Medical educators must train those studying to become physicians in the science of medicine. But because many medical schools fund their endeavors through research money, the social mission of medicine often gets neglected.
This nation, and by extension its medical schools, face the daunting task of addressing three interrelated issues: an insufficient number of primary care physicians, geographic maldistribution of physicians, and the lack of a representative number of racial and ethnic minorities in medical schools and in practice. The authors argue that through its role in educating the future physicians of this nation, our medical education system maintain a social mission that extends to the entire population. Therefore instead of being lauded and ranked based on their research funding, reputation, faculty opinion, and student selectivity, medical schools should instead be judged on these larger societal needs of primary care, access to care for the underserved, and workforce diversity.
Focusing on data for medical school graduates from 1999 to 2001 from the 141 allopathic and osteopathic schools, the authors calculated for each school: 1) the percentage of graduates practicing primary care, 2) the percentage of graduates physically located in health professional shortage areas (HPSAs), and 3) the ratio of underrepresented minority (URM) graduates to the total number of graduates, adjusting for public and private institutions who draw from a single state or a national pool respectively. Each measure was standardized with a mean value of 0. They then assigned a composite score (i.e. the social mission score) to each school by using a simple sum of each of the three standardized measures. For example, Morehouse School of Medicine had the highest ranking social mission score (13.98), with 43.7 percent of its graduates entering primary care, 39.1 percent of its graduates practicing in HPSAs, and a ratio of URMs in the school vs. the state of 3.15. In comparison, Vanderbilt University had the lowest ranking social mission score (-3.95), with 21.9 percent of its graduates entering primary care, 20.8 percent of its graduates practicing in HPSAs, and a ratio of URMs in the school vs. the state of 0.13.
Morehouse School of Medicine, Meharry Medical College, Howard University, Wright State University, and University of Kansas were the top five ranking schools, in order. Vanderbilt University, University of Texas Southwestern Medical Center, Northwestern University, University of California Irvine, and New York University were the bottom five ranking schools. Northeastern schools tended towards more negative social mission scores. Western schools produced more primary care physicians. Southern schools produced more physicians who practice in HPSAs. Schools in smaller metropolitan areas produced more primary care physicians and physicians who practiced in HPSAs. Public schools graduate higher proportions of primary care physicians. NIH funding was inversely associated with social mission score, a school’s output of primary care physicians, and physicians practicing in HPSAs.
The data undoubtedly show the merits of a primary-care based system in terms of improved quality of care and decreased medical costs. Regardless of the methods used for ranking, this study provides a unique perspective on the individual medical schools and their lack of response to this data. If medical schools compete with each other for funding and reputation, why can they not be provided the incentive to compete for the creation of a primary care workforce? In conjunction with the current discussion of comparative effectiveness research, there is plenty of opportunity to maintain a commitment to the generation of new scientific knowledge through primary care research while also promoting a primary care model.
Both a lack of physicians that provide care to the underserved and a lack of workforce diversity speak to the system’s failure to meet supply with demand. This study shows that medical schools are by no means exempt from this failure. Analysis should be made of the obstacles blocking URMs from matriculating into medical school. The argument that the pool of applicants is small is unacceptable. Further insight can be gained by analyzing those schools with higher social mission scores.
Kameron L. Matthews, MD, Esq.