In October, the Supreme Court heard Fisher v. University of Texas at Austin. You may have read about the case: the plaintiff, Abigail Fisher, applied for undergraduate admission to the University of Texas at Austin but was turned down. If she had graduated in the top 10% of her high school class, she would automatically have been admitted—but she did not.
When admitting students, the University of Texas first accepts all in-state students who place in the top 10%. This policy is race-neutral and fills about 80% of all spaces. The remaining seats are filled according to an evaluation process which considers six factors. Race is one of them.
Fisher is white and she claims that the explicit use of race as a factor in admission to the university violates the Equal Protection Clause of the 14th Amendment of the Constitution.
Within the next few months, the Supreme Court will announce its decision
What the Case Means for Medical Schools—and Patients
Last week, the New England Journal of Medicine published an editorial warning that the decision will “chart the future of affirmative action in American higher education . . . including admission of students to our nation’s medical schools.”
The editorial’s authors underline the need for a physician workforce that is ethnically and racially diverse:
“To provide good care, physicians must understand the communities and cultures in which they work. An important way to ensure that physicians understand the lives of their patients and to reduce health disparities is to promote diversity.”
I agree, and would add a second argument: if Fisher wins, the Court’s decision will leave millions of Americans without the medical care they desperately need because they live in a place where few physicians want to practice.
In this two-part post, I will be asking four questions:
1) How do we attract more physicians to underserved communities? Could we entice them with higher salaries? (Probably not. A doctor who doesn’t want to raise his kids in rural Alabama won’t set up shop there even if you double his income.)
2) Should we encourage medical schools to practice class-based rather than race-based affirmative action? This is, at best, a partial solution. A large percentage of low-income Americans are white. If they were admitted to medical school, those who grew up in rural areas might well decide to practice in similar communities where physicians are needed.. But this would not solve a larger problem—the shortage of Latino, African-American and Native-American primary care doctors available to work both in inner cities and in the many rural areas where minorities are rapidly becoming the majority.
Multiple studies show that outcomes, communication, and compliance improve when a patient is able to see a physician from his own racial or ethnic group. This is not to say that committed white physicians cannot overcome cultural barriers and build strong patient relationships in these communities. But many fewer choose to work, and raise their families, in remote rural areas that are primarily Latino, Native American, Mexican-American, or African American.
3) How do we attract more students who will wind up choosing primary care? (Reducing levels of debt does not seem to be the answer. Surprisingly, students who have no debt are least likely to go into primary care.)
4) Should medical schools re-think the criteria that they use when admitting students? In what ways? Should they change how and where they train medical students? Should the government revise the way it funds medical schools to reward institutions that produce more primary care doctors?
While health care experts debate whether we are facing a serious shortage of cardiologists, orthopedic surgeons and other specialists, one thing is clear: physicians are not well distributed in this country.
This is a long-standing problem. “In 2006, nearly 75 percent of U.S. counties . . . were designated Health Professional Shortage Areas (HPSAs). Areas that were not underserved had a surplus of more than 70,000 physicians” explains an article published in Virtual Mentor, the American Medical Association’s Journal of Ethics.
Building more medical schools, increasing admissions, or creating more slots for residents will only add to these surpluses. Physicians would continue to flock to Manhattan, L.A. and Miami, and their suburbs.
Indeed, in recent years, the number of physicians in the well-served areas has climbed while the number of doctors practicing in underserved areas has fallen.
A Shortage of Rural Doctors
HPSAs can be urban or rural, but the problem is particularly acute in rural America:
“While 21 percent of Americans live in rural areas, fewer than 10 percent of physicians practice in these areas,” reports the AMA’s Virtual Mentor. “As a result, rural residents (and the urban underserved) receive fewer preventive services and suffer from worse health outcomes.”
And the trend is accelerating: As of 2007, the American Association of Medical College notes that just 2.9% of medical students planned to practice in a small town or rural area. At the same time, “rural residents often are in greater need than their urban counterparts,” the same report observes. “For instance, rural communities have higher rates of chronic illness and disability and a poorer general health status than urban communities. Rural residents tend to be older and poorer than their urban counterparts.
“Rural residents have more health issues and adverse outcomes, and chronic conditions are more prevalent in rural areas. In addition, according to Healthy People 2010, injury-related deaths are 40% higher in rural communities than in urban communities, while heart disease, cancer and diabetes rates are also higher in rural areas.
These families desperately need primary care physicians: when hospital CEOs in rural areas are asked about physician shortages, doctors who practice family medicine appear at the top of the list.
Why We Need a Work-force that is Racially Diverse
Today, just 6.3% U.S. physicians are African American; 5.5 % are Hispanic. Meanwhile the demographics of this nation are changing. As the NEJM editorial points out: “We need to pick our medical students from a larger pool that does a better job of reflecting the diversity of the patient population.”
The need for Hispanic, African-American, and Native American doctors is growing not just because inner-cities are underserved because the number of low-income minorities living in rural America is climbing.
The population in rural and small town America shot up by roughly 3.5 million between 2000 and 2010, with minorities accounting for fully three-quarters of rural & small town population growth.
Here is an eye-popping number: Today, 25% of rural residents live in counties where the majority of the population belongs to a group that we now label a “minority.” By the middle of the century, Census Bureau statistics reveal that whites will comprise a majority in less than half of rural counties.
Multiples studies show that, particularly in the case of primary care and mental health care, outcomes improve “when patients are able to see a practitioner from their own racial or ethnic group. The quality of communication, comfort level, trust, partnership, and decision making in patient-practitioner relationships, all improve–thereby increasing use of appropriate health care and adherence to effective programs.”
Let me be clear: This is not to say that white doctors cannot be extremely effective when working in minority communities. But white med school graduates are less likely to choose to practice in inner cities or poor rural communities that are “majority minority”.
Over time, I suspect this may change. Over the next two or three decades, the U.S. will become more of a true “melting pot”; more Hispanics will speak English; we are likely to see more intermarriage; and both doctors and patients from different racial and ethnic groups will become far more comfortable with each other. But the patient-doctor relationship is based on trust, and it will take time for that trust to cross the barriers that exist today.
Physicians of All Races Tend to Head Home
Most physicians choose to practice in places where they feel comfortable—places that remind them of the communities where they grew up. The majority of today’s medical students were raised in affluent suburbs or cities. Is should not come as a surprise that they don’t want to move to inner city Detroit, rural Mississippi or even upstate New York..
As the cost of education rises, the percentage of students from high-income families grows. In 2000 50.8% came from families living on the top step of a five-step income ladder; by 2005, the share coming from the top quintile had grown to 55.2%. The American Association of Medical Colleges (AAMC) reports that the fraction of students from the lowest quintile remains below 5.5%
Research also shows that students from wealthy families are much less likely to choose primary care. This, too, makes sense. Money is relative, and it shapes expectations. If a student is coming from a family where his father earns $200,000 a year, the $186,000 median income for a primary care physician might well seem like low pay, not only to the student but to his family.
Like Wealthier White Students, Minorities and Students from Rural Areas Often Head Home
A recent survey of rural doctors points out that the “majority of physicians in this study mentioned ‘family ties’ as significant in their selection of practice location. While not all future rural health providers will necessarily want to return to their home communities for practice, this is a factor for many.For others, there may be a desire to return to a community similar to their rural home community.
A 2009 Graham Center study of “What Influences Student Choices” confirms these findings: “A rural background increases the odds that a student will choose to practice in a rural area by 2.4 times and nearly doubles the odds [that he will choose] Family Medicine. It also increases students’ odds of choosing primary care or serving in a community health center by approximately 50% and of serving in a shortage /underserved area by nearly 30%
“It is a potent marker if not a predictor of students who will make these important choices.”
Like students who grew up in rural American, low income minority students also are more likely to choose primary care. Many observers have argued that rising levels of student debt force students to choose the best-paid specialties. But the Graham Report refutes the conventional wisdom:
“The most comprehensive study of this issue concluded that students who choose primary care actually graduate with slightly more debt than their peers. This may be because these students are more likely to be from lower-income families and borrow more for their education than students in higher-income groups.” By contrast, “those from the highest socioeconomic strata who are most likely to be debt-free are also most likely to be interested in specialty care and in practice sites that afford them a similar lifestyle to that in which they were raised.”
Medical Schools Admit Fewer Students from Rural Areas –and Fewer Minorities
If we want to solve the problem of underserved communities, medical school admissions committees seem to be headed in the wrong direction.
The Graham Center report points to “significant declines in acceptance of rural-born students to medical schools” noting that this “overlaps so well with the declines in student interest in choosing primary care, rural practice, and care for underserved populations.”
“Admission of underrepresented minority students to medical schools” also “has fallen . . . despite an increasing or stable application rate,” Virtual Mentor observes. (In 2011, Hispanic admissions were up, but in recent years the trend has been anemic, at best.) “In the meantime, students of rural origin and those with an annual family income under $20,000 make up a disproportionately low percentage of medical school enrollment.”
The AMA’s Journal of Medical Ethics concludes: “Medical schools’ admission criteria seem to be at odds with society’s responsibility to produce physicians who care for the underserved.”
In part 2 of this post I will consider what medical schools might do to produce more students who would choose to practice primary care in underserved areas.