Jolly, Paul PhD; Garrison, Gwen PhD; Boulet, John R. PhD; Levitan, Thomas MEd; Cooper, Richard A. MD
Americans who wish to apply to medical school can take one of three pathways. The most common route is application to one or more of the 130 medical schools accredited to award the MD degree. As an alternative, some students apply to one or more of the 25 medical colleges accredited to award the DO degree. A third pathway is matriculation in an international medical school that awards the MD or an equivalent degree. Graduates of all three types of programs, after passing the appropriate licensure examinations,* may be licensed by a U.S. state or other political jurisdiction to practice medicine. (These applicant pathways are diagrammed on the “AM Last Page” in this issue.) Many students, unsure of their prospects, apply to more than one type of school. We carried out the study reported here to investigate the total pool of applicants to all three types of schools, to assess the degree of overlap in the three applicant pools, and to examine the characteristics of applicants shared and not shared.
Stimulated by a growing consensus that the United States is facing a shortage of physicians, medical education has begun a period of rapid growth after decades of nearly static aggregate enrollment.1 In 2006, the Association of American Medical Colleges (AAMC) issued a statement calling for a 30% increase in first-year enrollment over the 2002 baseline of 16,488 positions in U.S. MD-granting institutions (hereafter, “MD schools”). A recent AAMC survey indicates that there is likely to be a 21% increase in first-year enrollment by 2012 from both existing and new medical schools, when compared with baseline 2002 enrollment figures.2,3 According to public information from the Liaison Committee on Medical Education (LCME) and media reports,4–6 more than a dozen new U.S. MD schools are under development or discussion. The LCME has granted preliminary accreditation to three of these schools, and they plan to admit their first classes in the 2009–2010 academic year.
Although osteopathic education is carried out in fewer institutions, their number, too, has been growing rapidly, with new schools coming online and growth in existing schools as well. Enrollment in the accredited osteopathic medical colleges (hereafter, “DO schools”) is projected to grow to 5,227 in 2012–2013, an increase of 22% over 2007–2008. This projection includes planned growth in colleges enrolling students in 2007–2008 and two new colleges enrolling their first classes in fall 2008 (T.A. Levitan, A Report on a Survey of Osteopathic Medical School Growth, 2007–2008. Chevy Chase, Md: American Association of Colleges of Osteopathic Medicine; 2008 [unpublished]; and Annual Statistical Report on Osteopathic Medical Education, 20067). Enrollment of Americans in international medical schools has also increased, particularly in schools in the Caribbean that cater primarily to Americans.8,9
Some medical school officials and others involved with medical education are concerned about the adequacy of the applicant pool to support this expansion. As places in U.S. MD and DO schools increase, competition between these three types of programs may increase, potentially making it more difficult to fill international, DO, and even MD classes with applicants as well qualified as those who are being accepted today.
To understand the limitations of the applicant pool, it is important to learn the total size of the pool of first-time applicants, because ultimately that is what will limit potential expansion.
Data on applicants to MD schools are published by the AAMC, and application data for DO schools are reported by the American Association of Colleges of Osteopathic Medicine (AACOM). Data on applications to international medical schools are not available, but students in these schools who wish to practice in the United States must register with the Educational Commission for Foreign Medical Graduates (ECFMG). On the basis of this registration activity, the ECFMG can tally new registrations each year. American citizens who matriculate in an international medical school ordinarily register with the ECFMG after completing the first two years of the curriculum, when they are ready to take one of the Steps of the United States Medical Licensing Examination. Annual counts of these registrations by U.S. citizens† are a reasonable proxy for the number of new U.S. citizen entrants two years earlier. In the spring of 2007, the AAMC, the AACOM, and the ECFMG entered into a cooperative agreement to share identified data on applicants and international medical students. Once we had matched the data from the three organizations, we created a common, deidentified study file and used this file for the analysis reported here.
It has been more than 20 years since the ECFMG and the AAMC collaborated on a study of students whose data are present in the databases of both organizations.10 There have been no published reports on international students that are and are not applicants to U.S. MD programs since that time, and data on common applications to both U.S. MD programs and DO programs have never been documented. Here, for the first time, we are able to present data on applicants to all three types of schools, including measures of the overlaps among the three applicant pools.
We matched and linked identified data from the three sources (AACOM, AAMC, and ECFMG), using the AAMC’s common biographic record system. Almost all of the DO applicants were already known to AAMC, because DO schools require that their applicants take the Medical College Admissions Test (MCAT), administered by the AAMC. Those students and graduates of international schools were already included in the AAMC data warehouse if they had previously registered for the MCAT, applied to a U.S. MD school, or participated in a residency accredited by the Accreditation Council for Graduate Medical Education. We produced a common study file containing one record for each applicant, for each of the years for which data were available. We replaced the identifiers with a research ID, and the study file was shared with all three organizations, where it was used to answer questions pertinent to the research agenda. The research was approved by the AAMC institutional review board.
For the purpose of this study, we define U.S. applicants as all those students who have ever applied to a U.S. MD or DO school, plus students in international medical schools who have registered with the ECFMG and reported U.S. citizenship at the time they applied to the international medical school. Although most non-U.S. citizens who applied for ECFMG certification are excluded from the analysis cohort, our definition does include all those non-U.S. citizens who have ever applied to a U.S. MD or DO school. The matriculation year is the year for which the student made application, in the case of MD or DO schools, or two years before the year in which they registered with ECFMG, in the case of students in international medical schools.
There are some limitations in the data or in the approach we took to the analysis. Data were not available for osteopathic applications for years before 1981 or after 2006, nor for the years 1994, 1997, 1999, 2000, or 2001. We can estimate the number of DO applicants for the missing years by interpolating from data for adjacent years, but we cannot actually count them. Because U.S. citizen students generally register with the ECFMG at the end of their second medical school year, and because 2006 is the latest full year for which ECFMG data are available, data on international medical students are not available for years after 2004. As previously stated, no data are available on unsuccessful applicants to international medical schools, nor do we have data on students that entered an international medical school and either dropped out before registering with the ECFMG or did not register with the ECFMG, perhaps because they had no intention of practicing in the United States. Furthermore, our assumption that U.S. students in non-U.S. schools register for the licensure exam two years after matriculation may be wrong in some cases, causing us to assign the international students to an incorrect matriculation year.
Tallying data from the study file, we can obtain counts of the numbers of applicants to MD and DO schools in the United States and of the number of presumed new U.S. entrants in international medical schools in the same matriculation year. These numbers for the years 1981–2006 appear in Table 1. The DO applicant counts with an asterisk are interpolated from adjacent data, because data for these years were not available from the AACOM. Furthermore, because the DO applicant counts had to be interpolated, the totals had to be interpolated as well.
For convenience, for the remainder of this report, we will refer to all three types of students as applicants, with the understanding that in the case of international schools we can only include successful applicants. Specifically, we include those students in international medical schools who were U.S. citizens at entry to medical school and who have registered with the ECFMG.
It is obvious that the totals are much lower than the sum of the counts for the three types of schools, implying that there is substantial overlap in these applicant pools. Because we use the same unique identifiers for all three pools, we can measure and characterize these overlaps. In Table 2, counts for all seven possible combinations of applications are tallied. Note that unlike Table 1, the categories in Table 2 are mutually exclusive, and in this case the total column for each year is the sum of the counts in the other columns for that year. We have left the cells empty for the years where either the DO applicant data or the international medical student data are not available, because we cannot correctly categorize even the applicants we do have without knowing whether they applied to each of the three types of schools.
Despite the missing DO applicant and international student data for certain years, the study file that forms the basis for this analysis allows a good determination, for most years, of the number of applicants applying simultaneously to two or even three types of schools.
Because of the data limitations detailed above, 2004 is the latest year for which we have complete data for all three types of schools. Figure 1 shows, for 2004, the number of applicants to U.S. MD schools and DO schools and international medical students who made applications to one or more of the three types of schools. Approximately one in seven (5,189/35,735) applicants to a U.S. MD school also applied to a DO school in the same year. One in 45 (792/35,735) applied simultaneously and successfully to an international school, and fewer than 1% of U.S. MD applicants applied simultaneously to all three types of schools. More than two thirds (5,189/7,627) of DO applicants applied simultaneously to U.S. MD institutions in the same year, and 1 in 33 (234/7,627) DO applicants also applied to and was accepted by one or more international schools. A little more than 2% (177/7,627) of DO applicants applied in the same year to all three kinds of schools. Seventy-two percent (2,162/3,011) of international medical students apparently did not apply to either a U.S. MD or DO school in the same year.
Applicants to U.S. MD and DO institutions
Let us turn our attention to focus on the two types of U.S. institutions, to the applicants to U.S. MD and DO institutions, and to those who applied to both types of schools.
The overlap in the applicant pools for U.S. MD and DO schools is shown in Figure 2. Approximately two thirds of DO applicants also applied to U.S. MD schools in the same year. The high point for this statistic was reached in the mid-1990s, when the percentage of DO applicants also applying to U.S. MD schools reached 72%. In recent years, the percentage is about what it was in the early 1980s, about 68%.
When we link application data across years, we find that a substantial fraction of those who applied to DO schools, but not U.S. MD schools in any given year, had applied to U.S. MD schools in a prior year. In 2006, for example, when 3,083 students applied to DO but not U.S. MD institutions, 1,083 of the 3,083 had applied to one or more U.S. MD institutions in a prior year.
By contrast, the percentage of applicants to U.S. MD schools who also applied to DO schools in the same year has increased from only 7% in the early 1980s to approximately one in six or seven in more recent years. In 2006, it was 17%.
Common applicants to U.S. schools and international medical schools
As previously stated, data are not available for all applicants to international medical schools, but U.S. citizen students in international schools who register with the ECFMG may reasonably be assumed to have applied and matriculated in the international school two years earlier. Figure 3 displays the numbers of international medical students who applied also to U.S. MD or DO schools, either in the same year in which they are assumed to have applied to international schools or in a prior year.
The fraction of U.S. citizen international medical students who applied to a U.S. MD and/or DO school in the same year in which they are presumed to have applied to the international school has varied widely over the years, from only 9% in 1981 to 41% in 1993. Most of these same-year common applicants applied only to U.S. MD schools in addition to the international schools. A smaller number applied in the same year to all three types of schools, and a tiny fraction applied also to DO schools but not to U.S. MD schools in the same year. In recent years, upwards of 70% of new international students did not apply to a U.S. school in the same year.
When we link applications from prior years, however, we find that many of these students applied to U.S. MD or DO schools in a prior year. In 2004, only 28% of new U.S. citizen international medical students applied in the same year to U.S. MD or DO institutions, but an additional 34% had applied to a U.S. school in a prior year. Thirty-eight percent of new international medical students had no prior or concurrent applications to a U.S. MD or DO institution.
It may be that lead times for application to international schools are shorter, allowing students who are rejected by U.S. schools to apply successfully to foreign schools after they receive notice of rejection but, in many cases, in the same year.
At present, the applicant pool for U.S. MD programs is quite adequate, with 2.25 applicants per available entering class seat and 1.70 first-time applicants per seat, and with MCAT scores and grade point averages (GPAs) at an all-time high.1 DO schools had 2.67 applicants per place in 2007, and the quality of the DO applicant pool as measured by MCAT scores continues to increase. With the current rapid increase in the aggregate capacity of both U.S. MD and DO education, however, some are concerned that soon there may not be enough qualified applicants. Those concerned point especially to the number of first-time applicants, because total applicant numbers include students who have unsuccessfully applied previously, sometimes more than once before. The data in Table 1 do not address this concern. The table displays annual counts of applicants without duplication within the matriculation year, but a substantial number of applicants appear in more than one row of the table, because unsuccessful applicants often reapply in a subsequent year.
As one can see from Table 3, only 59% of the 2006 applicants to U.S. MD schools were applying to this type of school for the first time; some applicants had applied more than six times. The percentage of 2006 DO applicants who seem to be applying for the first time to a DO school is 85. Because data on DO applicants are not available for the years 1999–2001, a few of these applicants may have been misclassified by one or two; that is, a few who seem to have made their fourth, fifth, or sixth DO application might, in fact, have made their sixth, seventh, eighth, or even ninth or tenth. The pattern of applications indicates, however, that these uncertainties would be extremely small.
Ideally, we would have determined the number of first-time applicants to any type of school in each year, because this is a true measure of the potential applicant pool for any school or group of schools. Because complete data are available for U.S. MD applicants for every year from 1973 to 2007, and even taking account of the multiple application patterns displayed in Table 3, we know that we can determine the number of first-time U.S. MD applicants with great assurance. Data on international medical students who register for the licensure examination sequence are also complete. But, for DO applicants, the gaps in available data pose some problems. For example, because DO applicant data are missing for 1994, not only do we not know who the first-time osteopathic applicants are for 1994, but there will be problems with 1995 data as well. Some individuals who seem to be first-time applicants in 1995 will really have applied for the first time in 1994, but there is no way this can be known. As Table 3 demonstrates, this discrepancy is quite significant. The missing data for 1994 could theoretically result in overestimates of first-time applicants in 1996 and later years as well, but we would judge from Table 3 that these errors would be only a few percent in those years that are not adjacent to years with missing data.
For a detailed examination of the application patterns, we focus on the year 2004, the latest year for which we have data on international students. Data for that year should be little affected by missing DO data, because complete DO data are available for 2003 and 2002.
In 2004, 77% of first-time applicants to any medical program applied only to U.S. MD schools, 11% applied to both U.S. MD and DO schools, 5% applied only to DO schools, and 5% entered an international school with no U.S. MD or DO applications, leaving less than 2% for the remaining possible combinations. Figure 4 displays the actual number of first-time applicants for each combination of application school types. It is noteworthy that 72% of first-time applicants who entered a foreign medical school did not apply and had never applied to a U.S. MD or DO school.
We have determined the number of first-time applicants (and entering international students) to all schools for all years except for those years where DO or international medical student data are missing and those years immediately after the years with missing data. These results are combined in Figure 5 with data on the number of students who applied to U.S. MD schools for the first time.
As one can see in Figures 4 and 5 for those years where complete data are available, the difference between the total number of first-time applicants and the number of first-time applicants to U.S. MD institutions is surprisingly small. For the year 2004, there were 30,048 first-time applicants, and the number of first-time applicants to U.S. MD institutions was 27,122.‡
Most readers will not be surprised that U.S. MD institutions continue to play a predominant role in medical education, but enrollment in both DO institutions and international medical schools is growing rapidly. It will be worthwhile to explore the differences in applicant characteristics, including the prematriculation performance measures (scores on the MCAT and college GPAs) between applicants to the three types of institutions, and between applicants who applied to two or all three institutions and those who applied to only one. This additional analysis will be the subject of a subsequent report.
Many believe that a major expansion of enrollment in U.S. MD institutions will take applicants from DO medical schools and international schools, but these data show that there are not a great many more applicants to take. In 2004, if all first-time applicants to any medical school had applied to U.S. MD programs, the number of first-time applicants to these programs would have increased by only 11%. At the same time, DO enrollment is growing strongly, and competition for these first-time applicants may increase.
If past history is any guide, more applicants could be accepted, even without an increase in applicants. There were 1.65 first-time applicants for every matriculating medical student in 2006–2007. If the AAMC recommendation of a 30% increase in entering students over the 2002 baseline is achieved, even with no more applicants than in 2006–2007, this ratio would drop to 1.38. In 1988–89, when applications were at a low point, the ratio was 1.26. With mean MCAT scores and GPAs of applicants at an all-time high, admission committees could reach deeper into their applicant pools without materially increasing the number of students at risk of failure.1
Recent trends have shown a steady increase in the numbers of applicants to all types of schools, and it is possible that recently published projections of an impending shortage of physicians and reports of the creation of new medical schools and expansion of existing schools will stimulate additional interest in medical education. Even without an increase in the number of applicants, the number and quality of applicants seem adequate for the near term, but a number of factors make the future difficult to predict, and it would be wise to continue to monitor these trends.