The Brave New World of Medical School Admissions

To all the pre-med undergraduates out there, put down the organic chemistry text book and MCAT prep flashcards. You may be wasting your time.

In order to combat the current and soon-to-be-worsening shortage of primary care doctors, largely caused by government policy, medical schools are changing their admissions criteria.

A recent nation-wide initiative within the medical community will see to it that grades and test scores count for less in terms of admissions decisions while nebulous personal qualities such as “social accountability” count for more.

Walter Hartwig, a professional medical educator and author of Med School Rx, Getting In, Getting Through, and Getting On with Doctoring, discusses the new direction medical school admissions have taken as a result of this “Initiative to Transform Medical Education” (ITME). The initiative, prepared by a panel of experts commissioned by the American Medical Association (AMA), studied challenges facing the medical profession and in 2007 issued ten recommendations to address these challenges. The AMA, in conjunction with the American Association of Medical Colleges via the Liaison Committee on Medical Education, tightly controls the issuance of medical licenses, making its recommendations serious business for everyone in the medical profession.

The first recommendation instructs admissions officers at medical schools on who should be allowed into medical schools:

Apportion more weight in admissions decisions to characteristics of applicants that predict success in the interpersonal domains of medicine. Use valid and reliable measures to assess these traits.

“The basic intent of the recommendation,” Hartwig explains, “is to improve our ability to find future primary care physicians in the applicant pool, and history suggests that they are not among the high MCAT [the Medical College Admission Test] achievers.”

In the same spirit of decreasing the importance of the MCAT, the New York Times recently reported that Mount Sinai medical school in Manhattan has instituted a policy of admitting 35 students per year who have never taken the MCAT, classes in physics, or classes in organic chemistry. Additionally, East Carolina University’s Brody School of Medicine has had a policy for ten years now of admitting a few students each year from NC A&T and UNC-Pembroke without their having to take the MCAT, in the hope of getting more graduates to help underserved areas.

Both Hartwig and the authors of the initiative’s recommendations believe that they know why recently-minted M.D.s do not go into the area of primary care. For one thing, “physicians lose altruism and the caring aspects of medicine as they proceed through training.” For another, they lack the preparation “to be advocates for patients related to issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession.” Other deficiencies included a lack of “engaging in advocacy on public health issues.” In essence, Hartwig and the AMA contend that current doctors have revealed themselves to be defective community organizers. Hence the suggestion to “include issues related to social accountability among admissions criteria.”

Until now, the AMA claims, medical-school admission processes selected mostly for applicants’ “abilities to acquire knowledge and to problem-solve.” Thus, the medical education system reinforced such traits.  Emphasizing knowledge acquisition and problem-solving talent “may lead physicians to perceive patients simply as sources of data and ‘problems to be solved,’ instead of as individuals in need.”

To put it bluntly, the problem is that doctors care too much about money and are too stuck in the mental habit of problem-solving to go into general practice in underserved areas or to see patients as real people. The American Medical Association’s solution (recently reinforced with tens of millions of dollars worth of grants in the Rural Physician Pipeline Act of 2009, part of the new health care law) is to get different doctors.

The ITME, due to its broad scope and far reach, has been compared to the famous (or infamous, depending on your view) Flexner Report of 1910, which concluded that standards for admissions and graduations were too low; the result of the report was to effectively cartelize the profession of medicine by restricting entry into the field. That led to the closing of about half of the country’s medical schools within ten years (in addition to mandating a return to male-only medical schools).

The more recent initiative was aimed at updating physician education and training, areas that have seen “far less reaching and innovative” changes in the past century than in the way “care is organized, delivered, and financed.”

Hartwig and the AMA are presenting a narrative in which highly competitive medical students (top scorers on the MCAT, for example) have insufficient compassion to become primary-care doctors. That may be a compelling story, but it doesn’t capture the reality of what’s going on. In fact, if not for irrational government policy, the shortage probably would not exist at all.

The main reason that so few graduating medical students go into primary care today is that it pays a lot less—roughly half the amount, on average. This differential stems from an alliance of politicians, bureaucrats, and the medical-specialty organized labor lobby that has deemed it to be so.

In a 2007 article in the journal Annals of Internal Medicine titled “The Primary Care-Specialty Income Gap: Why It Matters,” Thomas Bodenheimer, Robert A. Berenson, and Paul Rudolf lay out four primary factors causing the discrepancy in income between specialists and generalists.  Some commentators have questioned their contention, but their arguments have generally withstood the criticism. The first factor the authors cite is that new technology and increased efficiency have caused some fields to increase the volume of procedures they perform at a faster pace than other fields. Primary care doctors find it harder to increase the number of patients—and thus their pay—without diminishing quality of care or patient satisfaction.

The second—and perhaps most important—factor is the way that treatment prices are assessed. Bodenheimer et al. make clear that market forces have been absent from the way medical care has been priced for a long time.

At the heart of the medical pricing system is a small panel of central planners called the Relative Value Scale Update Committee (RUC—try to keep up with the acronyms). RUC is part of the Resource-Based Relative Value Scale (RBRVS) system, developed by researchers at Harvard in the 1980s and codified into law in the Omnibus Budget Reconciliation Act of 1989. Since that time, the RUC has been arbitrarily setting prices based on what doctors feel they should get, totally detached from any sort of market discipline. The committee consists of 26 voting members, the vast majority of whom represent specialty societies.

The RUC has direct influence over the RBRVS system, the model that Medicare, Medicaid, and nearly all HMOs use to determine compensation for physician services. Under this system, a doctor is basically told what his or her fee is going to be. The RUC is in charge of assigning a value for each new procedure that develops every year and considering potential revisions for all existing service fees every five years.

Under this system, doctors’ representatives basically vote themselves raises. It is unsurprising, then, that “potentially overvalued procedures are rarely discussed at the RUC” and “many RUC members from procedural specialties tend to vote in favor of requested increases,” as Bodenheimer et al. note.

At this point you may be wondering: if doctors can all vote themselves pay raises, why do specialists tend to gang up on generalists?

The answer lies in the third factor leading to the discrepancy between primary care and specialty incomes: the Sustainable Growth Rate (SGR) formula, established in the Balanced Budget Act of 1997, replacing the Medicare Volume Performance Standard that previously attempted to control costs. Under the SGR, the total amount of money paid by Medicare is like a pie, and if one group receives a larger slice due to increased fees per procedure or increased procedure volume, everyone else gets a smaller slice. Primary care doctors usually make out the worst in this deal because, since they make up about half of all doctors, increasing the fees for primary care doctors would decrease fees for the majority of RUC voting members by a substantial amount. Increasing specialists’ fees decreases everyone else’s slice as well, but since they are each only a small slice of the pie, it doesn’t hurt the other members as much.

The final factor causing specialists, with a 2004 median compensation of $297,000, to make so much more than generalists, with a 2004 median compensation of $161,816 (figures from the Medical Group Management Association), is that private insurers go along with the RBRVS system and, due to the negotiating power of organized specialty groups like the American College of Radiology, they are forced to pay higher fees to specialists. Some specialties such as surgery are getting fees from private insurers that are 330 percent of Medicare’s fees. (Medicare and Medicaid do not, generally speaking, negotiate prices, but private insurers must).

In this way, technology, central planning, and organized labor have combined to make specialty medicine much more financially attractive to graduating medical students.

It is little surprise, therefore, that even the service-minded cohort that attend medical school would tend to favor specialized fields. For instance, in 2005 only eight percent of U.S. medical graduates went into family medicine. Doctors may care deeply about people, but they are also people themselves. You don’t need to be an economist on the level of Adam Smith to know that people tend to respond to incentives. For this reason (and especially without some sort of pre-medical school contract in which students agree to go into primary care), it is highly unlikely that the situation is going to change by searching for such elusive traits as “social accountability,” as the AMA has recommended.

Indeed, I even know of at least one medical-school applicant who lied about his intention to go into family practice in order to be a more attractive candidate. No doubt this is especially common at schools like East Carolina University’s Brody School of Medicine that have relatively low average MCAT scores and are dedicated to producing primary care physicians.

And, even if an applicant is sincerely committed to general practice in an underserved area at the time the admission decision is made, who is to say that he or she will still feel that way in eight years after finishing residency? Or, after a decade of providing care in an underserved area, what will keep this graduate from going back to train for a more lucrative field?

The AMA’s initiative calls for identifying criteria that correlate with maintaining “altruism.” I am no psychologist, but it seems to me that identifying the people who will have $100K+ worth of altruism every year for the rest of their working careers is a difficult if not impossible task. Personally, I can imagine all sorts of valid and convincing rationalizations that would satisfy my conscience while enabling me to leave a rural family practice (I’m still helping people, I’m putting my brains to better use, I can now give more to charity to help those who really need it, a lesser-trained professional could do this without me for cheaper, etc., etc.).

A much more reliable way of alleviating the shortage of primary care doctors would be to correct the pay differential between specialists and generalists. Another good idea would be allowing health care professionals such as physician’s assistants or nurse practitioners to take over the role of primary care, as Shirley Svorny of the Cato Institute has advocated.

The AMA’s initiative to produce significantly more primary care doctors through altering medical school admissions criteria, without taking into account the pay discrepancy and while leaving medical school graduates free to choose their own field a decade after admission, is almost certainly doomed to failure. The only thing likely to change is that our nation will have fewer qualified specialty doctors, which is bad news for everyone, including the intended beneficiaries in underserved areas.