The ongoing need to encourage physicians to practice in rural areas has been well documented.1,2 The medical school admission process is an important juncture in the multistep process of producing rural physicians, particularly since applicants from rural areas are much more likely to enter primary care after medical school, more likely to locate in rural areas, and more likely to stay in rural practice for the long term.1,3,4,5 Surveys completed by the Association of American Medical Colleges in 19936 and 1994 (unpublished) revealed that more than 60% of responding medical schools offered extra consideration at some point in the admission process to candidates likely to enter primary care, and rural applicants were frequently listed as one of those groups. Therefore, admission practices that favor applicants from rural areas are a logical component of a medical school's effort to produce rural practitioners.
The current legal pressures against offering additional consideration to minority applicants in higher education admission have prompted medical schools to re-examine their individual admission practices. The bulk of the public and published debate regarding the effects of discontinuing additional consideration practices has rightly focused on the effects upon enrollment of underrepresented minority (URM) applicants.7 However, there has been little discussion about how these changes in admission policy might affect the prospects of other demographic groups of interest. The medical school examined in this study historically adjusted the pre-interview scores of rural applicants and URM applicants in order to assure that those groups were adequately represented in the cohort offered admission interviews. While the school was under no direct legal mandate to change these practices, the uncertain legal environment in large part led to the school's decision to discontinue all systematic additional consideration for the class matriculating in August 2000.
The purpose of this study was to evaluate the extent of the impact of discontinuing additional consideration to applicants from rural areas at one publicly-owned medical school in the Southeast. We tested the hypothesis that failure to adjust for rural applicant status has a marked adverse effect on the pre-interview ranks of rural applicants, resulting in fewer rural applicants' gaining admission interviews.
Admission process. At the medical school evaluated in this study (the Medical University of South Carolina College of Medicine), applicants are initially ranked employing a formula incorporating the undergraduate GPA, an adjustment to that GPA based on the selectivity of the applicant's undergraduate institution, and the Medical College Admission Test (MCAT) scores. This formula is unique to the medical school and produces a score called the academic profile (AP). The AP score has an empirical range of 2.58 to 14.90. The school's decision to adjust for selectivity was based on internal calculations comparing how medical students who graduated from undergraduate institutions having different selectivity strata performed during the medical school curriculum. The selectivity adjustment is determined by the Barron's College Admissions Selector rating of the applicant's undergraduate college or school.8 Applicants from “competitive” and “competitive+” schools receive 0.19 additional points added to their GPAs. Students from “very competitive” and “very competitive+” schools receive 0.34 additional points. Students from “highly competitive” or “highly competitive+” schools receive 0.50 additional points, and students from “most competitive” schools receive 0.55 additional points added to their GPAs. In a final adjustment to the AP score, an additional 1.5 points were formerly added to the AP score of all special-consideration applicants—rural applicants and URM applicants—but only 1.5 points could be awarded if someone was from both categories. Therefore, the adjustment for being a rural applicant could improve the applicant's pre-interview (AP) score roughly 10% to 63%. Then and now, applicants who obtain AP scores above a predetermined cutoff (based on data from the three preceding applicant cohorts) are offered three one-on-one interviews. After interviews, the applicants are re-ranked.
Participants. The participants we chose for this study were the 1996, 1997, 1998, and 1999 in-state applicants. Final rankings (and therefore offers for admission) were determined by either 20% AP and 80% interview score (1996–1998) or 50% AP and 50% interview score (1999). We did not include out-of-state applicants (they are ranked by a different method than are in-state applicants) or applicants who did not take the MCAT (those admitted by the Early Assurance Program). Out-of-state residents constitute fewer than 15 matriculants and Early Assurance Program fewer than ten matriculants out of 130–135 matriculants per year. The definition of “rural” used for this study was the same as used by the enrollment services department at the school: any county with a largest town of fewer than 10,000 population, a conservative but accepted definition1 determined from data provided by the state office of budget and control.
Analyses. Evaluating each applicant cohort separately, we first compared the MCAT scores, undergraduate GPAs, and selectivity classifications of the undergraduate colleges of rural and non-rural applicants. For ease of presentation in Table 1, we combined the three highest selectivity strata (those receiving 0.50 and 0.55 additional points to their GPAs) into a “highly competitive” group. However, for the actual rank calculations, we employed the strata separately just as they are used in the actual admission calculations.
We calculated the AP score and resulting pre-interview rank of applicants (a) without adjustment for being a rural applicant, and (b) with adjustment for being a rural applicant. We elected to stop at the pre-interview ranking because the rankings up to that point occur objectively. We did not feel that we could adequately control for the subjectivity of the interview or for the admission committee deliberation and final vote for each admission decision.
Finally, we calculated the proportion of rural applicants who would have received admission interviews with adjustment for being a rural applicant and without, using the total number of interviews completed in the years evaluated as the reference point. Any applicant with a pre-interview ranking higher than the number of interviews completed was counted as having been offered an admission interview. For example, 320 in-state applicants received admission interviews in 1996. Therefore, any 1996 applicant with a pre-interview ranking of 1-320 was counted.
Analyses were conducted separately for each class because the cohorts had varying proportions of rural applicants from year to year. Because of the multiple statistical tests we completed, we adjusted for the number of comparisons made (Bonferroni method). The institutional review board of the university approved this study.
There were 2,033 in-state applicants with complete data (not missing MCAT scores) in the four cohorts. The breakdown of subjects by class year was: 1996 applicants, n = 387; 1997, n = 507; 1998, n = 514; and 1999, n = 625. Rural applicants comprised between 8.5% and 9.7% of applicants, depending on the year. MCAT science scores for rural applicants were significantly lower in three of the four years (see Table 1), but Verbal Reasoning scores were not significantly different between rural and non-rural applicants. Mean GPAs were not significantly different either. In three of the four years, rural applicants were half as likely to have attended undergraduate schools in the more competitive Barron's categories, but these differences reached statistical significance in only one year—1998 (Table 1).
Median ranks for rural applicants vs. non-rural applicants, calculated without and with adjustment to the ranking for being a rural applicant, are shown in Table 2. Without the adjustment for rural applicant status, the median ranks of rural applicants were lower than those for non-rural applicants in all four years. Across all four years the adjustment for being a rural applicant had a marked positive effect for rural applicants while having minimal effects on non-rural applicants (see percentages, Table 2). The adjustment for rural status did not ensure an admission interview for every rural applicant, but it did mean that a large majority of the rural applicants received admission interviews in all four years. Without the adjustment, fewer than half of the rural applicants would have received admission interviews in two of the years evaluated—1997 and 1999.
This study illustrates the potential adverse effect of the changing environment in medical school admission upon the matriculation of rural applicants. We found a marked reduction in the proportion of rural applicants offered admission interviews when additional consideration and score adjustment were not applied. Rural applicants are a desirable group to the school studied and many other medical schools because data consistently show such applicants to be more likely to enter primary care and rural practice.3,4,5,9 In a 1995 survey of all U.S. medical school graduates, Kassebaum and co-authors showed that applicants from rural areas were 37% more likely to enter primary care specialties than were non-rural applicants.3 Rural origin of the applicant is also a factor that an applicant can manipulate less, especially when compared with other strong predictors of generalism as a specialty choice, such as “stated interest in primary care” at matriculation.3 Pathman, using 1991–1996 and 1997 data, showed that physicians practicing in rural areas who were “prepared for small-town living” were much more likely to remain in rural practice.5 It seems logical for schools with a mission to produce generalists and for practitioners who will practice in rural areas to recruit applicants who are from rural areas already.
The current legal environment may leave medical schools uncertain whether granting preferential consideration to rural applicants can continue.10,11 The Hopwood case and other legal decisions do not directly address the issue of whether preference can be granted to rural applicants, but they create an environment where such additional consideration is viewed with disfavor and may subject a medical school to legal challenge. In truth, the “cost” (fewer non-rural applicants gaining interviews) of the additional consideration to rural applicants was minimal, given how much benefit a rural state in need of rural practitioners might gain. If not allowed to use other, non-racial demographic characteristics such as rural origin in the admission process, schools will have to consider other methods to try to meet the physician workforce needs of the citizens and states in which they reside. Pre-medical programs, combined with medical school admission practices, would ideally serve only to feed into a system that continues interest in rural practice through medical school curriculum and residency training.1,9 Schools can indicate a clear mission to produce rural practitioners, support rural premedical experiences for interested undergraduates, encourage rural practitioners to participate in medical school applicant interviews, and evaluate whether other medical school admission practices (such as adjusting for undergraduate school selectivity) positively or negatively affect groups of interest.
The most significant limitation to this study is that it involved students who applied to only one Southeastern medical school. However, our applicants come from a wide variety of undergraduate schools (130 in the four cohorts evaluated here). In addition, we feel that our results are probably reflective of the experiences and applicant mixes of many publicly-owned medical schools. Nevertheless, replication of these calculations with applicants to other medical schools would certainly help assess the overall impact that discontinuing additional consideration policies may have on rural applicants. The data contained in our analysis file suggests an increasing number of applicants over the four-year period. However, this is an artifact of the student data system used, with older years used for these analyses not containing all applicants. The final year of data (1999) contains the same number of applicants that the office of enrollment services at the university reports as having applied in 1999, and the findings for that year are similar to those for 1996–1998. With similar patterns holding for all four years, we feel comfortable that the data are representative if not as complete for 1996–1998. A final limitation is that we evaluated only the effects of adjusting for rural status on pre-interview rank, not on how it might affect eventual offers for admission. However, the marked declines in rural applicants' offered interviews would almost certainly translate into fewer rural applicants' being offered admission.
In summary, we found that not adjusting for rural status in the admission process at one medical school would have markedly reduced the number of rural applicants offered medical school admission interviews.
1. Geyman JP, Hart LG, Norris TE, Coombs JB, Lishner DM. Educating generalist physicians for rural practice: how are we doing? J Rural Health. 2000;16:56–80.
2. Council on Graduate Medical Education. Tenth Report: Physician Distribution and Health Care Challenges in Rural and Inner-city Areas. Washington, DC: Health Resources and Services Administration, U.S. Department of Health and Human Services, Public Health Service, 1998.
3. Kassebaum DG, Szenas PL, Schuchert MK. Determinants of the generalist career intentions of 1995 graduating medical students. Acad Med. 1996;71:197–209.
4. Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. The impact of multiple predictors of generalist physicians' care of underserved populations. Am J Public Health. 2000;90:1225–8.
5. Pathman DE, Steiner BD, Jones BD, Konrad TR. Preparing and retaining rural physicians through medical education. Acad Med. 1999;74:810–20.
6. Keys-Welch M, Martin D. Generalist Physician Initiatives in U.S. Medical Schools. Washington DC: Association of American Medical Colleges, 1993.
7. Butler WT. Project 3000 by 2000: progress during tumultuous times. Acad Med. 1999;74:308–9.
8. Barron's Profiles of American Colleges, 23rd ed. Hauppauge, NY: Barron's Educational Series, July 1998.
9. Rabinowitz HK. The role of the medical school admission process in the production of generalist physicians. Acad Med. 1999;74(1 suppl):S39–S44.
10. Hopwood v. Texas, 78 F.3d 932 (5th Cir.), cert. denied, 518 U.S. 1033 (1996).
11. Edwards JC, Maldonado FG, Engelgau GR. Beyond affirmative action: one school's experiences with a race-neutral admission process. Acad Med. 2000;75:806–15.
12. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286:1041–8.