Admissions By Income Quintiles

Robert C. Bowman, M.D.

Studies have demonstrated that those most likely to gain admission are the least likely to distribute to rural areas, underserved locations, and careers in primary care and family medicine. Those most likely to gain admission have the highest income levels, are children of professionals, were born in medical school counties, were Asian, or were foreign born (outside of economic desperation immigration). Comparing income levels to admissions ratios reveals a strong linear relationship.

Out of the 16000 allopathic medical students, and increasing yearly, this is what to expect by the income level of the admissions

Top Quintile or top 20% in Mean Household Income in the US involves 60 - 65% of allopathic medical students (AAMC Student Debt) and is increasing by 2 or more percentage points a year. (comparisons of AAMC Minorities in Medicine Reports) This group has a mean household income of $140,309 according to census data for 1997 adjusted to 2003 dollars. About 1 out of 60 who are medical school age are admitted to medical school (see table regarding Admissions), about 1 out of 20 if you are Asian Indian. Basically those that want medical school can get medical school in this income group. The students in this group grew up in high income and professional families and private schools in greatest percentages.

This group appears to have the least choice of family medicine, rural locations, and primary care poverty. There is supporting data for income and family medicine by Cooter and others. I verified the family medicine, rural, and office primary care poverty choices by student origins from the income levels of the top income counties, the counties with the top population density, and by top quintile of medical school based on MCAT scores. The income, population density, and income proxy variables did not appear to influence office based internal medicine, Cardiology, and Orthopedics.

Medical School County Birth is also a consideration beyond income. Those born in medical school counties may be more likely to be children of professionals or physicians.

Distribution by Income Levels

This quintile involves mostly white and Asian students and high income students of other ethnicities. Foreign born students are also contributors. There are fewer rural born students and older students. This group is likely to be the youngest students, those who are potentially less mature, and are the ones who are more easily influenced by surroundings such as charismatic faculty, medical school environment, peers, and health policy. In the Asian and white students of all income levels, there is very little difference between the scores and grades of those admitted or not. Ranking based on the MCAT or any other socioeconomic variable is certain to give the advantage to a student of slightly higher score, most probably due to socioeconomic advantage.Studies also note that Asian students, those with the most consistent advantage in socioeconomics, perform much better on the MCAT and less well on USMLE 1 than predicted.

2nd Quintile Income - About $65,812 in mean family income. This group of second highest income includes 18 - 22% of medical students. this group is average in income, in admissions level at 1 out of 209, and has a balanced choice of family medicine, rural, and poverty careers at the national averages. this group has at least some income and some access to better schools by ability to move, live in a nicer area, or private school.

Not so for the remaining three groups below that involve the remaining 20% of medical students (and decreasing). The remaining groups have poor schools, schools with teachers who are less likely to be qualified in subject areas, schools that are not college prep, and schools where out of 25 kids and 44 parents, only 5 or 6 show up for parent-teacher conferences. In the schools at the top, the parent teacher events are SRO.

3rd Quintile Income about $42,490 in income (9 - 13% of allopathic students) this group has half the level of admissions compared to average at 1 in 403. The choices of family medicine, rural careers, and poverty primary care are increasing and do so throughout decreasing income and increasing levels of poverty. This is a level of admissions similar for the averages of all Black students and rural students, and Native American students. Native students are difficult to assess depending on how "pure" the group is in terms of mixed race or not. 

Vietnamese are in this group in income, but have admissions ratios equal to the top quintile. Family and community efforts, structure, education emphasis, and new entry to America/not being enmeshed in generational poverty are some of the factors that shape better admissions for Vietnamese. Vietnamese also have about 20% choice of family medicine, like other lower income student types such as rural and Mexican American. All of these FP likely groups have greater first generation in the family to college levels.

4th Quintile  Income - About $25,256 in income (6 - 8% of med students) 1 in 706 gain admission. This area is reserved for black males and rural males and Mexican American males. Mexican American females have lower probability of admission somewhere between 4 an 5. Choice of rural, family medicine, and poverty primary care is moving up.

Bottom Quintile Income about $10,140 in income (1 - 3% of med students) because this group is small and variable, it is more difficult to calculate. According to AAMC MIM studies in 2004 matriculants, about 1.3% of this group had parents making less than $10,000 and 2.8% making $10,000 to $20,000. Therefore Only 1.5 to 3% of total medical students come from this lowest income quintile. An average is 1 in 2751 but the range for consideration would be 1 in 1600 to 1 in 4500.
This lowest income group most likely involves students with a combination of barriers. Gender plus race barriers for black males and white rural males and Mexican American females, Gender, race, rurality, and poverty barriers for Native American reservation females.

Anyone who attempts to use an MCAT as the major measurement to evaluate this group should be removed from further contact with medical school admissions. Other measures of admission and application are more likely to be relevant in who makes it and who does not. Each degree of separation from the top quintile in age, gender, income, education, college, language, culture, means that a fair standardized test is impossible.

This is the group that will have 10 - 15% failure rates, but studies demonstrate that it is impossible to predict the individuals who will pass and who will fail. Admissions committees that deny admission based on higher potential for failure, even though well intentioned, are taking away perhaps the only chance that these students will have at a level playing field in their entire lives.

This is the group that is most likely to choose primary care, rural locations, and poverty primary care locations, especially in states where education has not been such a barrier so that only those with elite test taking ability survived. It is also a group that may well be able to best understand those who are underserved. Of course it is a huge series of transitions from poverty survival realms to academic realms and also return.

Most of these students started out in generational poverty situations. By age 3 the top quintile preschoolers in professional families had more vocabulary and some have compared this to the vocabulary of adults enmeshed in generational poverty. Perhaps a more accurate rendition of this research is found in the Fresh Air interview of Geoff Nunberg, a researcher at Stanford Center for the Study of Language and Information and the author of the book "The Way We Talk Now." He noted the overinterpretation of the 1995 study by Betty Hart and Todd Risley, two researchers at the University of Kansas who looked at parent-child interactions among different social groups:

"Hart and Risley did find some striking differences. On average, professional parents talked to their toddlers more than three times as much as welfare parents did. And not surprisingly, that difference resulted in a big discrepancy in the children's vocabulary size. The average three-year-old from a welfare family had an active vocabulary of around 500 words, whereas a three-year-old from a professional family had a vocabulary of over 1,000 words. Those differences get more pronounced as kids get older and have an effect on their success in learning to read. In all, it's strong evidence for the need for early intervention. By the time the low-income kids get to school and start to learn to read, they're already at an enormous disadvantage."

This poverty group had to learn to survive based on relationships, entertainment, and some very different rules than those in an academic professional world. (from Ruby Payne's web site)

For those in the lowest quintiles, getting out of generational poverty means superior ability in relationships, superior education, and unbelievable dedication - sounds like the prerequisites for an excellent primary care physician for the most challenging locations.

Even though the lowest income group is most likely to serve the underserved, this does not always mean rural or family medicine. Those who do tend to make it are inner city, urban, and live in the northeast or south where there are the greatest disparities between rich and poor and also where FP and rural choices are the lowest in the nation compared to the Midwest and West.

Urban primary care poverty is a good bet for these graduates if there is enough support for them in college, if admissions gives them consideration, if there is support for them in medical school, and if the military or an academic position does not get them sometime between medical school and residency graduation. Especially in those choosing family medicine, the military and academic FP takes big cuts out of these most valuable distributional primary care workforce who would likely choose rural underserved or urban underserved. In many ways both of these careers allow them to value the family structure and family orientation that allowed them to escape poverty, and also make a contribution to those most similar to their origins. The losses due to military and to academic FP are not accounted for in the Federal Title VII (primary care funding) studies so far.

Without saturating the needs for professionals of all types that are more likely to serve the underserved, there will always be "losses" that are not accounted for until the nation has more equitable distribution of education and income.

The author was not granted income or MCAT data, but there are proxies for income such as birth county income and birth county population density. The distribution of rural physicians and the choice of family medicine and office based primary care in poverty locations is clearly related to socioeconomic origins.

As a practical note, the most dominant groups are higher income, and these students numerically are the most likely to be found in underserved areas and rural areas in practice. However when percentages are considered, fewer of the urban high income types are found where they are most needed. Gaining on health access is about graduating those with a higher probability of distribution, and enhancing the probability of distribution. Admitting those of the lowest probability and then detracting from this with health policy is not a reasonable course of action.

Medical School County Birth

Admissions Ratios and US Medical Students

Distribution by Income Levels

Physician Workforce Studies

www.ruralmedicaleducation.org