In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”(1), Fitzhugh Mullan argues that medical schools should be committed to their social mission, which is “…about making health not only better but fairer—more just, reliable, and universal”. This means commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, and increasing diversity within the health professions. He cites some medical schools as having made significant advances, including Morehouse, Mercer, Florida International University, and the AT Still Mesa Campus. But he also talks about “mainstreaming”, the need for consciousness about, and more important implementation of, social mission in all medical schools.
I believe that the most important measures of a health professions school’s social mission are its outputs, the criteria used by Mullan and colleagues in their seminal 2010 article (2): Are its graduates diverse? Do they practice more in underserved areas? Are they in primary care specialties? Studies show that a well-functioning health system needs at least 40-50% of physicians in primary care; the US is well below 30% and decreasing.
Because virtually all family physicians practice primary care and because family medicine is the specialty most suited for practice in rural areas, family medicine match rates are the most sensitive indicators of primary care production. In 2012, John Delzell and I looked at 10 years of data (2002-2011) from the American Academy of Family Physicians (AAFP), and found only a few schools were relatively high in both number and percent (3). But even those schools and the “socially conscious” schools cited by Mullan do not produce primary care physicians near the 50% rate. In 2015, Minnesota had the highest number, 42 (18.2%), but in 1999 it was first with 62!(4) We are headed in the wrong direction.
“Output variables” (income, status, and life experience) may be the most important in determining specialty choice. Many students graduate with very high debt, and many specialists earn far more than primary care physicians. Output variables are also the area in which schools have the least ability to influence. “Process variables”: a school’s curriculum; its vision and mission; the teaching of social mission, determinants of health, and disparities in classrooms and clinics; opportunities for students to serve in free clinics; and mentoring and role modeling by faculty are very important, but are clearly insufficient to motivate sufficient numbers of the students currently in medical school to choose primary care and practice in underserved areas.
Given the difficulty of effecting change through the output and process variables, in order to increase the number of medical students who will end up choosing family medicine or primary care, we need to focus on the “input variable,” that is on the question of who is admitted into medical schools in the first place. From the numbers, it is evident that medical schools do not admit students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups at rates anywhere close to their percentage of the population. Medical schools mostly admit white and Asian students from well-to- do suburbs of large cities who went to the “best” public and private schools, and have the highest grades and MCAT scores. However, the strongest predictor of where a student will practice is where they come from. Minority students are more likely to practice in minority neighborhoods; rural students are more likely to practice in rural areas; and white upper middle class students from the suburbs are more likely to practice in the suburbs. This is a problem because most of our medical students are from areas that already have an adequate number of physicians. In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people.
Further, the bachelors, masters, and doctoral graduates of nursing, pharmacy, psychology, physical and occupational therapy are whiter, more suburban, and from families with higher socioeconomic status than the overall population. The disparities within the graduating classes of these health professions may not be as extreme as the disparities within the graduating classes of medical schools, but the students who enter degree programs in nursing, for example, come from very different backgrounds than those who become LPNs or MAs. And it makes a difference. For example, many states are looking at training advanced practice dental hygienists to care for people in areas where there are no dentists. This is not going to work if the students for these programs are recruited, as they currently tend to be, from suburban areas.
In order to best serve American’s healthcare needs, health professions schools must ensure that admitted students have the demographic and/or personal characteristics that make them more likely to serve underserved populations. This would involve admitting students from rural, minority and lower socioeconomic backgrounds, and students with demonstrable past record of service, such as service through the Peace Corps, Americorps, Teach for America, etc. Second, we also need to urgently address the “output variables” to ensure that students who choose primary care do not suffer dramatic loss of potential income. Third, all health professions schools must also address the “process variables” through their formal and informal (“hidden”) curricula.
It cannot be stressed enough that these changes and programs must happen not just in medical schools, but at all health professions schools. Given the immediacy of the problem of unaddressed population health needs and the reducing numbers of health professionals capable of addressing them, the time for limited experiments and pilot programs is at an end. These efforts must be scaled up, or, in Mullan’s word, “mainstreamed”. And now is not too soon.