3) Medical School Admissions

 

Rosenblatt RA, Whitcomb ME, Cullen TJ, Lishner DM, Hart LG.

Which medical schools produce rural physicians?

JAMA 1992 Sep 23-30;268(12):1559-65

 

 

OBJECTIVE--To examine the hypothesis that medical schools vary systematically and

predictably in the proportion of their graduates who enter rural practice.

 

DESIGN--The December 1991 version of the American Medical Association Physician Masterfile was used to examine the rural and urban practice locations of physicians who graduated from American medical schools between 1976 and 1985. Selected characteristics of the medical schools--including location, ownership, and

funding--were linked to the Physician Masterfile.

 

MAIN OUTCOME MEASURES--The percentage of the graduates from each medical school who were practicing in rural areas in December 1991, disaggregated by physician specialty.

 

RESULTS--Of the practicing graduates from our study, 12.6% were located in rural counties; family physicians were much more likely than members of other specialties to select rural practice, particularly in the smallest and most isolated rural counties. Women were much less likely than men to enter rural practice. Medical schools varied greatly in the percentage of their graduates who entered rural practice, ranging from 41.2% to 2.3% of the graduating classes studied. Twelve medical schools accounted for over one quarter of the physicians entering rural practice in this time period. Four variables were strongly associated with a tendency to produce rural graduates: location in a rural state, public ownership, production of family physicians, and smaller amounts of funding from the National Institutes of Health.

 

DISCUSSION--The organization, location, and mission of medical schools is closely related to the propensity of their graduates to select rural practice. Increasing policy coordination among medical schools and state and federal governmental entities would most effectively address residual problems of rural physician shortages.

 

 PubMed Identifier 1308662

 

 

Glasser M. Stearns MA. Stearns JA. Londo RA. 

Screening applicants for a rural medical education program.

Academic Medicine. 75(7):773, 2000 Jul.

 

Abstract

     The goal of the Rural Medical Education (RMED) Program of the University of Illinois College of Medicine at Rockford is to train rural family physicians. This article

describes the screening instrument developed by RMED to identify appropriate candidates.

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Stearns JA. Stearns MA. Glasser M. Londo RA. 

Illinois RMED: a comprehensive program to improve the supply of rural family physicians.  Family Medicine. 32(1):17-21, 2000 Jan.

 

Abstract

BACKGROUND: Rural areas of the United States are perennially medically underserved, and the state of Illinois is no exception. A recent survey showed that 75 of

Illinois' 84 rural counties are primary care physician shortage areas. In response to this chronic physician shortage, the Illinois Rural Medical Education (RMED)

Program was developed by the University of Illinois College of Medicine at Rockford. The RMED program is a comprehensive, multifaceted program that combines

recruitment, admissions, curriculum, support, and evaluation components and is longitudinal across all 4 years of the medical school experience. The admissions process

seeks to select students who possess traits indicative of success in eventual rural family practice. These traits are fostered and developed by the 4-year rural curriculum,

which emphasizes family medicine, community-oriented primary care, the physician functioning in the context of community, relevant aspects of the "hidden" curriculum,

and service learning. After 6 years, RMED has graduated 39 physicians; 69% have gone into family practice, and a total of 82% have selected primary care residencies.

 

 

Boulger JG. 

Family practice in the predoctoral curriculum: a model for success.

J Fam Pract 1980 Mar;10(3):453-8

                      

 

                       Fifty-five percent of students who began their medical education at the University of Minnesota, Duluth, School of Medicine have elected family practice residencies. A coordinated and concentrated approach to admissions and curriculum, emphasizing family practice as an institutional goal, is described and discussed. As the national average for graduating seniors seems to have stabilized at approximately 13 percent, this approach may serve as a model for other institutions which wish to increase the number of family physicians. Family physicians are heavily involved in all aspects of

the teaching program. Institutional parameters which are necessary for success are briefly discussed.

 

                       PMID: 7354291 [PubMed - indexed for MEDLINE]

 

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 Sep 5;286(9):1041-8

 

 

 

                       CONTEXT: The Physician Shortage Area Program (PSAP) of Jefferson Medical College (Philadelphia, Pa) is one of a small number of medical school programs that addresses the shortage of rural primary care physicians. However, little is known regarding why these programs work.

                       OBJECTIVES: To identify factors independently predictive of rural primary care supply and retention and to determine which components of the PSAP lead to its outcomes. DESIGN: Retrospective cohort study.

                        SETTING AND PARTICIPANTS: A total of 3414 Jefferson Medical College graduates from the classes of 1978-1993, including 220 PSAP graduates. MAIN                                   OUTCOME MEASURES: Rural primary care practice and retention in 1999 as predicted by 19 previously collected variables. Twelve variables were available for all classes; 7 variables were collected only for 1978-1982 graduates. RESULTS: Freshman-year plan for family practice, being in the PSAP, having a National Health Service Corps scholarship, male sex, and taking an elective senior family practice rural preceptorship (the only factor not available at entrance to medical school) were independently predictive of physicians practicing rural primary care. For 1978-1982 graduates, growing up in a rural area was the only additionally collected independent predictor of rural primary care (odds ratio [OR], 4.0; 95% CI, 2.1-7.6; P<.001). Participation in the PSAP was the only independent predictive factor of retention for all classes (OR, 4.7; 95% CI, 2.0-11.2; P<.001). Among PSAP graduates, taking a senior rural preceptorship was independently predictive of rural primary care (OR, 2.5; 95% CI, 1.3-4.7; P =.004). However, non-PSAP graduates with 2 key selection characteristics of PSAP students (having grown up in a rural area and freshman-year plans for family practice) were 78% as likely as PSAP graduates to be rural primary care physicians, and 75% as likely to remain, suggesting that the admissions component of the PSAP is the most important reason for its success. In fact, few graduates without either of these factors were rural primary care physicians (1.8%).

                        CONCLUSIONS:  Medical educators and policy makers can have the greatest impact on the supply and retention of rural primary care physicians by developing programs to increase the number of medical school matriculants with background and career plans that make them most likely to pursue these career goals. Curricular experiences and other factors can further increase these outcomes, especially by supporting those already likely to become rural primary care physicians.

 

Rabinowitz HK, Paynter NP. 

The role of the medical school in rural graduate medical education: pipeline or control valve? 

J Rural Health 2000 Summer;16(3):249-53

 

 

                       Although rural-based graduate medical education is critically important in the training of competent rural family physicians, the number of physicians selecting these programs is highly dependent on what happens earlier in the pipeline, i.e., during medical school. Using the experience and outcomes research from Jefferson Medical College's Physician Short-age Area Program, as well as from published literature describing six other medical school programs with similar goals, this paper addresses the important role of these programs in substantially increasing the number of physicians interested in rural family practice. Although each of these programs differs in its structure, all contain three core features: a strong institutional mission; the targeted selection of students likely to practice in rural areas, predominantly those with rural backgrounds; and a focus on primary care, especially family practice. Outcomes show that all seven programs have been highly successful. Medical schools, therefore, can have a major impact on the number of rural physicians they produce by acting not only as a pipeline or conduit to residency programs, but also as a control valve, beginning as early as the admissions process. In order to maximize their impact on the supply and training of rural family physicians, rural residency programs should understand, support, collaborate with and help develop medical school programs whose mission is to provide rural physicians.

 

                       PMID: 11131769 [PubMed - indexed for MEDLINE]

 

Rabinowitz HK, Diamond JJ, Veloski JJ, Gayle JA. 

The impact of multiple predictors on generalist physicians' care of underserved populations. 

Am J Public Health 2000 Aug;90(8):1225-8

 

 

 

                       OBJECTIVES: This study examined the relative and incremental importance of multiple predictors of generalist physicians' care of underserved populations.

                        METHODS: Survey results from a 1993 national random sample of 2955 allopathic and osteopathic generalist physicians who graduated from medical school in 1983 or 1984 were analyzed.

                        RESULTS: Four independent predictors of providing care to underserved populations were (1) being a member of an underserved ethnic/minority group, (2) having participated in the National Health Service Corps, (3) having a strong interest in

practicing in an underserved area prior to attending medical school, and (4) growing up in an underserved area. Eighty-six percent of physicians with all 4 predictors were providing substantial care to underserved populations, compared with 65% with 3 predictors, 49% with 2 predictors, 34% with 1 predictor, and 22% with no predictors. Sex, family income when growing up, and curricular exposure to underserved populations during medical school were not independently related to caring for the underserved.

                        CONCLUSIONS: A small number of factors appear to be highly predictive of generalist physicians' care for the underserved, and most of these predictive factors can be identified at the time of admission to medical school.

 

                       PMID: 10937001 [PubMed - indexed for MEDLINE]

 

Rabinowitz HK, Diamond JJ, Hojat M, Hazelwood CE. 

Demographic, educational and economic factors related to recruitment and retention of physicians in rural Pennsylvania.

J Rural Health 1999 Spring;15(2):212-8

 

 

 

                       While prior studies have identified a number of factors individually related to physician practice in rural areas, little information is available regarding the relative importance of these factors or their relationship to rural retention. Extensive data previously collected from the Jefferson Longitudinal Study were analyzed for 1972 to 1991 graduates of Jefferson Medical College practicing in Pennsylvania in 1996, as were recent self-reported perceptions of Jefferson Medical College graduates in rural practice. Rural background was overwhelmingly the most important independent predictor of rural practice, and freshman plans to enter family practice was the only other independent predictor. No other variable, including curriculum or debt, added significantly to the likelihood of rural practice. None of these variables, however, including rural background, was predictive of retention, which appeared to be more related to practice issues such as income and workload. These results suggest that increasing the number of

physicians who grew up in rural areas is not only the most effective way to increase the number of rural physicians, but any policy that does not include this may be unsuccessful.

 

                       PMID: 10511758 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK. 

The role of the medical school admission process in the production of generalist physicians.  Acad Med 1999 Jan;74(1 Suppl):S39-44

 

 

                       Medical education research has identified a number of medical student characteristics that are related to graduates' entering generalist careers. These include initial specialty preference, geographic background, gender, age, ethnicity, economic and lifestyle factors, attitudes and personal values, service orientation, and premedical academic performance. Identifying and giving weight to these factors in the medical school admission process is likely to increase the number of graduates who choose generalist specialties. This paper discusses these medical student characteristics and presents strategies that medical schools could use in the selection process to enhance the matriculation of students who are most likely to become generalists. In this way, medical schools will be able to recruit and select students who are most likely to become excellent physicians, and also produce a more appropriate balance of all specialists to meet the needs of the population.

 

                       PMID: 9934307 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. 

A program to increase the number of family physicians in rural and underserved areas: impact after 22 years. 

JAMA 1999 Jan 20;281(3):255-60

 

 

                       CONTEXT: The shortage of physicians in rural areas is a longstanding and serious problem, and national and state policymakers and educators continue to face the challenge of finding effective ways to increase the supply of rural physicians.                                                 OBJECTIVE: To determine the direct and long-term impact of the Physician Shortage Area Program (PSAP) of Jefferson Medical College (JMC) on the rural physician workforce.

                        DESIGN:   Retrospective cohort study.

                        PARTICIPANTS AND SETTING: A total of 206 PSAP graduates from the classes of 1978 to 1991.

                        MAIN OUTCOME MEASURES: The PSAP graduates currently practicing family medicine in rural and underserved areas of Pennsylvania, compared with all allopathic medical school graduates in the state, and with all US and international allopathic graduates. All PSAP graduates were also compared with their non-PSAP peers at JMC regarding their US practice location, medical specialty, and retention for the past 5 to 10 years.

                       RESULTS: The PSAP graduates account for 21% (32/150) of family physicians practicing in rural Pennsylvania who graduated from one of the state's 7 medical schools, even though they represent only 1% (206/14710) of graduates from those schools (relative risk [RR], 19.1). Among all US and international medical school graduates, PSAP graduates represent 12% of all family physicians in rural Pennsylvania. Results were similar for PSAP graduates practicing in underserved areas. Overall, PSAP graduates were much more likely than their non-PSAP classmates at JMC to practice in a rural area of the United States (34% vs 11%; RR, 3.0), to practice in an underserved area (30% vs 9%; RR, 3.2), to practice family medicine (52% vs 13%; RR, 4.0), and to have combined a career in family practice with practice in a rural area (21% vs 2%; RR, 8.5). Of PSAP graduates, 84% were practicing in either a rural or small metropolitan area, or one of the primary care specialties. Program retention has remained high, with the number of PSAP graduates currently practicing rural family medicine equal to 87% of those practicing between 5 and 10 years ago, and the number practicing in underserved areas, 94%.

                        CONCLUSIONS: The PSAP, after more than 22 years, has had a disproportionately large impact on the rural physician workforce, and this effect has persisted over time. Based on these program results, policymakers and medical schools

can have a substantial impact on the shortage of physicians in rural areas.

 

                       PMID: 9918481 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK. 

Recruitment, retention, and follow-up of graduates of a program to increase the number of family physicians in rural and underserved areas. 

N Engl J Med 1993 Apr 1;328(13):934-9

                      

 

 

                       BACKGROUND. To help address the geographic and specialty maldistribution of physicians, Jefferson Medical College initiated the Physician

Shortage Area Program (PSAP) in 1974. This unique program, which combines a selective medical school admissions policy with a special educational program, has been shown to be successful in increasing the number of family physicians in rural and underserved areas, but it is not known whether they remain in this type of practice.                                   METHODS. Graduates of the PSAP were tracked longitudinally and compared with their non-PSAP classmates. Information was obtained about the retention of family physicians in rural areas and areas with a physician shortage over the previous five years, the geographic and specialty choices of more recent graduates, and the recruitment of applicants into the program.

                        RESULTS. Of the 47 PSAP graduates from the classes of 1978 through 1981, reported on earlier, the number who combined a career in family medicine with

practice in a rural area or one with a physician shortage remained unchanged, although there was substantial attrition among non-PSAP graduates practicing family medicine in rural (32 percent) and underserved (40 percent) areas. Among the 101 PSAP graduates of the classes of 1982 through 1986, the results were similar to those for the first four classes. Overall, PSAP graduates from the classes of 1978 through 1986 were approximately four times as likely as non-PSAP graduates to practice family medicine (55 percent vs. 13 percent), to practice in a rural area (39 percent vs. 11 percent), and to practice in underserved areas (33 percent vs. 8 percent). They were approximately 10 times more likely to combine a career in family medicine with practice in a rural (26 percent vs. 3 percent) or underserved (23 percent vs. 2 percent) area. Overall, 85 percent of PSAP graduates were either practicing a care specialty or practicing in a rural or small metropolitan area or one with a shortage of physicians. In parallel with national trends, the number of applicants and matriculants to the program decreased during the past decade, so that the percentage of available places filled decreased from 97 percent to 33 percent. However, there has been a recent increase in the number of applicants and matriculants.

                       CONCLUSIONS. The results of this study indicate that the PSAP was successful in increasing the number of family physicians in rural and underserved areas as well as in retaining them. This suggests that medical schools can have a substantial influence on the distribution of physicians according to specialty choice and the geographic location of their practices, principally through admission criteria.

 

                       PMID: 8446141 [PubMed - indexed for MEDLINE]

 

 

Rabinowitz HK.

Evaluation of a selective medical school admissions policy to increase the number of family physicians in rural and underserved areas. 

N Engl J Med 1988 Aug 25;319(8):480-6.

 

 

 

                       Jefferson Medical College initiated the Physician Shortage Area Program (PSAP) in 1974; this program preferentially admits medical school applicants from rural backgrounds who intend to practice family medicine in rural and underserved areas. Evaluation of the program has shown that PSAP graduates from the classes of 1978 to 1985 have performed slightly less well than their peers (non-PSAP) during medical school, although there was no difference in attrition between the two groups. Nor did the performance of PSAP and non-PSAP graduates differ during their postgraduate training. PSAP graduates from the classes of 1978 to 1981 were almost five times as likely as non-PSAP graduates to practice family medicine (59.6 vs. 12.6 percent, P less than 0.001), three times as likely to practice in rural areas (37.8 to 42.2 percent vs. 10.0 to 11.8 percent, P less than 0.001), and two four times as likely to practice in areas where there is a physician shortage (26.7 to 40.0 percent vs. 9.2 to 11.2 percent, P less than 0.01). They were 7 to 10 times as likely as their peers to combine a career in family medicine with practice in a rural or underserved area (24.4 to 31.1 percent vs. 3.1 to 3.9 percent, P less than 0.001), thereby fulfilling the goals of the PSAP. This study concludes that the medical school admissions process can have a major influence on the specialty choice and geographic practice location of physicians, and suggests one mechanism for increasing the number of family physicians in rural and underserved areas.

 

                       PMID: 3405255 [PubMed - indexed for MEDLINE]

 

                      

Rabinowitz HK.

Relationship between US medical school admission policy and graduates entering family practice. 

Fam Pract 1988 Jun;5(2):142-4.

 

 

                       Rural areas in the United States continue to lack an adequate supply of primary care doctors, particularly family physicians, despite the oversupply of physicians nationally. Previous studies have provided strong evidence that students from rural backgrounds, as well as those who expressed an interest at the time of medical school admission for a career in family medicine, are significantly more likely to eventually practice family medicine in rural areas than their peers. US medical schools were classified into three groups based on their written selection factors for preferentially admitting students into the graduating class of 1982. Of those schools with selection factors for students from both a rural background and an interest in a future career in family medicine, 23.7% of their graduates entered family medicine training programs. This compares with 14.5% of graduates from schools with a preference for students from a rural background, and 12.4% from all other schools (P less than 0.001). Coupled with previous data which shows that family physicians from rural areas are more likely to eventually practice in rural areas than their peers, preferentially admitting students from rural backgrounds interested in a career in family medicine could help to solve the problem of the shortage of primary care physicians in rural areas in the US.

 

                       PMID: 3391355 [PubMed - indexed for MEDLINE]

 

 

Michael H. Malloy, M.D., M.S.*, Christine A. Stroup-Benham, Ph.D.†  

Impact of Generalist Physician Initiatives on Residency Selection.  Medical Education Online

 

http://www.med-ed-online.org/issue2.htm#res00019 

 

              *Department of Pediatric

              †Office of Institutional Analysis

              University of Texas Medical Branch

              Galveston, Texas

 

              Objective:To compare the residency selection choices of students who experienced courses resulting from generalist physician initiatives to choices made by students prior to the implementation of those courses and to describe the characteristics of students selecting primary care residencies.

              Background:In the fall of 1994 a first year Community ContinuityExperience course was initiated and in the summer of 1995 a third year Multidisciplinary Ambulatory Clerkship was begun at the University of Texas Medical Branch in Galveston. These courses were inserted into the curriculum to enhance and promote primary care education.

              Design/Methods:We examined the residency selections of cohorts of graduating medical students before (1992-1996) and after (1997-1999) the implementation of the primary care courses. Survey information on career preferences at matriculation and in the fourth year of medical school were available for students graduating after the programs began. We compared the career preferences and characteristics of those students who selected a primary care residency to those who did not.

              Results:Prior to the implementation of the programs, 45%(425/950) of students graduating selected primary care residencies compared to 45% (210/465) of students participating in the programs (p=0.88). At matriculation, 45% of students had listed a primary care discipline as their first career choice. Among the students who had indicated this degree of primary care interest 61% ended up matching in a primary care discipline.

              At year 4, 31% of students indicated a primary care discipline as their first career choice and 92% of these students matched to a primary care residency. By univariate analysis, minority students (53%) were more likely to select a primary care residency than non-minority students (40%); students in the two lowest grade point average quartiles (55% and 50%) selected primary care residencies compared to 37% and 38% of students in the top 2 quartiles; and students who stated that income potential had little or no impact on their choice were more likely to select a primary care residency (48%) than those who said income potential was important (37%).

              Conclusions:We observed no significant trend towards higher proportions of graduating students selecting primary care discipline residencies as a result of implementing courses that emphasized primary care. Those students expressing an interest in a primary care discipline at their entrance into medical school were more likely to select a primary care residency. A more significant impact on graduating students interested in primary care may be made through the medical student selection process than by altering the curriculum.