I SPEClAL ARTCLE Medical School Applicants and the Appeal of Medicine as a Career AB SADEGHI-NEJAD,M.D., BOS~OII, Massachusetts, MARIONM. MARQUARDT,Ph.D., Sharon, Massachusetts
T
he medical school applicants of yesteryear were predominantly white males from the upper middle strata of our society. Competition was keen and acceptance implied a sharp intellect, high academic achievement in college, and possession of attributes thought to be desirable in a physician. Over the past 25 years, medical schools opened their doors to the underrepresented minorities. The number of these new students, primarily women and Asians and to a lesser extent blacks, Hispanics, and Native Americans, gradually increased to the extent that they now collectively constitute almost 50% of the applicants and of medical school graduates. By 1990, women represented 34.6% of the graduating class, Asians 9.2%, and blacks 4.6% [l]. Since the potential for acceptance is now a reality for the majority of the population who were previously denied admission, the expectation might have been a larger pool of applicants, more stringent standards, and tougher competition. Yet the statistics indicate otherwise. The applicants are still high achievers, bright and motivated. Their numbers, however, have been decreasing. In the 1969-1970 academic year, there were 24,465 applicants for the 10,401 medical school seats, a ratio of 2.3:1 [2,3]. In the early 19708, in response to the perceived need for more doctors, the number of places in the class increased, as did the number of the applicants. In the 1974-1975 academic year, 42,624 students sought admission and 10,963 (22.3% women) were accepted, a 2.81 ratio [2]. However, by the end of the decade, the number of students interested in medicine had declined, so that in 1979-1980,36,141 applicants competed for 16,886 available seats, a ratio of 2.1:1 [3]. This trend continued in the 1980s and caused concern among medical educators [4]. In 1989-1990, the number of students seeking admission had decreased to 26,915, and 16,975 were accepted, a 1.6:1 ratio [3]. The following year, 1990-1991, the number of applicants rose for the From the Department of Pediatrics (ASN). Tufts University School of Medicine, and the Division of Pediatric Endocrinology and Metabolism (ASN), Floating Hospital for Infants and Children, New England Medical Center, Boston, Massachusetts, and Sharon Public Schools (MMM), Sharon, Massachusetts. Requests for reprints should be addressed to Ab Sadeghi-Nejad. M.D., Box 399, 750 Washington Street, Boston, Massachusetts 02111, Manuscript submitted January 29,1992, and accepted April 25,1992.
first time in a decade. Of the 29,243 who applied (40.3% women), 17,206 were accepted, a ratio of 1.7:1 [5]. Whether this increase heralds a reversal of the trend for the 1990s is yet to be seen. Medical education has always been rigorous, characterized by hard work and long hours, stretched over many years encompassing medical school and postgraduate education. But, at least in the minds of those desirous of entering the field, the rewards of practicing medicine well compensated for the hardships encountered. Today the rigors of initiation still persist but, in the eyes of many, the rewards have lost their appeal.
SERVICETO MANKIND For most individuals, service to humanity always has been and remains the primary motivation to enter medicine. Many of the students remember their childhood marked by an illness of their own, a family member, a close friend or a neighbor and desire to be in the position of the healer, rather than standing by helplessly, watching the suffering. Ironically, while the younger generations are more idealistic than their elders, the emergence of the “me” generation has taken its toll. It is difficult to determine the underlying motivation for pursuing any endeavor, and even more so to assess its absence. In all likelihood, however, the self-centered attitude prevalent in the 1980s has had a negative impact on the number of college graduates wishing to pursue medicine. Those who apply may seek higher ideals than did the students of the past, but comparatively their numbers are fewer.
PERSONALINCOME American medicine in the past was an all-service profession. Physicians, like the educators and clergy, worked hard for small monetary compensations. Theirs was not a life of riches but that of service to their neighbors, their communities, and the society at large. Many doctors in other parts of the world continue to have a similar existence to this day. In this country, however, in the post-World War II era, with the proliferation of health insurance policies and involvement of the government in medical education and research as well as in the delivery of health care, physicians prospered. They were
September 1992 The American Journal of Medicine
Volume 93
335
MEDICINE
AS A CAREER
/ SADEGHI-NEJAD
AND MARQUARDT
now able to afford a good, if not a luxurious, lifestyle. Their income increased disproportionately to that of the rest of the society so that while the majority were not rich, they were well within the higher income brackets. Money thus became another incentive for entering medicine. After almost half a century of prosperity, the pendulum is swinging back. The escalating cost of medical education has diminished the prospects for many would-be medical students. The graduates of our medical schools now start their postgraduate years with a large burden of indebtedness that is increasing every year. The average educational loan for 1988 graduates was $38,489. Among 1989 graduates, over 81% required loans, a mean of $42,374 [6]. By 1990, 5% of graduates owed $100,000 or more, and the average indebtedness had increased to $46,224 [l]. Many of these students, of economic necessity, shy away from the relatively low-paying service-oriented specialties such as internal medicine and pediatrics and enter fields of medicine that promise a higher earning potential. At the same time, simultaneous with the financial prosperity of many other professionals, societal pressures to contain the astronomical cost of medical care have made the future earning potential of all physicians less secure. Doctors still are well compensated for their services, but the influence of money as an incentive to enter medicine is diminishing.
PRESTIGE The old-timers in medicine had little to offer in terms of scientific therapeutics but were respected for the care they rendered their patients. The general practitioner of the past not only functioned as a pediatrician, an internist, and a surgeon but also as a friend and counselor. The work of these physicians was perhaps best exemplified in the persona of television’s all-caring, all-knowing, and all-loving Dr. Marcus Welby. The widespread branching out of medicine into many subspecialties brought about fragmentation of medical care, and led to the prominence of tertiary-care medical centers. Meanwhile, as an increasing number of patients were referred away to the specialists, community physicians gradually lost their prestige and influence. They were no longer seen as individuals capable of responding appropriately, or better yet heroically, to all matters related to health care. Furthermore, in recent years, in the interest of the “right to know,” the personal shortcomings of prominent individuals have been discussed widely by the news media. As a result, society has lost respect for most, if not all, its leaders. Physicians
336
September 1992 The American Journal of Medicine
have not been immune to this downfall. They are now viewed more realistically, albeit less glamorously, as fellow human beings. Doctors still are accorded prestige that often exceeds that of other professionals. However, the respect, more often than not, is for the medical science, which the society is paying for dearly, and not for the physicians. It is now their individual and collective failures that receive the public’s attention and not their accomplishments. The latter are taken for granted.
INDEPENDENCE Young men and women who sought a career in medicine in the past often cited the independence it offered its practitioners as one of the incentives for entering the field. Throughout the years, until relatively recently, doctors worked as solo practitioners to the best of their abilities, and adjusted their work schedule according to their individual needs, lifestyles, and personalities. They were their own boss and practiced as they wished, confined only by the general guidelines that were set by the local or national medical societies. Now, in much of the country, the solo practitioner is a stark minority, almost extinct. In a field dominated by corporate health care and group practice plans, physicians have traded off their long-cherished independence for a fixed income and regular, shorter hours, less frequent night calls, and longer vacation schedules. On another front, the bureaucratization of medicine has had an impact on the content and style of medical practice. The wise and independent practitioners of the past have been replaced by generations of physicians who strive to comply with the numerous rules and standards set up by various regulatory agencies. At the same time, because of the increasing involvement of the courts in medicine, doctors have come to practice “defensive” medicine in the fear that malpractice lawyers are in hot pursuit and may not be far behind. Thus professional independence is no longer an incentive for entering medical school.
SUGGESTIONSFORCHANGE What can be done to induce more young people to seek a career in medicine? The problem is complex and multifaceted, and defies easy solutions. However, several approaches should be considered. Easing the financial strains caused by medical education would undoubtedly enhance its appeal, or at a minimum make it more available to economically disadvantaged students. Universities should set aside a larger portion of their endowment funds for scholarships, and lower the tuition at medical schools. In the 1988-1989 academic year, tuition
Volume 93
MEDICINE
and fees accounted for only 4.5% of total medical school revenues [6]. Since students contribute relatively little to the overall financial solvency of the schools, a reduction in tuition would pose little hardship for most medical schools or their parent universities. Adoption of this policy, however, because of the goodwill generated, in the long run would benefit the universities directly in the form of increased donations from the medical alumni. Biomedical industries, especially pharmaceutical companies, should support medical schools financially with no strings attached, as they are among the beneficiaries of the advances in biomedical sciences. Enormous sums are spent annually by drug companies for the advertising and promotion of their products. Allocation of a portion of this money to help the financially strapped medical students and schools would have little impact on drug sales, but would go a long way toward improving the economics of medical education. Finally, the federal government should once again increase its share of support for medical education. At the same time, using money as an incentive, the government could lead the way to alleviate the maldistribution of doctors and improve health care for the poor and the uninsured. Given the deplorable state of health care in many inner-city and rural communities, financial support for the students should be linked to a form of service payback system in medically disadvantaged areas. Lack of interest in medicine is in part related to the well-publicized poor preparation of students in science and mathematics and the malaise in our educational system. There is reason to believe that students’ interest in science and medicine is kindled early on, during high school years or possibly even earlier. Improving science education in elementary schools, high schools, and colleges, with financial support from the industry and charitable foundations, is a first step toward “turning on” young people to science. Recently, in order to improve science education in public schools, 10 states started to work with universities and industrial companies forming “think tanks” to help the local schools, and bringing scientists and engineers into the classrooms. Using a similar approach, working through their energetic, articulate, and charismatic members, state and local medical societies should get involved in schools. Doctors should bring the reality of medicine to schools and stimulate the stu-
September
AS A CAREER
/ SADEGHI-NEJAD
AND MARQUARDT
dents through lectures, career planning services, and summer work projects in their offices. Only physicians can truly act as advocates for medicine and, through personal contact with students, convey the excitement, intellectual challenge, and emotional satisfaction that a career in medicine can bring.
CONCLUSION Many factors contributed to the loss of luster of medicine as a career and resulted in the diminishing number of young people wishing to enter medical schools. However, despite the widespread disenchantment with its shortcomings and failures, medicine remains an excellent profession. The combination of art and science in medicine can, and does, provide lifelong personal and professional satisfaction regardless of one’s area of endeavor. For the intellectually curious, the expansion of the scientific basis of medical practice has widened the horizons and made research potential virtually limitless. For those interested in maintaining the traditional aspects of medicine, clinical practice retains its attraction. Despite all the complaints and the harsh criticisms voiced periodically by physicians, medicine is still cherished by most, if not all, doctors. As we approach the 21st century, more than ever before, there is a real opportunity to heal and to solve the mysteries of the diseases that have plagued mankind for millennia. Physicians must strive to stimulate and encourage bright, enthusiastic, and hard-working young men and women to follow the path, for the future of medicine is in their hands.
REFERENCES 1. American Association of Medical Colleges. The 1990 medical student graduation questionnaire results. Washington, DC: American Association of Medical Colleges, 1991: l-30. 2. AMA Department of Undergraduate Medical Education and AAMC Division of Operational Studies. Undergraduate medical education. JAMA 1976; 236: 2957-70. 3. Jonas HS. Etzel SI. Barzansky B. Undergraduate medical education. JAMA 1990; 264: 801-g. 4. The declining applicant pool. Proceedings of AAMC Invitational Conference, June 13-14, 1988. Washington, DC: American Association of Medical Colleges, 1989. 5. Jonas HS, Etzel SI, Barzansky B. Educational programs in US medical schools. JAMA 1991; 266: 913-20. 6. Jolly P, Krakower JY, Beran R. Williams D. US medical school finances. JAMA 1990; 264: 813-20.
1992
The American
Journal
of Medicine
Volume
93
337
T
he medical school applicants of yesteryear were predominantly white males from the upper middle strata of our society. Competition was keen and acceptance implied a sharp intellect, high academic achievement in college, and possession of attributes thought to be desirable in a physician. Over the past 25 years, medical schools opened their doors to the underrepresented minorities. The number of these new students, primarily women and Asians and to a lesser extent blacks, Hispanics, and Native Americans, gradually increased to the extent that they now collectively constitute almost 50% of the applicants and of medical school graduates. By 1990, women represented 34.6% of the graduating class, Asians 9.2%, and blacks 4.6% [l]. Since the potential for acceptance is now a reality for the majority of the population who were previously denied admission, the expectation might have been a larger pool of applicants, more stringent standards, and tougher competition. Yet the statistics indicate otherwise. The applicants are still high achievers, bright and motivated. Their numbers, however, have been decreasing. In the 1969-1970 academic year, there were 24,465 applicants for the 10,401 medical school seats, a ratio of 2.3:1 [2,3]. In the early 19708, in response to the perceived need for more doctors, the number of places in the class increased, as did the number of the applicants. In the 1974-1975 academic year, 42,624 students sought admission and 10,963 (22.3% women) were accepted, a 2.81 ratio [2]. However, by the end of the decade, the number of students interested in medicine had declined, so that in 1979-1980,36,141 applicants competed for 16,886 available seats, a ratio of 2.1:1 [3]. This trend continued in the 1980s and caused concern among medical educators [4]. In 1989-1990, the number of students seeking admission had decreased to 26,915, and 16,975 were accepted, a 1.6:1 ratio [3]. The following year, 1990-1991, the number of applicants rose for the From the Department of Pediatrics (ASN). Tufts University School of Medicine, and the Division of Pediatric Endocrinology and Metabolism (ASN), Floating Hospital for Infants and Children, New England Medical Center, Boston, Massachusetts, and Sharon Public Schools (MMM), Sharon, Massachusetts. Requests for reprints should be addressed to Ab Sadeghi-Nejad. M.D., Box 399, 750 Washington Street, Boston, Massachusetts 02111, Manuscript submitted January 29,1992, and accepted April 25,1992.
first time in a decade. Of the 29,243 who applied (40.3% women), 17,206 were accepted, a ratio of 1.7:1 [5]. Whether this increase heralds a reversal of the trend for the 1990s is yet to be seen. Medical education has always been rigorous, characterized by hard work and long hours, stretched over many years encompassing medical school and postgraduate education. But, at least in the minds of those desirous of entering the field, the rewards of practicing medicine well compensated for the hardships encountered. Today the rigors of initiation still persist but, in the eyes of many, the rewards have lost their appeal.
SERVICETO MANKIND For most individuals, service to humanity always has been and remains the primary motivation to enter medicine. Many of the students remember their childhood marked by an illness of their own, a family member, a close friend or a neighbor and desire to be in the position of the healer, rather than standing by helplessly, watching the suffering. Ironically, while the younger generations are more idealistic than their elders, the emergence of the “me” generation has taken its toll. It is difficult to determine the underlying motivation for pursuing any endeavor, and even more so to assess its absence. In all likelihood, however, the self-centered attitude prevalent in the 1980s has had a negative impact on the number of college graduates wishing to pursue medicine. Those who apply may seek higher ideals than did the students of the past, but comparatively their numbers are fewer.
PERSONALINCOME American medicine in the past was an all-service profession. Physicians, like the educators and clergy, worked hard for small monetary compensations. Theirs was not a life of riches but that of service to their neighbors, their communities, and the society at large. Many doctors in other parts of the world continue to have a similar existence to this day. In this country, however, in the post-World War II era, with the proliferation of health insurance policies and involvement of the government in medical education and research as well as in the delivery of health care, physicians prospered. They were
September 1992 The American Journal of Medicine
Volume 93
335
MEDICINE
AS A CAREER
/ SADEGHI-NEJAD
AND MARQUARDT
now able to afford a good, if not a luxurious, lifestyle. Their income increased disproportionately to that of the rest of the society so that while the majority were not rich, they were well within the higher income brackets. Money thus became another incentive for entering medicine. After almost half a century of prosperity, the pendulum is swinging back. The escalating cost of medical education has diminished the prospects for many would-be medical students. The graduates of our medical schools now start their postgraduate years with a large burden of indebtedness that is increasing every year. The average educational loan for 1988 graduates was $38,489. Among 1989 graduates, over 81% required loans, a mean of $42,374 [6]. By 1990, 5% of graduates owed $100,000 or more, and the average indebtedness had increased to $46,224 [l]. Many of these students, of economic necessity, shy away from the relatively low-paying service-oriented specialties such as internal medicine and pediatrics and enter fields of medicine that promise a higher earning potential. At the same time, simultaneous with the financial prosperity of many other professionals, societal pressures to contain the astronomical cost of medical care have made the future earning potential of all physicians less secure. Doctors still are well compensated for their services, but the influence of money as an incentive to enter medicine is diminishing.
PRESTIGE The old-timers in medicine had little to offer in terms of scientific therapeutics but were respected for the care they rendered their patients. The general practitioner of the past not only functioned as a pediatrician, an internist, and a surgeon but also as a friend and counselor. The work of these physicians was perhaps best exemplified in the persona of television’s all-caring, all-knowing, and all-loving Dr. Marcus Welby. The widespread branching out of medicine into many subspecialties brought about fragmentation of medical care, and led to the prominence of tertiary-care medical centers. Meanwhile, as an increasing number of patients were referred away to the specialists, community physicians gradually lost their prestige and influence. They were no longer seen as individuals capable of responding appropriately, or better yet heroically, to all matters related to health care. Furthermore, in recent years, in the interest of the “right to know,” the personal shortcomings of prominent individuals have been discussed widely by the news media. As a result, society has lost respect for most, if not all, its leaders. Physicians
336
September 1992 The American Journal of Medicine
have not been immune to this downfall. They are now viewed more realistically, albeit less glamorously, as fellow human beings. Doctors still are accorded prestige that often exceeds that of other professionals. However, the respect, more often than not, is for the medical science, which the society is paying for dearly, and not for the physicians. It is now their individual and collective failures that receive the public’s attention and not their accomplishments. The latter are taken for granted.
INDEPENDENCE Young men and women who sought a career in medicine in the past often cited the independence it offered its practitioners as one of the incentives for entering the field. Throughout the years, until relatively recently, doctors worked as solo practitioners to the best of their abilities, and adjusted their work schedule according to their individual needs, lifestyles, and personalities. They were their own boss and practiced as they wished, confined only by the general guidelines that were set by the local or national medical societies. Now, in much of the country, the solo practitioner is a stark minority, almost extinct. In a field dominated by corporate health care and group practice plans, physicians have traded off their long-cherished independence for a fixed income and regular, shorter hours, less frequent night calls, and longer vacation schedules. On another front, the bureaucratization of medicine has had an impact on the content and style of medical practice. The wise and independent practitioners of the past have been replaced by generations of physicians who strive to comply with the numerous rules and standards set up by various regulatory agencies. At the same time, because of the increasing involvement of the courts in medicine, doctors have come to practice “defensive” medicine in the fear that malpractice lawyers are in hot pursuit and may not be far behind. Thus professional independence is no longer an incentive for entering medical school.
SUGGESTIONSFORCHANGE What can be done to induce more young people to seek a career in medicine? The problem is complex and multifaceted, and defies easy solutions. However, several approaches should be considered. Easing the financial strains caused by medical education would undoubtedly enhance its appeal, or at a minimum make it more available to economically disadvantaged students. Universities should set aside a larger portion of their endowment funds for scholarships, and lower the tuition at medical schools. In the 1988-1989 academic year, tuition
Volume 93
MEDICINE
and fees accounted for only 4.5% of total medical school revenues [6]. Since students contribute relatively little to the overall financial solvency of the schools, a reduction in tuition would pose little hardship for most medical schools or their parent universities. Adoption of this policy, however, because of the goodwill generated, in the long run would benefit the universities directly in the form of increased donations from the medical alumni. Biomedical industries, especially pharmaceutical companies, should support medical schools financially with no strings attached, as they are among the beneficiaries of the advances in biomedical sciences. Enormous sums are spent annually by drug companies for the advertising and promotion of their products. Allocation of a portion of this money to help the financially strapped medical students and schools would have little impact on drug sales, but would go a long way toward improving the economics of medical education. Finally, the federal government should once again increase its share of support for medical education. At the same time, using money as an incentive, the government could lead the way to alleviate the maldistribution of doctors and improve health care for the poor and the uninsured. Given the deplorable state of health care in many inner-city and rural communities, financial support for the students should be linked to a form of service payback system in medically disadvantaged areas. Lack of interest in medicine is in part related to the well-publicized poor preparation of students in science and mathematics and the malaise in our educational system. There is reason to believe that students’ interest in science and medicine is kindled early on, during high school years or possibly even earlier. Improving science education in elementary schools, high schools, and colleges, with financial support from the industry and charitable foundations, is a first step toward “turning on” young people to science. Recently, in order to improve science education in public schools, 10 states started to work with universities and industrial companies forming “think tanks” to help the local schools, and bringing scientists and engineers into the classrooms. Using a similar approach, working through their energetic, articulate, and charismatic members, state and local medical societies should get involved in schools. Doctors should bring the reality of medicine to schools and stimulate the stu-
September
AS A CAREER
/ SADEGHI-NEJAD
AND MARQUARDT
dents through lectures, career planning services, and summer work projects in their offices. Only physicians can truly act as advocates for medicine and, through personal contact with students, convey the excitement, intellectual challenge, and emotional satisfaction that a career in medicine can bring.
CONCLUSION Many factors contributed to the loss of luster of medicine as a career and resulted in the diminishing number of young people wishing to enter medical schools. However, despite the widespread disenchantment with its shortcomings and failures, medicine remains an excellent profession. The combination of art and science in medicine can, and does, provide lifelong personal and professional satisfaction regardless of one’s area of endeavor. For the intellectually curious, the expansion of the scientific basis of medical practice has widened the horizons and made research potential virtually limitless. For those interested in maintaining the traditional aspects of medicine, clinical practice retains its attraction. Despite all the complaints and the harsh criticisms voiced periodically by physicians, medicine is still cherished by most, if not all, doctors. As we approach the 21st century, more than ever before, there is a real opportunity to heal and to solve the mysteries of the diseases that have plagued mankind for millennia. Physicians must strive to stimulate and encourage bright, enthusiastic, and hard-working young men and women to follow the path, for the future of medicine is in their hands.
REFERENCES 1. American Association of Medical Colleges. The 1990 medical student graduation questionnaire results. Washington, DC: American Association of Medical Colleges, 1991: l-30. 2. AMA Department of Undergraduate Medical Education and AAMC Division of Operational Studies. Undergraduate medical education. JAMA 1976; 236: 2957-70. 3. Jonas HS. Etzel SI. Barzansky B. Undergraduate medical education. JAMA 1990; 264: 801-g. 4. The declining applicant pool. Proceedings of AAMC Invitational Conference, June 13-14, 1988. Washington, DC: American Association of Medical Colleges, 1989. 5. Jonas HS, Etzel SI, Barzansky B. Educational programs in US medical schools. JAMA 1991; 266: 913-20. 6. Jolly P, Krakower JY, Beran R. Williams D. US medical school finances. JAMA 1990; 264: 813-20.
1992
The American
Journal
of Medicine
Volume
93
337
