The characteristics of future physicians

In my blog from 2/4/11 "Why do we put so much import on the MCAT?", I discussed some of the negative characteristics that can be associated with a higher MCAT. The conclusion of the article by Dr. Gough¹ was that students with higher MCATS and a scientific orientation were found to "less adept in interpersonal skills, less articulate, narrower in interests, and less adaptable than their fellows". 

Wow!  I don't think those are characteristics that I want in my doctor.  What about you?

What are the characteristics that we want in our medical students? We want them to be great at science, right?  On average, academic performance in undergraduate classes only predicted about 9% of the variance in medical school performance.² What about MCAT? We want them to have a high MCAT, right? Well, a high MCAT is good at predicting performance on the USMLE step 1 and preclinical grades,³ but as someone who is really smart once told me "we are not trying to make step 1 passers".

Sade and colleagues asked this same question a few years ago. Their specific question was to identify the specific characteristics that are important qualities of a superior physician. They also asked which of these qualities are hardest to teach in the medical curriculum. They based their work on a study by Price, et al⁴ who had previously generated a list of positive traits associated with a superior physician.  

Dr. Sade took this list of traits and showed them to the faculty of the College of Medicine at the University of South Carolina. The faculty were asked to rate the personal qualities on a scale of 1-10, where 1 is non-teachable and 10 was easily teachable. The survey was sent to all of the faculty at the college of medicine. They also asked a select group of experienced medical educators to take the survey. There was remarkable agreement between the faculty, greater than 80% inter-rater reliability. There was also a high correlation between the basic science faculty's ratings and the clinical faculty's ratings of the importance of characteristics (r=0.87, p<0.001) and the teachability of characteristics (r=0.93, p<0.001). 

The outcome of this survey was a list that ranked the characteristics from 1 to 87.  Each characteristic was given a rank for importance and for difficulty in teaching. The authors converted the rankings to a Z-score. (***Note: This was my favorite line in the manuscript...)  "The teachability Z-score was subtracted from the importance Z-score, and the combined Z-scores were multiplied by 10 and added to 50."  This gave a combined score that they called the NonTeachable-Importance Index (NTII). The NTII gives you a list of characteristics that are ranked from highest to lowest based on importance and the difficulty of teaching it to medical students.

That sounds like a good list of pre-matriculant variables to me.  If we can't easily teach it but it is important then obviously we should select students that have these characteristics before coming to medical school.

Using the NTII ranking, some of the characteristics are obvious: (1) is emotionally stable; (2) is a person of unquestionable integrity; (5) is unusually intelligent; and (6) has sustained genuine concern for patients during their illness.  Some are less obvious but seem really important: (9) is motivated primarily by idealism, compassion, and service; (14) is able and willing to learn from others; (17) is observant; and (18) is adaptable. The list goes on from 1 to 87. 

The characteristic that was ranked as the most difficult to teach was: is unusually intelligent. The next four were: (2) is naturally energetic and enthusiastic; (3) is imaginative and creative; (4) has a warm, friendly, outgoing personality; and (5) is motivated by sheer liking of people.

So why are we still choosing medical students based on the MCATs and GPAs? Maybe, we should be looking at these factors.

Next time, I am going to write about personality factors that influence medical student performance.

References

(1) Gough HG. Some Predictive Implications of Premedical Scientific Competence and Preferences. J Med Educ  1978; 53: 291-300.

(2) Ferguson E, James D, Madeley L. Factors associated with success in medical school: systematic review of the literature. BMJ  2002; 324: 952–7.

(3) Donnon T, Paolucci EO, Violato C. The predictive validity of the MCAT for medical school performance and medical board licensing examinations: a meta-analysis of the published research. Acad Med  2007; 82(1): 100-6.

(4) Price PB, et al. Measurement and predictors of physician performance: two decades of intermittently sustained research. Salt Lake City: Aaron Press, 1971; 121-149.

Why do we put so much import on the MCAT?

Every year thousands of potential medical students spend a lot of time and money to study for the MCAT. Students spend a lot of money, for example,  $1,749 to take the Kaplan Complete MCAT Preparation and $1,000 for the Princeton Review. Why?? They spend this money preparing themselves to sit for this life changing examination. The test itself is actually comparatively inexpensive-- $235 dollars. 

The worst part is that the MCAT is probably not measuring any of the most important variables for our matriculating medical students. I have been on the admissions committee at two different medical schools.  Both were State supported medical schools with a strong commitment to graduating students interested in primary care, rural practice, and practice in underserved areas. But at the Admissions Committee level there is a serious lack of understanding of the importance of pre-matriculant noncognitive data and the variables used to select students to enter the school. Many of my colleagues (physicians and basic scientists) over the years have held the belief to some extent or another that higher pre-admission scores lead to better medical students which leads to better doctors.

Nothing could be further from the truth. In fact, for most of the variables there is very little correlation. And even more worrisome for many of the important characteristics of being a physician, there is an inverse relationship.  At this point, many of you are thinking, "Delzell is completely off his rocker!". In fact, one of my basic science colleagues said as much last year.  Well, that may be true, but I do have evidence to back up these statements.

Let's go back. Way back, to 1978. Harrison Gough, PhD, a psychologist at the university of California-Berkley, published one of the most fascinating studies (1) that I have seen in the medical educational literature. It is also one of the best written papers that I have ever read, and as an editor for a major medical journal I get to read a lot of manuscripts. Dr. Gough collected data on medical students from the University of California-San Francisco from 1951 to 1977. Wow! That is like the Framingham study of medical students. A longitudinal study of a medical school and its medical students.  This study reports on 1,195 UCSF students from 1972 to 1977. Data collected included MCAT scores, undergraduate GPA, and a measure to assess scientific preferences.  He created a composite index score by adding the "measures of scientific talent" (MCAT Science subtest and Undergraduate Science GPA) to Science Preference.

Science Preference is a fascinating concept that was developed by Goldstein (2) and modified by Dr. Gough. Students rated the three subjects from college that they liked best and the three that they liked least. The average score for the three least liked subjects was subtracted from the average score for the three subjects liked best. This gives an overall score, which was termed the students' preferences for science.  

The next step was to measure correlations between these measures and performance during medical school. He looked at grades in all four years of school. As you would expect, there was a significant correlation between the composite index and GPA in year 1 (Pearson Product- Moment correlation .34; p < 0.01) and year 2 (Pearson Product- Moment correlation .21; p < 0.01). But, there was no significant correlation with GPA in years 3 and 4. More importantly medical school faculty ratings of clinical competence and general competence were not significantly correlated (Pearson Product- Moment correlation .01; p = ns).

Ok, so maybe MCAT and GPA are not great at predicting things after the first two years but those years are important. Right???  Someone very smart once told me, "they would be really important if we were trying to make Step 1 passers, but we are not trying to make Step 1 passers, we are trying to make doctors."

Fortunately, Dr. Gough didn't stop there, there was another part to his study. He selected 70 students for an intensive study of personality at the UC- Berkley Institute of Personality Assessment and Research. The students were evaluated by 10-15 trained assessment staff members. Students were observed closely for an entire day and the staff members described them using a 300 item Adjective check list. These descriptors were then correlated with the four previously evaluated science predictors for each student.  

There was no statistical correlation between MCAT scores and personality descriptors. But, Science GPA was correlated with "painstaking"(r =.26) and "silent"( .26). There were negative correlations with adjectives such as "poised" (r = - .32), "self-controlled" (- .30), and "interests wide" (- .27).  When compared to the composite index there were also several significant correlations, such as "awkward" (r = .27), "cautious" ( .23), and "conservative" ( .27).  The composite index was negatively related to several descriptors, such as "stable" (r = - .28) and "relaxed" (- .28).  

Each of the students was also judged by all of the observers. The reliability of their judgment is striking. The inter-rater reliability was greater than .80.  The students with higher composite index were rated lower in their ability to communicate (r = - .28), breadth of interests (r= - .35), self-acceptance (r = - .26), and verbal fluency (r= -.29). All of these correlations were significant. By the way, the MCAT by itself also had a negative correlation with every measure, with r values between - .11 and - .20.  Dr Gough's conclusion was that scientifically oriented students were "less adept in interpersonal skills, less articulate, narrower in interests, and less adaptable than their fellows.". 

Wow! That is amazing. Why didn't anybody tell about this when I joined the admissions committee? For my next blog, I am going to write about some important characteristics of future physicians and how we can better select students that will have those characteristics.

References

(1) Gough HG. Some Predictive Implications of Premedical Scientific Competence and Preferences. J Med Educ  1978; 53: 291-300.

(2) Goldschmid ML.  Prediction of College Major by Personality Tests. J Counseling Psychol  1967; 14: 302-308.

Dr Jerry Kruse's Seussian rhyme

The following Seussian rhyme was imagined and written by Dr Jerry Kruse, Professor and Chair, Department of Family & Community Medicine, Southern Illinois University School of Medicine.
It was given during the final plenary session at the 2011 STFM Conference on Medical Student Education.

The Saga of Michael Klein

Or…..

 Ein Kleiner Schnitt

Or…..

The Triumph of Reason Over Power, Finally!

By Dr. Kreuss*

In that faraway land to the North, in Quebec,

Lived a doctor whose practice was very low tech.

A family doc, accoucher Michael Klein,

Who didn’t like forceps or women supine

Or ‘lectronic monitors, stirrups or sections

Or enemas, shaving or IV injections.

He hated electrodes and IUPC’s

And treatment of labor as if a disease.

And one of the worst – epidural blockade –

A stab in the back to start the cascade

Of catheters, tubing, Nubain and pit

And Sulfate of Mag so she won’t have a fit.

Blood pressure cuffs and punctures of veins,

Cesarean Sections and Tucker-McLains

Retained placenta, post partum metritis

I’ll bet you a buck she’ll come down with mastitis.

“I don’t like these women to all be strapped down.

Stand up and walk!”  he cried with a frown.

Michael knew in his heart, way deep down inside

That obstetrical knowledge was not well applied. 

“Technology’s great, for those who are ill,

But for those who are healthy it’s really no thrill

To be strapped down and poked, and scared stiff as a board.

This just isn’t right!”, his fervent voice roared.

One thing more than others, did gnaw at his heart,

Made his blood boil, and stung like a dart

He just couldn’t stand it, to see a long slice,

A cut, an epis - what a terrible vice,

Disruption of skin for no reason at all,

A snip with the scissors that starts very small

But rips and extends as the baby comes through

Tears into the sphincter and up the wazoo.

A third, then a fourth, oh my what a mess

“They must like to sew, is my only guess.”

So Michael jumped up, and he raised his right hand

And opened his mouth, and he took a firm stand

“I’ll study this problem,” he said with a shout

“And when I am finished there won’t be a doubt

That these cuts are no good…the whole world will see….

This idea’s a good one, they’ll have to agree.

I’ll start up a randomized, single blind study

And I’ll work with Michel who’s my very good buddy

And we’ll put ole’ McGill right here on the map.

This study of perineal trauma’s a snap.

“We’ll put in a grant, we’ll get recognition.

We send all this stuff to a good statistician.

Our alpha will be less than point zero five

And beta point two will let us derive

The number of women we’ll need.  It’s a slew.

We’ll enroll ‘bout a thousand five hundred and two.”

He worked and he toiled, he felt quite convicted—

The results were exactly the ones he predicted.

“Midline epis, when routinely done

For women in labor, is not very fun.

Our EMG’s show that sliced muscles get weak,

They heal up quite slowly and let urine leak.

And that isn’t all that comes out that should not.

She’ll find our real quick when she sits on the pot.

“The relative risk for a fourth degree rip

Is greater than twenty, with each little snip.

And all of us know, if the rectum is torn

That a permanent hole will often be born

That connects the vagina and rectal mucosa

And where it comes out then will make you nervosa.

So my warning to you, who practice OB

Is to use the epis quite conservatively.

Don’t be in a rush, and don’t interfere

Throw down the scissors, they’re not needed here.”

Now Michael was proud, and really excited

With his results he was very delighted.

He wanted to spread the good news he had found

He wanted to broadcast this stuff all around,

But a funny thing happened.  He couldn’t believe it

No one would listen, they just couldn’t perceive it.

The doctors in charge of the medical journal

The ones who are experts in issues maternal

Did not want to hear about data that’s new.

It was hard to convince that conservative crew.

“No one will believe it,” the editors cried

And they wrote down “REJECTED” with feelings of pride

And one after another they all did the same.

They suppressed this great knowledge – oh my what a shame!

But this story’s not over, he didn’t back down

He battled the towers who sport cap and gown.

Then once, then again and a third time, it’s true

His papers were granted another review.

And though eight years late and quite overdue

All three ended up in the publishing queue.

And now the world knew, both up in the North

And in states to the South, the new message went forth.

The paradigm shifted, the good word was this:

“The epis is archaic, and you’ll be remiss

To ignore this great knowledge that newly exists

And to squander this chance to cause perineal bliss!”

The rēsearch of Michael had ended the reign

Of procedure and practice we all thought mundane,

Of cuts and incisions most surely inane

And the scissors were thrown to the floor with disdain.

In just over a decade, the rate of epis,

Of pelvic dysfunction and fourth gaping degrees

Had tumbled to levels that went far below

The figures observed just a few years ago.

From sixty percent of all getting cleaved

To just nine in a hundred a cut to receive.

“Never give up!”  Michael’s voice still rings clear.

The moral today is to be of good cheer

To persistently fight, in the face of all the odds.

To battle ideas of conventional gods

To fight for new facts, and new evidence find

To give power to reason and sight to the blind.  (THE END).

*Dr. Kreuss                 Jerry Kruse, MD, MSPH

                                    Professor & Chair

                                    Department of Family & Community Medicine

                                    Southern Illinois University School of Medicine

                                    Springfield, Quincy, Carbondale and Decatur, Illinois

Bibliography:

1.      Klein MC, Gauthier RC, Jorgensen SH, Robbins JM, Kaczorowski J, Johnson B, et al.  Does episiotomy prevent perineal trauma and pelvic floor relaxation?  Online J Curr Clin Trials, Doc 10, July 1, 1992.

2.      KIein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, et al.  Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.  Am J Obstet Gynecol 1994; 171:591-8.

3.      Klein MC, Kaczorowski J, Robbins JM, Gauthier RJ, Jorgensen SH, Joshi AK.  Physician beliefs and behavior within a randomized controlled trial of episiotomy; consequences for women under their care.  Can Med Assoc J 1995; 153:769-79

4.      Huston P.  The pursuit of objectivity [editorial].  Can Med Assoc J 1995; 153:735.

5.      Schultz KF.  Unbiased research and the human spirit: the challenges of randomized controlled trials [editorial].  Can Med Assoc J 1995; 153:783-6.

6.      Klein MC.  Studying episiotomy:  When beliefs conflict with science.  J Fam Pract 1995; 41:483-8.

7.      Frankman EA, Wang L, Bunker CH, Lowder JL.  Episiotomy in the United States:  has anything changed?.  Am J Obstet Gynecol 2009; 200: 573.e1-573.e7

8.      Hyer R.  ACOG 2009:  Steep decline in episiotomy rates credited to research, peer pressure.  ACOG 57^th Annual Clinical Meeting, Medscape Medical News.  http://www.medscape.com/viewarticle/702541

The rhyme contained in this blog is the intellectual property of Dr. Kruse and cannot be copied without his express consent.  Thanks. JED

The STFM Conference on Medical Student Education

Last week I had the privilege of chairing the 37th annual STFM Conference on Medical Student Education. Until 2010, the conference was known as the STFM Predoctoral Education Conference. We changed the name to the Conference on Medical Student Education. You may not know much about STFM. The Society of Teachers of Family Medicine is my academic and professional home. All of my mentors, my teachers, my peers, and my colleagues are in STFM. It is a great organization. The Conference on Medical Student Education is a premier educational meeting that includes most of the family medicine educators from around the country. 

Let me give you some highlights of the meeting. 

We started the meeting with an amazing plenary speaker. Dr Kevin Eva, Senior Scientist from the Centre for Health Education Scholarship (CHES) at the University of British Columbia in Vancouver, Canada. Dr Eva gave an invigorating talk about medical decision making. My favorite concept from the talk was that we have to make errors in order to get better, and maybe more importantly, we as educators have to provide safe environments that allow students to make those mistakes. His talk is posted on FMDRL.

There was a great talk by Stacy Brungardt, CAE (Executive Director of STFM) about the alphabet soup of family medicine. She described several of the organizations that make up the "family" of family medicine (AAFP, CAFM, COGME, etc...). There was an excellent peer session describing a study of teaching students about the Four Habits model of patient-centered communication, by Dr Hannah Maxfield and colleagues. (full disclosure here, Drs. Maxfield, Zaudke and Chumley are my colleaguesy at KU)

Dr. Chumley and I presented some of our data about using Artificial Neural Networks to classify students' information gathering patterns to make a diagnosis. We looked at 200 students' performance on a standardized patient case, with a 22 item checklist. We used the first 100 patients to train the ANN, and then we tested the neural network with the second 100 cases.  We found that the ANN was able to predict whether the student got the right or wrong answer/diagnosis with a 85% accuracy.  This was better than two other standard classifiers called Bayesian and KNN (K Nearest Neighbor).

There was an awesome dance party on Friday night that brought together faculty (old and young) with medical students.  

The Saturday morning plenary was by Dr Cathy Pipas from the Dartmouth medical college. Dr. Pipas is the Vice Chair of Community and Medicine. She gave a stimulating talk about the transformation of the Dartmouth practices to patient centered medical homes. The scary part of that talk was that the senior administration at Dartmouth have still not aligned the financial incentives with the clinical practices that are transforming to PCMHs.

Drs. Jana Zaudke and Hannah Maxfield presented an interesting randomized trial of giving feedback about the Four Habits model of communication after watching the students perform on a standardized patient.

On Sunday morning Dr. Joshua Freeman moderated a special session on social justice and family medicine. There's were several medical students at the session and we had a great discussion after his talk.

The final plenary for Sunday morning was Dr. Jerry Kruse. Dr. Kruse is the Chair of the Department of Family and Community Medicine at Southern Illinois University School of Medicine. I asked Dr. Kruse to talk about his views of health care reform. He said that there are two different and divergent views of healthcare reform and its importance to the nation's progress toward the future.  He called the passage of the health care reform bill last year, "the triumph of reason over power". Dr Kruse is famous amongst his friends for his poetry. He gave the most amazing Seussian rhyme describing the saga of Dr Michael Klein, the Canadian doctor that studied the routine use of episiotomy. Dr. Kruse gave me permission to post the lyrics of this poem for your edification. Look for it coming in a couple of days.

Dr. Kruse also presented the new COGME report, "Advancing Primary Care" and its recommendations. The most important recommendation from COGME was that the percentage of primary care physicians should be at least 40% of all physicians.

Overall, this was a great meeting.  Thanks to all of the presenters for your great work. Thanks to all the attendees, including over 200 students attending the national student-run free clinic forum. Thanks to the STFM staff for your hard work, in particular Ray Rosetta, the hardest workin' man in the conference business.  Next year, the meeting will be February 2-5, 2012 in sunny Long Beach, California. The Call for Papers opens in March, so get ready!

Criteria for selecting students in the Match

We are fast approaching a very important day in the academic calendar. On February 23, 2011 residency programs around the country have to enter their Rank Order List. This day is the culmination of a lot of work by the Program Director, faculty and residents from the program, and from students applying to that program. The actual day that the results of the Match are released is about a month later on March 17. But the work is all done once the lists are in on February 23.

You may not understand this process, so let me walk you through it. Medical students around the country decide what specialty they are interested in applying to at some point during the third year of medical school. Students gather letters of recommendation from faculty over the next several months. Frequently, they will do a fourth year elective rotation in their specialty of interest. They also have to decide if they are going to try to go to another school and do an “away” rotation. For most students, they are obligated to enter the National Resident Matching Program.  If they are a fourth-year student at an allopathic medical school in the US, they have no choice but to enter the Match.

Beginning in October, students begin their job interviews. We call these residency interviews, but honestly the students are trying to land a job as a resident in a particular program. Students will have anywhere from 10 to 40 interviews depending on the competitiveness of the specialty that they are applying to enter. These interviews may be anywhere across the country, but are mostly in larger cities (that is where the teaching hospitals are located).

So, on February 23 the students enter their Rank Order List. The program that they like best is Number 1. Their least favorite is last. Residency programs do the same. They rank all of the students that they interviewed from 1 to however many they want to rank.  The programs don’t have to rank all of the students that they interview, and the students don’t have to rank all of the programs.  But the Match is a binding contract,¹ if they rank someone (student or program) they are legally bound to that ranking.

The question for today is how do programs decide how to rank the students that they interview? There are several ways, some good, some really bad! Let’s start with the good ways.

Letters of recommendation can be very helpful, if they are written by honest faculty physicians, who know the student, and have personally worked with a student. These letters can be a great assessment of a student’s global performance. An old study by Keynan, et al ² done in 1987 compared objective faculty ratings to other types of assessment. This study compared a global faculty rating, a multiple choice question (MCQ) test, and an oral examination.  They found that the “the 'subjective' expert assessment of performance through global rating scales is comparable to that of 'objective' evaluation through written MCQ.” They also found, using a stepwise regression analysis, that the ratings of 'reliability', 'knowledge', 'organization', 'diligence,' and 'case presentation' were the most predictive of the overall global rating. Chair’s letters which are often written by the Chair of a department (who probably does not know the student very well) are generally not much help.

Another good way to rank students is through an interview. Skilled interviewers can pick up on many communication and personality issues that probably don't show up on a paper application. Maybe the applicant is very introverted and has difficulty talking during the interview. Or maybe they are a jerk or a racist or a sexist. A personal interview can pick up these problems (not always, but often).

Unfortunately, there are also some bad ways to rank students.  Commonly, grades and boards are used. Frequently, medical school grades and USMLE board scores are the screens that decide whether a program invites a student to interview.

I want to focus on USMLE scores. Grades are quite variable from school to school. Some schools have an A to F scale, some have Pass/Fail, and others have Satisfactory to Superior. Preclinical grades don't have a lot of predictive value for clinical grades and neither are very predictive for performance in residency.

Board scores are just as bad. They seem to be an objective way to compare students. Everyone, across the country takes the same test. There is one big problem. The USMLE is designed to measure knowledge and application of knowledge. It was created to be used by the State Licensing agencies as a common evaluation for licensure. There are statistical problems when you try to interpret the scores that are given with a pass/fail based test. There have been several studies that all show basically the same thing about board scores. Performance on the boards does not correlate to performance as a physician.

In 2005, Rifkin and Rifkin³ compared the performance of all the first year Internal Medicine residents at a large academic medical center on standardized patient encounters to their scores on the USMLE Step 1 and 2. They found very low correlations. For Step 1, the correlation was 0.2 (df=32, p=0.27) and for Step 2 it was 0.09 (df=30, p=0.61). Remember a higher number means that the two measures are more strongly related.

A more recent study is very critical of the use of USMLE scores for selection of residents. This study by McGaghie and colleagues,⁴ was a research synthesis using a critical review approach.⁵ They collected and reported correlations between USMLE Step 1 and 2 and several reliable measures of clinical skills. These skills included auscultation of the heart, performance of ACLS (Advanced Cardiac Life Support), communication with patients, thoracentesis, and central line placement. They found correlations from -0.05 to 0.29 to Step 1 and -0.16 to 0.24 for Step 2.

Their conclusion sums it all up. "Use of these scores for other purposes, especially postgraduate residency selection, is not grounded in a validity argument that is structured, coherent, and evidence based. Continued use of USMLE Step 1 and 2 scores for postgraduate medical residency selection decisions is discouraged."

I couldn't agree more. If I need a neurosurgeon to operate on my brain, I want to know that he has a very steady hand, not the highest board score. If I need a radiologist, I want to know that her visual pattern recognition is outstanding, not that she scored well on a multiple-choice question test. And if I need a family doctor, I want to know that his clinical reasoning and communication skills are excellent, not that he scored well on the boards.

References

1. http://www.nrmp.org/res_match/policies/map_main.html

2. Keynan A, Friedman M, and Benbassat J.  Reliability of global rating scales in the assessment of clinical competence of medical students. Med Educ  1987;21(6):477-81.

3. Rifkin WD, Rifkin A. Correlation between house staff performance on the United States Medical Licensing Examination and standardized patient encounters. Mt Sinai J Med. 2005;72(1):47-9.

4. McGaghie WC, Cohen ER, and Wayne DB. Are United States Medical Licensing Exam Step 1 and 2 scores valid measures for postgraduate medical residency selection decisions? Acad Med  2011;86(1):48-52.

5. Eva KW. On the limits of systematicity. Med Educ. 2008;42:852–853.

Christmas gift

On Christmas morning as we were opening presents with our kids and family, I got to thinking about how lucky I am. I really don't know how I got into medical school.

I grew up in a pretty modest home. These days you would have called us poor. At the time I thought we were middle class but, I didn't know that middle class families were not on WIC. But we never went hungry and my mom kept us in clean clothes (though they were rarely new clothes). We lived in several places growing up but my grandparents lived on a farm in rural SW Missouri, so I thought of myself as a country (rural) boy. We didn't have any doctors in my immediate family, although my grandmother was a nurse and my great ,great uncle was a country doc (more about him some other time).

So, how did I get into medical school???

These days my chances would be pretty slim at most medical schools. The vast majority (65%) of our current medical students come from the top quintile of wage-earning families.(1)  From 1997 to 2004, students admitted to medical school with a family income of greater than $100,000 increased over 60%, while those from the middle and lower income quintiles declined. The median income for the parents of a medical student is over $110,000 per year. 59.7% of students' parents make over $100,000. (2)

Many of our students at Kansas come from urban counties. In Kansas that means basically one of five counties/metropolitan areas (KC, Overland Park, Wichita, Topeka, and Lawrence). We have to work very hard to get and keep qualified applicants from small towns and the rural counties. On the 2009 AAMC Matriculant survey, only 2.8% of matriculating students were planning to practice in an area with a population of 2,500 or less.(3)

We have seen an increase in students whose parents are physicians. Some of these are physicians from the community and some are kids of our own faculty. Most medical students' parents have a high level of education. 52% of the fathers of medical students have a graduate degree compared to 12% in the general population. For moms, it is 35% and 10%, respectively. (4)

So what?

Several things in my opinion.
First, as a state school, we have a contract with the state of Kansas. We are the only medical school in Kansas we have to provide doctors for the state. All of the state. Not just the urban/suburban parts of the state.

We also need to produce doctors that look like the population of the state. If all of our students are from the urban counties, they are going to be much more likely to be white or Asian and not underrepresented. If they are all from the highest income brackets, we are neglecting a large part of our population.

And they will be much less likely to practice in the places that we want/need doctors. Rural underserved counties. Urban underserved areas. Primary care practices. Community health centers. Rural health clinics.

Right now we are doing pretty well in this area when you compare us to the rest of the country. The problem is that the rest of the country is doing really badly. So, even though we look good in comparison, we aren't doing that great. A recent analysis done by Fitzhugh Mullan (5),  found that many of the "top" medical schools in the nation did pretty poorly when you measured them on social mission (Vanderbilt #141, Duke #124, Boston U #131, Mayo #103). Social mission is a construct that uses number of primary care physicians produced, graduates practicing in HPSAs, and numbers of underrepresented minorities. KU ranked 5th in the nation on that scale.

We also do pretty good at turning out primary care doctors, at least in Family Medicine. Over the last 10 years (1998-2009 graduating classes), KU and the University of Minnesota were ranked number 1 and 2 when you combine number and percentage of students that graduate and choose a residency in Family Medicine.

But, we have to continue to work hard to maintain what we have. It is a constant struggle to convince people on the admissions committee that we shouldn't just take the students with the highest GPAs. And it is easy for the Dean to say, "we need to raise the MCAT scores of our incoming students". And it is easy to decrease funding for programs that support students from underserved backgrounds.  But those are the battles that have to be fought.  As someone who is really smart told me, "we don't need programs to increase the number of white kids from Johnson County".

References
(1) Bowman B. personal communciation
(2) Jolly P. Diversity of US Medical Students by Parental Income. AAMC Analysis in Brief. 2008;8(1).
(3) AAMC Matriculating Student Questionnaire (MSQ) 2009
(4) Grbic D, et al. Diversity of US Medical Students by Parental Education.  AAMC Analysis in Brief  2010;9(10).
(5) Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The Social Mission of Medical Education: Ranking the Schools. Annals Intern Med  2010;152:804-811.

The clinical enterprise is to a medical school as the athletic department is to an undergraduate university

I love analogies and while no analogy is perfect, I find this one fascinating.  If you are like us, you probably watch a lot of college sports this time of year. I was watching a basketball game the other day (KU vs Arizona) and I was thinking about the athletic department at our school.  Like many large state schools, we have a pretty large budget for the athletic program. (more than $50 million in 2006) (1)  All of that money may translate to some success , at least on the basketball court, not so much on the football field.  A report last year from the Knight Commission on Intercollegiate Athletics detailed athletic department spending increases at major colleges and universities. Increases to the tune of 11% annually, and this was during the worst recession since the Great Depression.

Why do we spend so much money on the athletic department? And what does this have to do with medical education, which after all is what this blog is supposed to be about? It struck me that in a medical school system the clinical enterprise has some similarities to the athletic department at the undergraduate school.

Both the clinical enterprise and the athletic department are askew from the primary mission of the university at large. Each has a significant portion of the budget. Both generate significant revenue. Both attract philanthropy for their own use. World famous specialists and top athletic teams attract media attention. Attention leads to more patients and more fans and more money and higher rankings and goodwill from the local community. The highest paid people are the stars in these areas: the super subspecialists and the coaches for the money-making sports. They are arguably the highest paid because they bring in the most money. And, because of their ability to generate revenue, they seem to have a different set of expectations for their behavior. (2)

But here is where the analogy breaks down. It seems that few undergraduate universities have as part of their mission statement, “to have the best athletic department” or “to generate the most money on athletics.” And if US News and World Report has done a ranking on “most lucrative athletic departments,” I haven’t seen it. On the other hand, medical schools invariably have something about the clinical enterprise in the mission statement. And, that statement is not, “create a clinical enterprise that is sufficient to meet the educational needs of our students while providing excellent patient care.”

Perhaps the most important difference is that while the athletic department has some opportunity to impact the education of students, the clinical enterprise profoundly affects student education. The athletic department probably pulls some philanthropy away from other areas and definitely pulls attention away from other areas. But if the university decides to focus on football instead of swimming, the science majors are probably not affected by that decision. However, if the clinical enterprise focuses on higher revenue specialty practices and decreases lower paying primary care or generalist practices, the medical students are at risk of receiving inadequate or inappropriate medical training. If the clinical enterprise adopts policies that limit medical students' use of the electronic health record or participating in procedures, their education suffers. If the clinical enterprise needs the physicians to make more money by seeing more patients and spending less time teaching students, their education suffers.

Generally, about this time in the argument, someone pipes in with No Money, No Mission. And they go on to describe how the clinical mission funds the other missions of the medical school. Some people believe that the clinical enterprise and the athletic department works hard to make money for the university, so that the university can attend to its other, less interesting mission: education. And perhaps it does work that way in some places. Perhaps, but mostly they fund themselves. They make decisions based on revenue and they keep most of the profit. In fact, an article in USA Today says that for every dollar the university spends on the athletic department, they only realized one dollar in revenue. (3)  Not a great return on the university's investment.  At least the athletic department pretends that they aren’t trying to make money. 

Medical student education at allopathic schools in the United States is clearly in a marriage with the clinical enterprise – sometimes an abusive marriage and maybe sometimes a partnership, but nonetheless a marriage. So what can be done? Perhaps that is a good topic for another blog – what would a counselor say about the marriage of the clinical enterprise and medical education?

(1) King, Jason. "Hawk Market", The Kansas City Star (June 11, 2006), pp. C1

(2) http://bleacherreport.com/articles/11863-from-caron-butler-to-chris-andersen-how-should-we-handle-troubled-athletes

(3) http://www.usatoday.com/sports/college/2009-04-29-college-athletic-spending-report_N.htm