IS GETTING into medical school any easier than it used to be? Yes -- well, not exactly. Major changes within the medical profession, as well as a shift in attitude among potential applicants, are contributing to a downward trend in medical school applications that has educators concerned -- so in a sense it is now easier to get in. In 1973 there were 2.8 applicants for each place in medical school, in 1981 there were 2.1, and currently there are 1.9.
At the same time, the academic qualifications of medical school applicants have declined only slightly, if at all, according to the latest findings of the Association of American Medical Colleges (AAMC). "I'm speaking about hundredths of a point difference in their grade-point average," said Dr. Paul Jolly, who directed the study. "It may be down from 3.50 to 3.48." So while there is less competition for each place, getting in still requires, except in unusual cases, a high B average, plus good scores on the rigorous Medical College Admission Test (MCAT).
Why students continue to turn away from medicine in increasing numbers -- between 1981 and 1985 the decline reached 12.3 percent -- is the subject of intense debate and concern among medical educators, medical faculty and college pre-medical advisers. "We still don't know very much," Jolly said, but a picture is beginning to emerge of a confluence of social and economic factors.
Half-a-dozen of the typical reasons students offer for not pursuing a medical degree are cited by Dr. Carole Horn, director of admissions at George Washington University School of Medicine, where applications are down 8 to 10 percent: "There is fear. Fear about the quality of their professional lives, with the increasing restrictions on how doctors may practice and on their fees; fear about catching AIDS; concern about the process, the difficulty and stresses of medical training; concern about the cost of training, which can lead to substantial debt; and once they are out, uncertainty about how they will practice -- will there be a practice with an opening for them or will they have to incur further debt by starting a practice of their own?"
"Practical people," Horn concludes, "get overwhelmed by practicalities -- and preparing for a career as a doctor can be arduous." Certainly, it is more arduous than it once was. The average debt incurred by medical students now runs to $30,000 by the time they finish training and can run as high as $50,000 to $70,000. (This is due in part to federal cutbacks of subsidies for medical education, which occurred when the fear of a doctor shortage in the 1960s and 1970s gave way to fear of a doctor surplus in the 1980s.)
Doubt is cast on the debt factor as a deterrent, however, by a curious fact: female applicants to medical school have increased by one-third, while male applicants have decreased by the same proportion. If debt were a major deterrent, presumably it would affect males and females equally. (It is not reasonable to suppose that families are less willing to finance a son's education than a daughter's.) ANOTHER reason often given by students for not applying to medical school is a preference for certain other careers. Jolly, who studied a group of students who had already taken the MCAT but did not apply to medical school, found that "A substantial number thought their interest in medical science could be better served by attending graduate school in one of the bio-medical sciences, such as biochemistry, anatomy, physiology." At the University of Maryland, Dr. Nancy Love, director of premedical advising, reports that the fields academically talented students most often consider, aside from medicine, are computer science, business and engineering. "A lot of the talented ones -- and those are the ones we're concerned about here -- see that they can come out of these other programs at the top of the heap. They can have career stability, income, culturally positive regard, and they can go sailing on weekends. Why should they go in for the craziness of medical training?"
Some students in the AAMC study said they had been discouraged by physicians with whom they had discussed career plans. "Many of our faculty and staff were puzzled by this," Jolly said. "We find most physicians don't feel this way. It is a very satisfying profession, most feel. Maybe not as lucrative as it once was and there's not as much autonomy -- they have to answer now to the numerous regulatory bodies and to the insurance companies as other professions do -- but it's still a damn good profession." It seems clear, however, that the negative press the medical profession has received in recent years, as well as the highly publicized increase in malpractice suits against doctors, has had some effect.
"I think students -- or more correctly, their parents -- are becoming concerned about medicine as an appropriate career," says Love, who also notes a generational difference in the potential applicant pool. "This generation of 18- to 20-year-olds is the video-game generation. They grew up knowing that if you didn't like something, you could just switch channels. They think about four years of college, four years of medical school and three to eight years of residency and training after that -- all for a lifestyle that no longer means a continually increasing income. They can go out and get comparable money a whole lot faster in other fields."
Beyond such issues, the real underlying question is whether we need more doctors; and here opinion is divided. One side maintains that, since we have enough doctors already, encouraging more people to enter medicine is not correct. The other side, which does not believe that the excess is quite as well demonstrated as the first group does, argues that there may be a greater need for doctors than was anticipated when a surplus was predicted -- due, for example, to growing numbers of AIDS patients or other as yet unforeseen contingencies.
But with a 12 percent downturn in applicants between 1981 and 1985 alone -- and no one certain if the decline will abate soon -- an immediate concern is the quality of those students entering medical schools. What if the best and the brightest no longer want to study medicine?
To this end, medical schools are undergoing extensive self-examination and reevaluation, with changes in admissions procedures and curricula taking place all across the country. Even the most prestigious and sought-after schools, such as The Johns Hopkins School of Medicine and Harvard Medical School, have taken steps to enhance their programs and the kind of applicant they attract. Last year, Johns Hopkins took the lead in abolishing the traditional admission requirement of the MCAT scores. This test is a major source of pre-med syndrome -- stress among students, who may spend up to 100 hours reviewing for the exam and taking costly test preparation courses (an $8 million a year business). In addition to causing stress, the science examination can serve to narrow a student's undergraduate education, leading to heavy concentration on science courses with little opportunity for the studies necessary for a broad, general education.
The MCAT itself is also being modified to test abilities beyond factual memorization, and medical schools are implementing curriculum changes aimed at reducing some of the limitations of traditional training methods. A specific objective in many instances is to increase the efficiency of the learning process as well as the relevance of the material.
At Harvard Medical School, the admissions department has announced a policy of emphasizing personal qualities in the selection process and has also decreased the number of recommended science courses that applicants should have -- all in order to attract better-rounded candidates. A major, innovative experiment known as the New Pathway Program is underway, too, at Harvard. Students in this program begin their contact with patients in their first year, and throughout training they work closely with individual tutors and in small groups. One objective is to take steps to eliminate the information overload, with its unnecessary emphasis on specialized interests, that plagues medical students.
Other signs of change are evident in new courses being offered at some medical schools that aim to teach a more personal, humanistic, socially aware approach to medicine; and frequent articles in medical journals stress this aspect of training. While the success of such courses is difficult to evaluate, the importance of broadening a physician's education is not disputed: the demands placed on physicians are increasing as the decisions they are forced to make continually grow more complex, both from technological and ethical points of view.
Medicine still ranks, of course, among the most elite and esteemed professions. Medical schools continue to receive more applications than many other professional schools, such as dentistry and podiatry, which have far fewer applicants per place available. "There are still a lot of people who want to go into medicine," Love said. "There are still the highly motivated ones who want to make sick people feel better, regardless of the social atmosphere or the pressures -- just as there are still those who go into it for the prestige." But the predictions are that medical students as a group will become more heterogeneous, as schools begin to consider other qualities, assets and skills besides grades and test scores. This is especially likely if the applicant pool remains at its present level or drops further. Older applicants can expect better chances of getting in. Also romantics. "We need more romantics," as Horn of George Washington University puts it. "People who are coming to medicine because it's what they have to do to be happy and satisfied." ::
Carol Eron is the author of "The Virus That Ate Cannibals" and other books about medical subjects.