Education is the Key
I have been doing research, partly
assisted by Education Week state by state data, regarding medical school
These involve birth origin, education variables, the AMA Masterfile of US
physicians, and data from AAFP and the Robert Graham Center regarding Family
The effort most related to your recent article (accountability for education by
state) is the probability of admission to medical school, given rural or urban
birth in a state. I calculated a ratio of students admitted to medical school
1990 - 2002 who were born in rural parts of a state. My denominator was the
nonmetro live births of the state in 1966. This resulted in a ratio of 74 admits
from rural North Carolina for the most recent medical school graduates. This is
the lowest ratio. The highest was in metro DC with 1300 metro born students
admitted per 100000 life metro DC births. Actually, given more detailed census
data and income/education levels, DC would likely have the best and the worst
ratios. Across the nation, rural born students have half the probability of
admission compared to urban born. This level was 70% prior to medical school
expansion, fell paradoxically to less than 50% during 1970 - 1981 when medical
school positions doubled from 8000 to 16000, and has risen back to 50% in recent
The % of districts in a state that did not make AYP might be an interesting
variable, given NC with 80% although some controls on size and numbers might be
My studies on medical student choice involved regressions weighted for rural
population of the state of the medical school. The regressions explained over
70% of the variance. Medical schools with a higher MCAT average score, those in
eastern locations, those with less state education opportunity, those with a
lower percentage of students who older than 30 yrs at graduation, those with
less instate admissions, and those with a lower % born in rural areas all
graduated fewer family physicians.
I did similar regressions with choice of the other major physician specialties,
and none were significantly related to education variables.
The state education opportunity variable was the high school graduation rate
times the college continuation rate. Similar results were obtained using state
8th grade achievement score averages, teacher standards scores, median income,
and per capita education expenditures.
Studies of rural and inner city education note that these are the most costly
and difficult areas. Family physicians tend to come from lower income, rural,
inner city, and "different" sources. This seems to be related to socioeconomic
status, with rural, inner city, older, all being proxies for status. Studies in
the British Medical Journal confirm the admissions probabilities afforded by
status. Have not seen such for FP choice yet. Such studies are difficult in the
US because access to income, family origin, and ethnicity data are limited.
As far as rural born students, the key factor is again state education
opportunity. States with better college continuation rates admit more rural born
students to medical school. The other factor contributing is admissions
partnerships between medical schools and colleges or rural high schools. These
regressions explain about 44% of the variance.
The nation plans a 63% increase in population from 1970 - 2020, a 64% increase
in schoolteachers, a 56% increase in family physicians (likely less with
declines), and a 270% increase in total physicians, not including newly proposed
increases in total US physicians by expanding medical school positions.
DC is an interesting reflection on social status. At the lowest social status,
there is a 50 year life expectancy, with over 70 years at the high end. The
achievement scores are miserable. The expenditures are high for education and
perhaps higher for health. The abortion rate approaches 1000 per 1000 live
births, again related to education. Abortion rates are less than 50 per 1000 at
the highest status. Now add in the probability of admission to medical school at
the broadest range, from zero to 1300. For the lowest end we have to go to Great
Britain where blacks in the 5th or lowest social status have never been admitted
to Great Britain medical schools. Those in the highest status are rarely
rejected in comparison. There is no reason to believe that this is different in
I am not a great writer, but I have done some innovative research and would like
to do much more in this area. Clearly education is the key to better lives for
all of us, even those who are least aware of the need. The last time education
and medical education connected well, it was a high school principle named
Abraham Flexner who studied US colleges and then more expanded reports on
medical education that changed the nation, in medicine and in education. It is
my dream to visit widely with medical schools and educators to encourage
partnerships, similar to the many successful ones that exist, the ones that have
long been ignored despite great outcomes.
If fear that we are moving the other direction. Right now health care is eroding
education at all levels of government. This cannot continue. Somehow education
must become the top priority, with all other expenditures lower.
If we only planned 100% increase in schoolteachers, with the additions at the
lowest grades and in the most challenging districts.....
If we engaged medical education and other professional education to advance the
lowest levels, we would have even more in terms of education, health, and other
There are very few and very weak voices for "social responsibility" for medical
schools and many increasing and powerful voices for "market forces," the same
forces that could continue to divide our nation. Education is the key. It is the
primary means of social mobility and of facilitating the growth and development
of young professionals from underserved areas, the ones who actually do return.
A new generation of doctors is a small contribution compared to a new generation
of schoolteachers who understand such neighborhoods and peoples and work more
effectively in them, to bring forth a great and growing harvest of even more
young professionals and leaders from and for underserved areas. Right now we
need leadership that understand the long term approach that will bring us
progress, rather than short term efforts that are too little and far too late.
Robert C. Bowman, M.D.
Associate Professor, University of Nebraska Medical Center, Department of Family
Director of Rural Health Education and Research
Chair of Society of Teachers of Family Medicine Group on Admissions and also
Group on Rural Health