During the past year, the Association of American Medical Colleges (AAMC), responding to concerns that the country is on the verge of a serious shortage of physicians, called on medical schools to increase enrollments, perhaps by as much as 30%. This action has prompted the medical education community to focus a great deal of attention on the nature of the medical school applicant pool. At issue is whether there are enough academically qualified applicants to fill the projected increase in medical school entry positions.
I am not nearly as worried about this as others are. Those who express concerns about the overall quality of the applicant pool seem to believe that the best way to judge whether individual applicants are adequately prepared to study medicine is to compare their qualifications with those of current matriculants. But the current matriculants are a highly selected group whose qualifications reflect the traditional practice of basing admission decisions largely on academic performance in college courses in the natural sciences, and on recall of facts and problem-solving skills, learned in those courses, on the Biological Sciences and Physical Sciences test sections of the Medical College Admission Test (MCAT). In my view this is no longer an adequate way to judge the qualifications of individuals who wish to study medicine. After all, in the past few decades the emphasis placed on the biological sciences in the medical school curriculum has decreased dramatically. And in recent years, more attention has been focused on integrating the social sciences, behavioral sciences, humanities, and ethics into the medical school curriculum, recognizing the importance of these disciplines to the practice of medicine. Simple logic suggests that adequate preparation in those disciplines should receive as much attention as preparation in the natural sciences in judging the qualifications of medical school applicants.
Now, rethinking the most appropriate approach for judging the qualifications of medical school applicants is an important issue. But in this editorial I want to focus attention on an entirely different applicant pool issue—that is, the racial, ethnic, and socioeconomic characteristics of those applying to medical school.1 This past year, almost 70% of the medical school matriculants came from families ranked in the top quintile of family incomes. If one examines the most common path that students take to gain entry to medical school, this is not surprising. As a general rule, medical school matriculants are graduates of a four-year college or university (preferably a top-ranked institution). This alone affects the nature of the applicant pool, since a disproportionate percentage of the students attending those institutions come from high-earning families (see below). But in addition, students from upper-income families are more likely to apply to medical school because they are able to bear the costs of a medical education and thus are not dissuaded from studying medicine by the prospect of incurring a large educational debt.
Given these realities, I think the medical education community needs to address a very serious question: Are we approaching a time when becoming a doctor will be a career option available only for the rich? The AAMC Working Group on Medical Educational Costs and Student Debt suggested that this is a very real possibility.2 If nothing is done to reverse the current trend, I believe it will have a devastating effect on the nature of the profession and, therefore, on how health care is provided in this country. The leadership of the academic medicine community must make a commitment to achieve a different future than the one we are facing. And I am convinced that a series of bold steps will be required to reach that goal.
In a previous editorial, I suggested that one of the ways the medical education community could start addressing this issue is to create an option, for students who wish to use it, to complete the core elements of the undergraduate medical education program in three years.3 That approach might encourage some less-advantaged applicants to apply who otherwise would be dissuaded from doing so because of the cost and duration of a medical education. But in order to have a greater effect on the nature of the applicant pool, medical schools need to reach out to students enrolled in community colleges. The simple fact is that about four million students of traditional college age 18–24 are taking courses for credit in those institutions.4 This group represents almost 50% of all students enrolled in institutions of higher education, and it is growing much faster than the group of students enrolled in traditional four-year colleges and universities.
However, students enrolled in community colleges differ in significant ways from those enrolled in four-year colleges and universities.5 Twenty percent of the students come from families with annual incomes of less that $25,000, while 21% come from families with annual incomes over $75,000. In comparison, only 8% and 11%, respectively, of students enrolled in private and public four-year institutions come from families with annual incomes less than $25,000, while 41% and 57%, respectively, come from families with annual incomes over $75,000. It is not surprising, therefore, that the racial and ethnic distribution of the students enrolled in community colleges is far more representative of the population of the country than is that distribution of students enrolled in four-year colleges and universities.
So what’s to be done? I believe that medical schools should begin working with community colleges to create well-defined curriculum tracks that would allow their students to begin to prepare for entry into medical school. And by creating a visible presence in the community college environment, medical schools might give students in those institutions a reason to believe that it might really be possible for them to become doctors. I know that some schools are beginning to reach out in this way, but in my view all schools should develop programs designed to accomplish those goals.
Clearly, this is only one of several strategies that schools need to pursue if they are to attract a population of students that represents the racial, ethnic, and socioeconomic diversity of our country. Nevertheless, this strategy is a key one. In considering whether to undertake it, those holding leadership positions in medical schools need to recognize that the size of the community college student population will continue to grow. Several states have now adopted policies for expanding the number and size of community colleges to accommodate the need to provide educational opportunities for a larger percentage of their college-age residents. At the same time, they are adopting programs that would link community colleges more closely with four-year state universities to increase the opportunity for students studying in those colleges to obtain a bachelors degree or to transfer to a four-year institution in their state.
This country is likely to face a huge challenge in the coming years as the cost of health care continues to escalate and the size of the physician workforce becomes progressively more inadequate to meet the demands for medical care. As this situation evolves, who will be advocates for, and who will serve, the growing population of individuals and families who are inadequately insured and unable to bear the costs of medical care? The medical profession is more likely to address those challenges in an aggressive manner if there are within the profession doctors who have come from less advantaged families and who understand, therefore, the devastating effect that not being able to gain needed health care services has on those families. This will not be the case unless medical schools begin to adopt strategies for increasing the number of those students studying medicine who once believed being a doctor was an unattainable dream.
Michael E. Whitcomb, MD
1 Cooper RA. Impact of trends in primary, secondary, and postsecondary education on applications to medical school. II: Considerations of race, ethnicity, and income. Acad Med. 2003;78:864–76.
2 Medical Educational Costs and Student Debt. A Working Group Report to the AAMC Governance. Washington, DC: Association of American Medical Colleges, 2005.
3 Whitcomb ME. Who will study medicine in the future? Acad Med. 2006;81:205–6.
4 Wyner J. Educational equity and the transfer student. Chron High Educ. 2006;52:B6–B10.
5 Indicators of Opportunity in Higher Education. The Pell Institute for the Study of Opportunity in Higher Education. Washington, DC: The Pell Institute, 2004.