until recently. This increase in the proportion of women applicants appears related, in the case of all applicants, to decreases in the college enrollment of men and, in the case of African American applicants, to additional factors, which are not known.
We recommend that further studies be initiated to investigate the factors related to the decline in men applicants. Such a study needs to investigate the interactions across all the variables reported in this article, incorporating the sizes of the age cohorts in the population to determine other markers. It is critical to determine the causes of the decline in the number of men in the applicant pool, both in the total pool and in the African American pool. Without an understanding of the causes of the decline and the development of effective remedies, medical schools may be unable to stem the tide of the current applicant pool decline.