The pipeline of physiology courses in community colleges: to university, medical school, and beyond.

Community colleges are significant in the landscape of undergraduate STEM (science technology, engineering, and mathematics) education (9), including biology, premedical, and other preprofessional education. Thirty percent of first-year medical school students in 2012 attended a community college. Students attend at different times in high school, their first 2 yr of college, and postbaccalaureate. The community college pathway is particularly important for traditionally underrepresented groups. Premedical students who first attend community college are more likely to practice in underserved communities (2). For many students, community colleges have significant advantages over 4-yr institutions. Pragmatically, they are local, affordable, and flexible, which accommodates students' work and family commitments. Academically, community colleges offer teaching faculty, smaller class sizes, and accessible learning support systems. Community colleges are fertile ground for universities and medical schools to recruit diverse students and support faculty. Community college students and faculty face several challenges (6, 8). There are limited interactions between 2- and 4-yr institutions, and the ease of transfer processes varies. In addition, faculty who study and work to improve the physiology education experience often encounter obstacles. Here, we describe barriers and detail existing resources and opportunities useful in navigating challenges. We invite physiology educators from 2- and 4-yr institutions to engage in sharing resources and facilitating physiology education improvement across institutions. Given the need for STEM majors and health care professionals, 4-yr colleges and universities will continue to benefit from students who take introductory biology, physiology, and anatomy and physiology courses at community colleges.

The process of attrition in pre-medical studies: A large-scale analysis across 102 schools.

The important but difficult choice of vocational trajectory often takes place in college, beginning with majoring in a subject and taking relevant coursework. Of all possible disciplines, pre-medical studies are often not a formally defined major but pursued by a substantial proportion of the college population. Understanding students' experiences with pre-med coursework is valuable and understudied, as most research on medical education focuses on the later medical school and residency. We examined the pattern and predictors of attrition at various milestones along the pre-med coursework track during college. Using a College Board dataset, we analyzed a sample of 15,442 students spanning 102 institutions who began their post-secondary education in years between 2006 and 2009. We examined whether students fulfilled the required coursework to remain eligible for medical schools at several milestones: 1) one semester of general chemistry, biology, physics, 2) two semesters of general chemistry, biology, physics, 3) one semester of organic chemistry, and 4) either the second semester of organic chemistry or one semester of biochemistry, and predictors of persistence at each milestone. Only 16.5% of students who intended to major in pre-med graduate college with the required coursework for medical schools. Attrition rates are highest initially but drop as students take more advanced courses. Predictors of persistence include academic preparedness before college (e.g., SAT scores, high school GPA) and college performance (e.g., grades in pre-med courses). Students who perform better academically both in high school and in college courses are more likely to remain eligible for medical school.

Working with schools in deprived areas to raise aspirations for medicine and other healthcare science careers.

Educational attainment is inversely related to socio-economic status. The achievement gap widens as children progress through the system. Take up of science options is particularly poor and difficulties are compounded by lack of relevant science-based work experience in deprived areas. The interaction of these factors is examined in some detail in an area of socio-economic deprivation. High attainment in sciences is usually considered a core requirement for acceptance into medicine and widening access to medicine for school leavers is therefore very difficult in these circumstances. A partnership between hospitals and local schools, including science-based work placements, is described. Cooperation between the NHS and schools by provision of work experience and teaching materials could help to address these issues as well as potential staffing difficulties in other healthcare science careers in the future. Expenditure can be justified on the grounds of known links between health, education and employment.

Addressing physician shortages in New Mexico through a combined BA/MD program.

The University of New Mexico School of Medicine and College of Arts and Sciences developed its combined BA/MD degree program, which will increase the medical school class from 75 students to 100 in the fall of 2010, to address the critical issue of physician shortages in underserved New Mexico. The program, which began operation at the undergraduate (i.e., college) level in 2006, expands opportunities in medical education for New Mexico students, especially those from rural and underserved minority communities, and prepares them to practice in underserved areas of New Mexico. In the BA/MD program, students will earn a bachelor of arts, a medical degree, and a proposed certificate in public health. A challenging liberal arts curriculum introduces the principles of public health. Students have unique rural medicine and public health preceptorship opportunities that begin in the undergraduate years and continue throughout medical school. Students work with a community physician mentor in summer service-learning projects during the undergraduate years, then they return for required rural medicine rotations in the first, third, and fourth years of medical school. Simultaneously, the classroom curriculum for these rural medicine experiences emphasizes the public health perspective. High priority has been placed on supporting students with academic advising and counseling, tutoring, supplemental instruction, on-campus housing, and scholarships. The program has received strong support from communities, the New Mexico state legislature, the New Mexico Medical Society, and the faculties of arts and sciences and the school of medicine. Early results on the undergraduate level demonstrate strong interest from applicants, retention of participants, and enthusiasm of students and faculty alike.

A century after Flexner: the need for reform in medical education from college and medical school through residency training.

The last major change in medical education occurred almost 100 years ago following an independent investigation conducted by Dr. Abraham Flexner in 1910. Although individual institutions have implemented drastic changes in their own curriculum and the accrediting agencies have mandated other initiatives intended to maintain medical education at the cutting edge of science and technology, many facets of medical education, from the premedical requirements through medical school and residency training, have not changed in nearly half a century. There are areas that are completely lacking in the process of training physicians, and perhaps the assumption was that physicians were intelligent enough to figure this out on their own. While that may have been true in the past when things were less complicated, this approach offers too many opportunities for misadventure, ultimately to the detriment of physicians and patients. Perhaps what is needed is a more rigorous, didactic training program and more thought put into areas where judgment, morality and ethics converge to create potential hazards that can defeat the finest training, equipment and intent. Although American residency programs produce physicians fully capable of independent practice after their prescribed periods of training, there are elements of these training programs that are outdated, costly and perhaps not the best way to get to the desired endpoint. Perhaps these can be revised to more accurately reflect the changing times. This manuscript addresses some of these issues at all levels of training with recommendations for corrective action.

The plight of premedical education: myths and misperceptions--Part I: The "premedical syndrome".

The preparation for medical study and the process of gaining admission to medical school have long been contentious subjects, plagued by myths and misperceptions. In the first of two articles about the plight of premedical education, the author focuses on the myths of the "premedical syndrome" and the "cutthroat" medical student. He describes the origins of these myths, what purposes they may serve, why they persist, and why he believes they truly are myths and not accurate reflections of reality.

Impact of trends in primary, secondary, and postsecondary education on applications to medical school. I: gender considerations.

The number of applications to medical schools has been declining at a time when attention is beginning to focus on the potential need to expand the infrastructure of medical education to meet the nation's growing consumption of health care services. To gain an understanding of the dynamics affecting the availability of medical applicants, the author used data from several decades to study the transitions that occur throughout the process of education-from primary and secondary education to four-year colleges and, ultimately, to medical school application-from the standpoint of individuals' gender. (A companion article in this issue reports the findings of a parallel study from the standpoint of individuals' race and ethnicity.) A progressive erosion was found in the level of participation of men in postsecondary education over the past 25 years, and a parallel decline was observed in the percentage of baccalaureate men who sought further education at the doctoral level, including medicine. These dynamics have occurred aside rising levels of achievement of girls in early education, increasing numbers of women in four-year colleges, and high levels of interest among college women in medical education. But despite this peak of interest, women baccalaureates have displayed a low frequency of application to medical schools. Based on these observations and on population trends among 20 year olds, it is projected that the number of women applying to medical school will continue to increase, but only modestly, while the number of men who apply will remain relatively unchanged. The resulting growth will be sufficient to alleviate the recent paucity of medical school applications, but it will not be adequate for the needs that any significant expansion of medical school seats will create nor for the numbers of physicians that a predominantly female profession will require.

New York's statewide approach to increase the number of minority applicants to medical school.

The Associated Medical Schools of New York (AMS), a consortium of 13 public and private medical schools, has identified the problem of low minority enrollment as its top priority issue. Over the last six years, the consortium has established a multifaceted, statewide effort aimed at increasing the pool of qualified minority applicants. The programs include academic enrichment for precollege and college students, recruitment conferences, and a program to attract minority applicants to residency training in New York. The key to this effort is the work of the AMS Office of Minority Affairs, which provides statewide oversight and coordinates these programs. The consortium approach has proven attractive to both private philanthropy and government funding sources and provides a mechanism for evaluation. The most valid evaluation will occur in about three years, when graduates of the precollege program begin to apply to medical school.

Impact of trends in primary, secondary, and postsecondary education on applications to medical school. II: considerations of race, ethnicity, and income.

The availability of sufficient numbers of qualified medical school applicants has been a periodic source of concern. Over the past few years, this concern has emerged again, as fewer men have applied to medical school and as the number of minority applicants has stagnated. This time, however, the cause for concern is greater, because these declining numbers coincide with a growing need for physicians and the possibility that medical school capacity will have to be expanded to avert future physician shortages. Against this background, applications by members of racial and ethnic minorities, who represent an increasing fraction of the college age population, become particularly important. The author reports the trends in education, over several decades, by members of the principal racial-ethnic groups-whites, blacks, Hispanics, and Asians-traces their participation from kindergarten through college, and projects the likelihood of their applying to medical school over the next two decades. (A companion article in this issue reports a parallel study from the standpoint of gender.) One prominent observation is the firm link between academic achievement in the earliest grades and success thereafter. A second is the profound influence of parents' education, income, and expectations at each step along the way. Inadequacies in either sphere erode the potential for children to reach college and to do so in ways that predict interest in and capacity for medical school. Yet, even when that potential emerges, inadequate finances deflect qualified high school and college students from the paths that lead to medical education. These factors weigh most heavily on black and Hispanic children, particularly boys, but are prevalent among whites, as well. Without aggressive education in the earliest years and without adequate financial support in the later years, it is not clear that there will be a sufficiently large pool of qualified applicants for the number of medical school seats that must exist in the future.

Black men in the medical education pipeline: past, present, and future.

The authors discuss the decline in the numbers of black men enrolling in medical school over the last two decades and assess possible reasons for it, including the smaller numbers of men from nearly all races and ethnic groups now applying to medical school, the declining popularity of the undergraduate biology degree among men in general, the falling number of black students who go on to college, and, underlying all these, the pervasive effects of poverty on educational achievement, the dwindling employment opportunities for black men of limited education (brought on by dramatic changes in the American economy), and the rising indices of stress and alienation among black men. The authors review the larger social implications of the growing educational gap between black men and other segments of society, pose questions about some of the trends that have been mentioned, indicate lines for further research, and propose potential solutions to the problem of the deepening underrepresentation of black men in medical schools.

Slow progress: predoctoral education in family medicine in four Latin American countries.

BACKGROUND: Many countries in Latin America are seeking to expand primary care services provided through their health care systems. Family physicians are an essential component of an effective primary care workforce, but we know little about the status of family practice training in Latin America. This study examines predoctoral training in family practice in four Latin American countries and identifies factors affecting its incorporation into medical training institutions. METHODS: A Spanish language survey was mailed to the heads of all medical schools in Argentina, Colombia, Mexico, and Panama (n=100), asking about the status of family practice training at the school and factors perceived as facilitating or impeding its acceptance by the institution. Quantitative data were analyzed for frequency, and qualitative data were analyzed for content and theme. RESULTS: Sixty-five of the 100 schools responded to the survey. Of these, only 34 (52%) provide training in family practice at the predoctoral level, and only nine (14%) have established departments of family medicine. Barriers to inclusion of family medicine include lack of financial and human resources, definition of family practice as a subject rather than a specialty, and a perceived lack of interest among students. DISCUSSION: Inclusion of family medicine into medical education in Latin America has been slow. Unless strategies can be developed to increase training for family physicians in Latin American countries, governments in the region will have difficulty expanding primary health care services in their systems. Support is needed from governments, public health officials, funding agencies and organizations, and the academic community to increase training of family physicians in Latin America.

Impact of anti-affirmative action on medical school enrollment.

The nation's medical, dental and health profession school admissions of African American and other under-represented minority students needs reassessment in view of recent challenges to anti-affirmative action policies. Data suggest that low-income and medically underserved communities are more likely to be cared for by minority physicians. Experts project that the U.S. will need about twice as many African-American physicians as it now has to serve future patient needs. Currently, African Americans comprise 3% of the physician workforce. Decisive actions and policies--such as the recommendations made by the National Medical Association--are needed to ensure parity and cultural diversity in the medical workforce.