medical education: Despite doctors' high status in the US, applications to medical schools are falling, especially among ethnicminority students. Howard Berliner reports

Becoming a doctor has long been held in high esteem in the US, particularly after the Second World War, when physician incomes began to match their status.

Medical education in the US has followed a strict educational regimen since the upgrading exercise in the wake of the 1910 Flexner report: four years of college, followed by four years of medical school. The latter is divided into two years of basic sciences - preclinical education - and two years of apprenticeship training in different hospital departments.

Getting a medical licence requires one year of medical internship in a hospital, while specialty board certification requires three to seven extra years of training.As such, the seven to 10 year training period post-college means it takes far longer to become a doctor than other professional careers.

But despite the length of time it takes, the concerns about a loss of professional autonomy to insurance companies and reduced incomes, thousands of Americans apply to medical schools every year. In 2000, there were 37,092 applicants, of whom 16,301 enrolled. The schools had a total enrolment of 66,390 students for that year.Women constitute almost 46 per cent of new entrants and almost 45 per cent of all medical students.

1Roughly 16,000 medical students graduate each year, along with 5,000 international medical graduates. They fill postgraduate positions (internships and residencies) in hospitals to secure their medical licences and gain specialty certification.

The 2.2 applicants per admission is a sign that medical schools are selective, but this figure is well below the almost 10 applicants per place of the early 1970s and above the near to one-to-one ratio of the late 1980s.Most medical educators would argue that applications are set to rise again, as the dot. com bubble continues to burst and the chance to make obscene sums of money in the corporate world fades.

The fact that women are making up an increasing proportion of medical school admissions is testament to the allure that other sectors of the economy have held for men, so it will be interesting to see if the balance changes.

In 1998, the Pew Health Professions Commission released its fourth and final report. Among its recommendations, it noted: 'It is essential that the nation's health profession workforce represent the cultural diversity that is and will become an even more significant part of this society. This is not a quota borne out of a sense of equity or distribution of justice, but a principle that the best healthcare is delivered by those that fully understand a cultural tradition.'

1While many people might be sympathetic with the sentiments of this statement, putting it into practice has proved difficult.

Of the 37,000 applicants to medical school in 2000, only 2,900 (7.9 per cent) were AfricanAmericans, far below the 12 per cent in the general population. Reviewing the data on admissions from the past decade, the high point for applications from minorities was in the mid-1990s, when about 3,500 African-Americans applied to medical school.

Moreover, the acceptance rate for AfricanAmericans was 44 per cent for men and 37.4 per cent for women, compared with 49 per cent rates for whites. Thus only 1,168 African-Americans were admitted in 2000, well below the goal of 2,000 set by the Association of American Medical Colleges in its '2,000 by 2000' campaign.

Other minority applicants have not kept pace with their representation in the general population.One of the reasons for this has been the tortuous path of affirmative action in professional education.

Almost all medical schools have instituted affirmative action procedures to allow them to accept ethnicminority applicants even when their academic credentials and medical college admissions test scores are inferior to those of other candidates.

However, given the limited number of slots in medical schools, rejected candidates are able to sue the schools, citing reverse discrimination.

California was notable in backing a referendum that prohibited race-based criteria in professional school admissions and, as a direct result, minority applications to medical schools in the state fell dramatically.Other states have also restricted affirmative action programmes, and so far the lower courts in the US have not had definitive rulings on the legality of such restrictions. The current conservative bent of the US Supreme Court has made many advocates of affirmative action policies fearful of a major case being heard.

As the results of the 2000 census have been made public, it has become clear the US has grown more ethnically diverse than expected.While women are better represented than in the past, most minority groups are experiencing a downturn in representation in medicine. This clearly portends a problem for the future, as racial disparities in access to treatment and medical outcomes are increasingly being seen as related to a lack of cultural competency in treatment.

In the 1980s, it was widely believed that physicians needed to have a broad liberal arts education to relate to patients' needs beyond the strictly medical.

An understanding of literature, history, art, religion and other such subjects was needed to give doctors a universal and humanistic perspective of treatment.

To accomplish this, medical schools began to accept students who had life experiences outside schooling, or who had majored in subjects such as music, art history and foreign languages.

Medical schools did not want to increase their intakes (there was a belief that a surplus of doctors was looming) and thus rejected more traditional applicants.

Much as with whites denied entrance to medical school in favour of minorities, traditional science majors who were denied entry were none too happy.

At the same time, medical school faculties were not entirely enthralled with the new students either.

They had dedicated their lives to their particular science and wanted similar-minded students.

It turned out that because the humanities entrants had less science and maths than traditional students, they found it more difficult to pass national proficiency, and humanised medicine began to fade.

There is a widespread belief (at least among medical school deans) that the rapid growth of medical knowledge requires that medical students learn even more science than they did in the past.

New diseases, diagnostic and therapeutic technologies, and areas of medical research, including pharmacology and genomics, all require the medical student to have a deep grounding in science and research techniques.

At the same time, there are increasing demands for doctors to have a better understanding of health economics - for their own sake, if not for their patients' - gerontology, medical ethics, nutrition and prevention, alternative medicine and cultural competency, to name a few.How can all this possibly be added to a medical curriculum already overlong and overloaded?

A patient might well ask how they benefit from the doctor who learnt about medical research 10 years before going into practice; how it would change the medical interaction and why a patient would be better off with a doctor who once had that knowledge.Medical educators do not have profound answers to such questions, except to say that doctors should be well versed in science. But if an extra subject such as genomics is added to the curriculum, what can be removed to make way?

What can they afford not to know?

Many believe that if less emphasis were placed on rote memorisation, and more use were made of information technology, medical students could be taught more, if differently. Several medical schools, including NYU, Stanford and Harvard, are giving new students palmtop computers, pre-loaded with facts that previously had to be committed to memory. Others require that students become intimately familiar with the Internet and medical communications.Hospitals are obliging this trend by installing computers by bedsides to enable accurate information to be accessed directly.

As noted earlier, it was widely believed 20 years ago that there was a looming physician surplus in the US and that by 2000 there would be over 150,000 surplus doctors. The anticipated growth of managed care and improved productivity would require far fewer doctors than the nation was producing.

Today, there is a view that the country could do with more physicians.Managed care has not reduced the use of doctors and productivity has not increased much. Perhaps most important, the ageing population and the growth of chronic illness may require the US to produce even more physicians than it does today.

Key points

Most US medical schools have adopted programmes of affirmative action but these have not been completely successful in increasing diversity.

There have been some law suits against medical schools brought by rejected students claiming reverse discrimination.

Most minority groups are experiencing a downturn in representation in medicine.

The movement to humanise medicine through widening entrance criteria has faded away.