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The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce. To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the Association of American Colleges of Osteopathic Medicine. U.S. medical schools. 60 043 physicians in active practice who graduated from medical school between 1999 and 2001. The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings. Public and community-based medical schools had higher social mission scores than private and non-community-based schools. National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas. The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates. The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates. Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation. These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities.
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The Social Mission of Medical Education: Ranking the Schools
Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; and Michael Spagnola, BA
Background: The basic purpose of medical schools is to educate
physicians to care for the national population. Fulfilling this goal
requires an adequate number of primary care physicians, adequate
distribution of physicians to underserved areas, and a sufficient
number of minority physicians in the workforce.
Objective: To develop a metric called the social mission score to
evaluate medical school output in these 3 dimensions.
Design: Secondary analysis of data from the American Medical
Association (AMA) Physician Masterfile and of data on race and
ethnicity in medical schools from the Association of American Med-
ical Colleges and the American Association of Colleges of Osteo-
pathic Medicine.
Setting: U.S. medical schools.
Participants: 60 043 physicians in active practice who graduated
from medical school between 1999 and 2001.
Measurements: The percentage of graduates who practice primary
care, work in health professional shortage areas, and are underrep-
resented minorities, combined into a composite social mission score.
Results: The contribution of medical schools to the social mission of
medical education varied substantially. Three historically black col-
leges had the highest social mission rankings. Public and community-
based medical schools had higher social mission scores than private
and non–community-based schools. National Institutes of Health
funding was inversely associated with social mission scores. Medical
schools in the northeastern United States and in more urban areas
were less likely to produce primary care physicians and physicians
who practice in underserved areas.
Limitations: The AMA Physician Masterfile has limitations, includ-
ing specialty self-designation by physicians, inconsistencies in re-
porting work addresses, and delays in information updates. The
public good provided by medical schools may include contributions
not reflected in the social mission score. The study was not de-
signed to evaluate quality of care provided by medical school
graduates.
Conclusion: Medical schools vary substantially in their contribution
to the social mission of medical education. School rankings based
on the social mission score differ from those that use research
funding and subjective assessments of school reputation. These
findings suggest that initiatives at the medical school level could
increase the proportion of physicians who practice primary care,
work in underserved areas, and are underrepresented minorities.
Primary Funding Source: Josiah Macy, Jr. Foundation.
Ann Intern Med. 2010;152:804-811. www.annals.org
For author affiliations, see end of text.
Medical schools in the United States serve many func-
tions, but one of their most basic purposes is to
educate physicians to care for the national population.
During the latter half of the 20th century, with federal and
state support, medical education expanded to meet popu-
lation needs (1). However, 3 specific interrelated issues
challenged medical educators and policymakers: an insuf-
ficient number of primary care physicians, geographic
maldistribution of physicians, and the lack of a representa-
tive number of racial and ethnic minorities in medical
schools and in practice.
As early as the 1950s, commissions concerned with the
medical workforce in the United States issued reports that
raised these concerns (2–4). These reports helped launch leg-
islation beginning with the Health Professions Educational
Assistance Act of 1963 that provided support for expansion of
medical education with particular attention to primary care,
physician distribution, and educational opportunities for mi-
nority medical students. The National Health Service Corps,
created in 1970, provided scholarships for students who com-
mitted to practice in underserved communities. Of the 28
allopathic medical schools opened with the aid of substantial
state and federal support between 1970 and 1982, the
Association of American Medical Colleges designated 17 as
community-based (Salsberg E. Personal communication).
Nevertheless, problems in these 3 areas remain. Evi-
dence increasingly shows that primary care is associated
with improved quality of care and decreased medical costs
(5, 6). However, an insufficient number of primary care
physicians has hampered efforts to provide expanded
health care access in states, such as in Massachusetts (7),
and business groups and insurers have begun to speak out
about the need for increased access to primary care (8).
Rural communities have a chronic shortage of physi-
cians (9, 10), and federally supported community health
centers report major deficits in physician recruitment (11,
12). African-American, Hispanic, and Native-American
physicians continue to be severely underrepresented in the
U.S. workforce. Underrepresented minorities made up
28% of the general population in 2006 (13) but accounted
for only 15% of medical students and 8% of physicians in
practice (14). These minority physicians provide a dispro-
portionate share of health care to the growing minority
U.S. population (15).
See also:
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Academia and Clinic
804 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 www.annals.org
Medical schools contribute numerous important pub-
lic goods to society beyond training the future physician
workforce. They generate new scientific knowledge, are the
home of leading-edge clinical treatments, and often pro-
vide substantial health care to underserved communities
through their university hospitals and affiliates. Medical
schools, however, are the only institutions in our society
that can produce physicians; yet assessments of medical
schools, such as the well-known U.S. News & World Report
ranking system, often value research funding, school repu-
tation, and student selectivity factors (16) over the actual
educational output of each school, particularly regarding
the number of graduates who enter primary care, practice
in underserved areas, and are underrepresented minorities.
As citizens and policymakers reconsider the U.S.
health care system and seek “quality, affordable health care
for every American” (17), the nature of the physician
workforce is becoming a key concern (18, 19). Many peo-
ple believe that medical schools are accountable to society
for their actions and accomplishments (20–22). Beyond
their general educational mission, medical schools are ex-
pected to have a social mission to train physicians to care
for the population as a whole, taking into account such
issues as primary care, underserved areas, and workforce
diversity (23–26).
We describe the analytic method that we used to mea-
sure the output of U.S. allopathic and osteopathic medical
schools in these historically linked and traditionally chal-
lenging dimensions. We constructed a social mission score
to summarize overall school performance in these areas.
METHODS
Our analysis is based on the percentage of medical
school graduates who practice primary care, work in health
professional shortage areas (HPSAs), and are underrepre-
sented minorities. The analysis was performed using data
on graduates from 1999 to 2001 to capture the most recent
cohort of graduates who had completed all types of resi-
dency training and national service obligations, such as the
National Health Service Corps and the military’s Health
Professions Scholarship Program, both of which may in-
volve up to 4 years of service. These factors were essential
to determine graduates’ actual choices of location and spe-
cialty rather than intermediary placements.
We analyzed multiple years to account for annual vari-
ations and included the 141 U.S. allopathic and osteo-
pathic schools that graduated students between 1999 and
2001. We used the 2008 American Medical Association
(AMA) Physician Masterfile to calculate the percentage of
graduates practicing primary care and located in HPSAs.
All physicians except for those listed as residents or fellows
or those employed as administrators, primarily engaged in
research or teaching, or who were no longer active (7.4%
of the study group) were included. International medical
school graduates were excluded. We used publicly available
data on the race and ethnicity of graduates from the Asso-
ciation of American Medical Colleges and the American
Association of Colleges of Osteopathic Medicine (27) to
calculate the percentage of graduates who were underrep-
resented minorities.
We obtained standardized values for each of the 3
measures, with a mean value of 0 (SD, 1).
Primary Care Measure
Primary specialty information from the AMA Physi-
cian Masterfile was used to calculate the percentage of pri-
mary care graduates for each medical school. Primary care
physicians included those in family medicine, general in-
ternal medicine, general pediatrics, or internal medicine
pediatrics.
HPSA Measure
The Health Resources and Services Administration
identifies HPSAs on the basis of 3 primary criteria
(population–provider ratios, poverty rate, and travel dis-
tance or time to the nearest accessible source of care) and
several secondary criteria (including infant mortality and
low-birthweight rates and proportion of the population
younger than 18 years or older than 65 years. We calcu-
lated the percentage of graduates from each medical school
with an address in an HPSA. Health professional shortage
area geographic data were downloaded from the Health
Resources and Services Administration’s Geospatial Data
Warehouse (28). We geocoded addresses from the AMA
Physician Masterfile by using the spatial mapping tool Arc-
GIS (ESRI, Redlands, California) to determine physician
location within a primary care HPSA using geographic and
population-based definitions of primary care HPSAs to de-
termine the greatest number of graduates working in
HPSAs.
This method probably overestimates the number of
physicians practicing in underserved areas by including
some physicians working in non-HPSA settings, such as
academic health centers. For physicians with a preferred
mailing address not identified as a work address, we used
the alternative address, if available, to increase the likeli-
hood of obtaining a work rather than home address (29).
Underrepresented Minority Measure
On the basis of conventions used by the Association of
American Medical Colleges, we defined underrepresented
minorities as African-American, Hispanic, and Native-
American persons. For the medical school graduating
classes of 1999 to 2001, we divided the total number of
underrepresented minority graduates for each medical
school by the total number of graduates to create a raw
percentage of minority medical school graduates for each
school. Because the percentage of underrepresented minor-
ities among states varied substantially, we adjusted each
school’s raw percentage.
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www.annals.org 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 805
Public medical schools primarily admit students from
within their states; therefore, we calculated the ratio of the
proportion of underrepresented minorities graduated by
the school to the proportion of underrepresented minori-
ties living in the state. For private schools, which admit
students from a more national pool, we calculated the ratio
of the proportion graduated by the school to the national
proportion. We calculated ratios for public and private
Puerto Rican schools by using the proportion of underrep-
resented minorities in Puerto Rico because these schools
primarily recruit from and produce physicians who prac-
tice in Puerto Rico. To calculate the percentage of state
and national underrepresented minorities, we used data
from the U.S. Census Bureau.
Three historically black medical schools with a high
proportion of graduates who are underrepresented minor-
ities created a significantly skewed distribution. To normal-
ize the skewed distribution, we calculated the standardized
scores without these 3 schools, then reincluded them by
using the calculated mean value and SD.
Table 1. Medical School Rankings Based on Social Mission Score*
Rank School State Social Mission
Score†
Primary Care
Physicians
Physicians
Practicing in
HPSAs
Highest 20
Total,
%
Standardized
Score‡
Total,
%
Standardized
Score‡
1 Morehouse School of Medicine GA 13.98 43.7 1.20 39.1 1.40
2 Meharry Medical College TN 12.92 49.3 2.00 28.1 0.14
3 Howard University DC 10.66 36.5 0.19 33.7 0.78
4 Wright State University Boonshoft School of Medicine OH 5.34 49.2 1.98 28 0.12
5 University of Kansas KS 4.49 45.2 1.42 43.9 1.96
6 Michigan State University College of Human Medicine MI 4.13 43.6 1.20 26.5 –0.05
7 East Carolina University Brody School of Medicine NC 3.72 51.9 2.36 34.2 0.84
8 University of South Alabama AL 3.15 42 0.97 52.7 2.97
9 Ponce School of Medicine PR 3.02 33 –0.31 43.8 1.94
10 University of Iowa Carver College of Medicine IA 2.97 37.1 0.28 21 –0.69
11 Oregon Health & Science University OR 2.93 43.8 1.22 43.8 1.94
12 East Tennessee State University Quillen College of Medicine TN 2.88 53.5 2.58 32.7 0.67
13 University of Mississippi MS 2.86 33.5 –0.24 62.5 4.11
14 University of Kentucky KY 2.61 39.8 0.65 32.5 0.64
15 Southern Illinois University IL 2.59 45 1.39 46.5 2.26
16 Marshall University Joan C. Edwards University WV 2.51 46.8 1.64 20.9 –0.70
17 University of Massachusetts Medical School MA 2.48 45.9 1.52 36.7 1.12
18 University of Illinois IL 2.27 36.7 0.21 35.7 1.01
19 University of New Mexico NM 2.25 46.7 1.63 30.7 0.43
20 University of Wisconsin WI 2.24 35.7 0.07 19.3 –0.87
Lowest 20§
1 Vanderbilt University TN –3.95 21.9 –1.86 20.8 –0.70
2 University of Texas Southwestern Medical Center TX –3.64 26.8 –1.18 15.1 –1.36
3 Northwestern University Feinberg School of Medicine IL –3.11 24.4 1.51 19.5 –0.86
4 University of California, Irvine CA –3.02 32.9 –0.32 14.2 –1.47
5 New York University NY –2.65 24.3 –1.53 22.1 –0.55
6 University of Medicine and Dentistry of New Jersey—NJ NJ –2.46 23.7 –1.61 17.8 –1.05
7 Uniformed Services University of the Health Sciences MD –2.36 29.6 –0.78 21.4 –0.64
8 Thomas Jefferson University PA –2.34 32.1 –0.42 20.6 –0.72
9 Stony Brook University NY –2.21 29.1 –0.85 20.4 –0.76
10 Albert Einstein College of Medicine of Yeshiva University NY –2.13 26.1 –1.28 24.8 –0.25
11 Boston University MA –2.12 26.7 –1.19 23.3 –0.42
12 Loyola University Chicago Stritch School of Medicine IL –2.06 33.7 –0.20 20.7 –0.72
13 University of Pennsylvania PA –2.03 19.1 –2.27 20.4 –0.76
14 Medical College of Wisconsin WI –2.02 33.5 –0.23 15.9 –1.28
15 Albany Medical College NY –2.00 30.7 –0.63 24.2 –0.32
16 Columbia University NY –1.98 20.3 –2.10 31.8 0.57
17 Texas A&M University TX –1.95 37 0.26 16.2 –1.24
18 Duke University NC –1.91 22.3 –1.82 23.9 –0.34
19 Stanford University CA –1.90 27.4 –1.10 16.2 –1.23
20 Johns Hopkins University MD –1.90 24.3 –1.53 26.7 –0.02
HPSA health professional shortage area.
*The ranking of all 141 schools is in the Appendix, available at www.annals.org.
The sum of the primary care, HPSA, and underrepresented minority standardized scores.
The standardized value calculated for each measure, with a mean value of 0 (SD, 1).
§Ranked from lowest to highest (i.e., rank 1 is the lowest-performing school).
Academia and Clinic The Social Mission of Medical Education
806 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 www.annals.org
Composite Index and Aggregate Analysis
We constructed a composite score by using a simple
sum of these 3 standardized measures. We also developed
an alternative composite score comprising the sum of each
school’s within-component ranking on a theoretical scale
from 3 (1 11) to 434 (141 141 141) (rank-sum
approach). We reported results using the composite mea-
sure sum ranking because these findings were not very dif-
ferent from those using the rank-sum approach and be-
cause the simple sum measure preserves information about
the magnitude of differences across schools for each measure.
We also analyzed schools in aggregate by geographic
region, size of the metropolitan area of the school’s main
campus, private or public status, National Institutes of
Health (NIH) support (30), allopathic or osteopathic sta-
tus, and classification as a community-based school by the
Association of American Medical Colleges and determined
weighted mean scores for each classification (Appendix,
available at www.annals.org). Because of the differences in
school sizes, the numbers of graduates per school were
weighted into the mean value. We obtained regional clas-
sifications from the U.S. Census Bureau (31) and county
size classifications from the U.S. Department of Agricul-
ture’s Rural–Urban Continuum Codes (32). We used
analysis-of-variance models to compare the composite
scores and the 3 specific scores across different school
characteristics.
Role of the Funding Source
This study was conducted as part of the Medical Ed-
ucation Futures Study, which is funded by the Josiah
Macy, Jr. Foundation to examine the social mission of
medical education during the current period of medical
school expansion. The funding source had no role in the
study design, data collection, or interpretation of results.
RESULTS
Table 1 shows the 20 schools with the highest and
lowest social mission scores and the primary care, HPSA,
and underrepresented minority measures on which the
schools’ composite scores were based. The ranking of all
141 schools is in the Appendix (available at www.annals
.org).
Aggregate analyses (Table 2) suggest differences in so-
cial mission score and components by geographic region
and the size of the metropolitan area in which the schools
are located. No region was clearly advantaged in all 3 mea-
sures; however, the South, West, and Midwest had positive
social mission scores, whereas the Northeast had a negative
social mission score. Western schools produced more pri-
mary care physicians, and Southern schools produced more
physicians who practice in underserved areas. Southern
schools also had the largest percentage of underrepresented
minorities among their graduates but, after correction for
underrepresented minorities in the regional population,
had the same relative representation of minorities as Mid-
western schools. Schools in progressively smaller metropol-
itan areas produced increasingly more primary care physi-
cians and physicians who practice in underserved areas but
graduated fewer underrepresented minorities.
Compared with allopathic schools, osteopathic schools
produced relatively more primary care physicians but
trained fewer underrepresented minorities. Public schools
scored higher on the composite social mission score and in
all 3 component measures, although the differences be-
tween public and private schools were not statistically sig-
Table 1—Continued
School–State (Nation)
Ratio of
Underrepresented
Minorities
Underrepresented
Minorities in the
School, %
Underrepresented
Minorities in the
State (Nation), %
Ratio Standardized
Score‡
3.15 11.38 83.3 26.5
2.99 10.78 79.3 26.5
2.71 9.68 71.9 26.5
1.31 3.23 19.0 14.5
0.77 1.12 11.6 15.1
1.24 2.99 23.7 19.1
0.62 0.52 17.3 28.1
0.29 –0.78 8.2 28.7
0.84 1.38 82.5 98.8
1.35 3.38 8.1 6.0
0.43 –0.23 5.5 13.0
0.39 –0.37 7.6 19.5
0.23 –1.01 8.8 38.3
0.82 1.32 8.0 9.8
0.22 –1.06 6.1 28.3
0.89 1.58 4.2 4.7
0.44 –0.16 5.9 13.3
0.75 1.05 21.2 28.3
0.53 0.19 28.8 53.9
1.26 3.03 13.8 11.0
0.13 –1.38 3.6 26.5
0.21 –1.09 9.3 44.7
0.30 –0.74 7.9 26.5
0.17 –1.24 7.0 41.2
0.34 –0.57 9.0 26.5
0.54 0.20 14.8 27.7
0.24 –0.95 6.5 26.5
0.18 –1.19 4.8 26.5
0.33 –0.60 10.5 31.7
0.33 –0.60 8.8 26.5
0.35 –0.52 9.4 26.5
0.20 –1.14 5.2 26.5
0.74 0.99 19.5 26.5
0.36 –0.51 9.4 26.5
0.22 –1.06 5.7 26.5
0.37 –0.45 9.8 26.5
0.24 –0.97 10.6 44.7
0.55 0.24 14.5 26.5
0.59 0.43 15.7 26.5
0.40 –0.35 10.5 26.5
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www.annals.org 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 807
nificant for the underserved area and underrepresented mi-
nority components.
Funding by the NIH was inversely associated with so-
cial mission score and with a school’s output of primary
care physicians and physicians practicing in underserved
areas. Community-based schools scored higher than non–
community-based schools in the composite social mission
score and in all 3 component measures, although
the differences between community-based and non–
community-based schools were not statistically significant
for the underserved area and underrepresented minority
components.
School rankings obtained by using the social mission
score in a secondary analysis based on the rank-sum ap-
proach were strongly correlated with rankings obtained by
using the social mission score as a sum of composite score
measures (r0.971). Fifteen of the top-20 schools in the
composite-score sum rankings were also ranked among the
top-20 schools when the alternative rank-sum scoring
method was used. Giving greater weight to individual out-
liers with our composite measure caused some of these
differences. For example, the University of Mississippi
ranked 13th on social mission on the basis of composite
score measures but 63rd in the alternative rank-sum rank-
ing, because a very high percentage (62.5%) of the school’s
graduates practice in HPSAs; the school’s relatively low
percentage of graduates who practice primary care (33.5%)
or are underrepresented minorities (school–state ratio,
Table 2. Comparison of Social Mission Scores, by Location, School Type, and Funding*
Characteristic Schools,
n
Social
Mission
Score†
Primary Care
Physicians
Physicians Practicing in
HPSAs
School–State
(Nation) Ratio of
Underrepresented
Minorities
Underrepresented
Minority
Graduates, %
Total,
%
Standardized
Score‡
Total,
%
Standardized
Score‡
Ratio Standardized
Score‡
Region§
Midwest 37 0.14 36.0 0.12 25.5 –0.16 0.53 0.18 9.3
Northeast 34 –1.05 31.2 –0.55 23.8 –0.36 0.45 –0.13 11.4
South 49 0.46 35.4 0.03 28.6 0.19 0.54 0.23 14.8
West 18 0.12 38.6 0.49 24.1 –0.32 0.47 –0.04 13.8
Pvalue¶ 0.015 0.001 0.027 0.417
Rural–urban continuum§
MSA 1 million persons 85 –0.38 33.6 –0.22 24.7 –0.26 0.51 0.10 13.3
MSA, 250 000–1 million persons 34 0.48 37.1 0.28 28.5 0.18 0.49 0.03 10.1
MSA 200 000 persons 15 1.10 38.8 0.51 28.8 0.21 0.58 0.38 8.8
Non-MSA 4 0.57 39.2 0.57 30.0 0.36 0.39 –0.36 6.1
Pvalue¶ 0.065 0.006 0.072 0.855
Community-based
(allopathic medical schools only)
No 107 –0.20 33.4 –0.24 25.7 –0.14 0.53 0.18 13.4
Yes 17 1.47 39.8 0.66 28.4 0.17 0.64 0.64 19.7
Pvalue¶ 0.024 0.003 0.335 0.346
School type
Allopathic 124 –0.07 33.9 –0.17 25.9 –0.12 0.54 0.21 13.9
Osteopathic 17 0.08 39.9 0.67 26.7 –0.03 0.34 –0.57 8.3
Pvalue¶ 0.782 0.001 0.710 0.029
Funding
Private 59 –0.58 32.7 –0.34 25.1 –0.21 0.47 –0.03 13.5
Public 82 0.37 36.3 0.17 26.7 –0.02 0.54 0.22 12.9
Pvalue¶ 0.009 0.001 0.244 0.255
NIH support
Quartile 1 ($0–$17 million) 36 0.15 38.9 0.53 27.0 0.01 0.39 –0.39 11.1
Quartile 2 ($18–$84 million) 35 0.64 35.1 –0.01 29.2 0.26 0.57 0.39 15.9
Quartile 3 ($85–$244 million) 35 –0.37 34.2 –0.14 24.2 –0.31 0.50 0.08 12.5
Quartile 4 ($246–$897 million) 35 –0.52 31.4 –0.54 24.2 –0.31 0.57 0.32 13.1
Pvalue¶ 0.090 0.001 0.026 0.130
HPSA health professional shortage area; MSA metropolitan statistical area; NIH National Institutes of Health.
*Social mission scores and percentages and scores of primary care physicians, HPSAs, and underrepresented minorities are averages weighted by school size.
The sum of the primary care, HPSA, and underrepresented minority standardized scores.
The standardized value calculated for each measure, with a mean value of 0 (SD, 1).
§These weighted averages exclude Puerto Rican schools.
These data were obtained from the U.S. Census Bureau.
Pvalues are obtained from analysis of variance comparing scores within categories.
Academia and Clinic The Social Mission of Medical Education
808 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 www.annals.org
0.23) contributed to its lower score compared with the
sum of each school’s within-component ranks.
DISCUSSION
Primary care physician output, practice in under-
served areas, and a diverse physician workforce have per-
sistently challenged the U.S. health care system and
medical education. This analysis reveals substantial vari-
ation in the success of U.S. medical schools in address-
ing these issues.
Ranking schools is not new. Since 1983, U.S. News &
World Report has published rankings of colleges and grad-
uate schools (33) that are based on the amount of spon-
sored research at the schools; student selectivity criteria,
such as Medical College Admission Test scores and grade
point averages; and subjective assessments made by medical
school deans and residency directors (34). In 1995, U.S.
News & World Report added a primary care rating system
that takes into account the percentage of graduates enter-
ing primary care residencies. However, their primary care
rating continues to include faculty opinion and student-
selectivity measures (17). Moreover, this system does not
measure the actual number of graduates entering primary
care practice after completing their residencies or score the
number of graduates who practice in underserved areas or
are underrepresented minorities. Because of these differ-
ences, our results vary considerably from the U.S. News &
World Report’s rankings. Our findings suggest numerous
areas that are relevant to public policymakers and medical
educators as they consider the design of new medical
schools and the expansion of current ones.
The 3 historically black colleges and universities with
medical schools (Morehouse School of Medicine, Meharry
Medical College, and Howard University) score at the top
of the social mission rankings. These results are not unex-
pected, as 70% to 85% of each of these schools’ graduating
classes were underrepresented minorities compared with
only 13.5% in all medical schools during the same period.
The higher underrepresented minority scores alone signif-
icantly increase these schools’ social mission scores. How-
ever, all of these schools also score in the top half of the
primary care and underserved output measures.
Previous studies have shown that underrepresented
minority physicians provide relatively more care to minor-
ity and underserved populations compared with non-
minority physicians (35, 36). Our findings, in conjunction
with these studies, suggest that expansion programs fo-
cused on the recruitment and training of underrepresented
minority medical students could have disproportionately
favorable effects on the geographic misdistribution of phy-
sicians and inadequate primary care workforce.
Public schools graduate higher proportions of primary
care physicians. Public schools also seem to graduate
greater proportions of physicians practicing in underserved
areas and of minority physicians than private schools; how-
ever, the differences between public and private schools in
these 2 components were not statistically significant. These
findings indicate that public schools are more responsive to
the population-based and distributional physician work-
force needs that concern legislators, and suggest that en-
hanced support for medical education at the state level
could address workforce needs more effectively than would
investment in private schools.
Furthermore, the higher social mission score of
community-based medical schools suggest that a school’s
explicit commitment to educate physicians who will pursue
careers compatible with community needs has long-term
effects on the career choices of its graduates. However, the
difference between the high proportion of graduates prac-
ticing in underserved areas and that of minority physicians
at these schools was not statistically significant compared
with those of non–community-based colleges, and the suc-
cesses of Morehouse School of Medicine (1 of the 17
community-based colleges and a clear outlier in at least the
underrepresented minority component) may have contrib-
uted to the higher social mission score for community-
based colleges overall.
The level of NIH support that medical schools re-
ceived was inversely associated with their output of primary
care physicians and physicians practicing in underserved
areas. High levels of research funding clearly indicate an
institutional commitment to research and probably indi-
cate missions that value technical medicine and specializa-
tion rather than training in primary care and practice in
underserved areas. Our findings suggest that schools with
smaller research portfolios are more likely to focus on
training physicians for community and population needs,
although schools in the lowest quartile of NIH funding
also scored lower for underrepresented minority output
than did schools with higher levels of NIH funding. Nev-
ertheless, we propose that educational ranking systems that
place significant weight on research funding may confuse
discussions of national educational policy by conflating re-
search values with national clinical needs.
Compared with other U.S. regions, the Northeast,
with its preponderance of private, traditional, and research-
intensive medical schools, had the lowest scores in the
primary care and underserved areas components and a
distinctly lower social mission score. The size of the met-
ropolitan area in which schools are located also seems to
affect the social mission score. For example, medical
schools in less urban areas were more likely to produce
primary care physicians and physicians practicing in under-
served areas. These findings may be particularly useful for
individuals or organizations considering building new
schools or developing branch campuses of existing schools.
Our findings indicate that osteopathic schools con-
tinue to place substantially more graduates into primary
care and marginally more graduates into underserved areas,
suggesting that osteopathic medicine has continued to be
influenced by its traditional focus on primary care and
Academia and ClinicThe Social Mission of Medical Education
www.annals.org 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 809
rural practice (37–39). However, allopathic schools have
recruited more underrepresented minorities than osteo-
pathic schools. Osteopathic medicine has been creative in
establishing new schools in nontraditional locations, such
as Pikeville, Kentucky, and Harlem, New York, and in
developing innovative community-based programs, such as
A.T. Still University in Mesa, Arizona, where all clinical
work is based at 1 of 10 community health centers. The
outcomes of these programs need to be measured, but their
flexibility and inventiveness commend them to planners
concerned with training a broad-based physician work-
force.
Our analysis also provides an opportunity to identify
schools that defy the trends. Four large research institu-
tions (University of Minnesota; University of Washington;
University of California, San Diego; and University of
Colorado) are in the top quartile of medical school recipi-
ents of NIH funding and of primary care output rankings.
In addition, University of Washington and University of
Minnesota are in the top quartile for overall social mission
score. These findings invite questions about what factors
influence graduates of these schools to choose primary care
and whether those influences might be transferable to other
schools. Our findings also raise questions about why some
community-based public medical schools that seem well
situated to have high social mission scores do not have
them.
Our study has limitations. First, we used the AMA
Physician Masterfile as a primary data source, although
self-designation by physicians, inconsistencies in reporting
work addresses, and a delay in information updates (40
42) raise concerns about its accuracy. Where possible, we
addressed these problems by, for example, attempting to
minimize location inaccuracy by preferentially using sec-
ondary addresses when the primary address was a home
address. These shortcomings may cause some inaccuracies,
but we did not clearly identify any likely systematic biases.
Second, we selected a 1999 to 2001 graduating class
cohort to allow graduates to complete transitional place-
ments in residency training and service obligations. Our
findings therefore do not reflect changes in medical school
policies in the past 10 years and social mission performance
of newer medical schools. These factors suggest the need
for future analyses, possibly on an ongoing basis, to mon-
itor more recent performance or trends.
Third, our measurement of social mission may raise
objections on the grounds that the values taught in medical
school are subject to influences beyond the control of med-
ical educators, such as specialty incomes, student debt, and
lifestyle preferences. Although this concern is understand-
able, medical schools as an enterprise have enormous influ-
ence over the creation of physicians, including the location
and mission of the school and its recruitment and admis-
sion practices, curriculum, and values that the faculty
model for students. No other institution involved in creat-
ing physicians has as much influence as the medical school.
The variable career patterns of graduates of different med-
ical schools, as shown here, seems to validate the premise
that schools have considerable influence in the type of
graduate that they produce.
Finally, our measure of social mission says nothing
about the quality of education that medical schools provide
or the quality of care that their students deliver 7 to 9 years
after graduating. Standardization of competency is ensured
in the U.S. medical education system through institutional
and individual accreditation processes, such as the Liaison
Committee on Medical Education and the United States
Medical Licensing Examination, respectively, as well as
through specialty certification processes by medical spe-
cialty boards meant to verify and maintain the quality of
graduates. In this context, we propose that graduates of
schools with strong social mission measures are likely to be
among the most well-prepared practitioners for primary
care and for the care of minority or underserved popula-
tions.
In conclusion, we found substantial variation in the
success of individual U.S. medical schools in recruiting and
educating students to address the social mission of medical
education, defined as graduating physicians who practice
primary care and work in underserved areas and recruiting
and graduating young physicians who are underrepresented
minorities. Some schools may choose other priorities, but
in this time of national reconsideration, it seems appropri-
ate that all schools examine their educational commitment
regarding the service needs of their states and the nation. A
diverse, equitably distributed physician workforce with a
strong primary care base is essential to achieve quality
health care that is accessible and affordable, regardless of
the nature of any future health care reform.
From George Washington University, Children’s National Medical Cen-
ter, and Robert Graham Center, Washington, DC.
Grant Support: By the Josiah Macy, Jr. Foundation.
Potential Conflicts of Interest: Disclosures can be viewed at www.acponline
.org/authors/icmje/ConflictOfInterestForms.do?msNumM09-2257.
Reproducible Research Statement: Study protocol and statistical code:
Available from Dr. Mullan (e-mail, fmullan@projecthope.org). Data set:
Not available.
Requests for Single Reprints: Fitzhugh Mullan, MD, Department of
Health Policy, George Washington University, 2121 K Street NW, Suite
210, Washington, DC 20037; e-mail, fmullan@gwu.edu.
Current author addresses and author contributions are available at www
.annals.org.
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Academia and ClinicThe Social Mission of Medical Education
www.annals.org 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 811
Current Author Addresses: Drs. Mullan and Chen, Ms. Kolsky, and
Mr. Spagnola: Department of Health Policy, George Washington Uni-
versity, 2121 K Street NW, Suite 210, Washington, DC 20037.
Dr. Petterson: The Robert Graham Center, 1350 Connecticut Avenue
NW, Suite 201, Washington, DC 20036.
Author Contributions: Conception and design: F. Mullan, C. Chen, G.
Kolsky.
Analysis and interpretation of the data: F. Mullan; C. Chen, S. Petterson,
M. Spagnola.
Drafting of the article: F. Mullan, C. Chen.
Critical revision of the article for important intellectual content: F.
Mullan.
Final approval of the article: F. Mullan, C. Chen.
Statistical expertise: S. Petterson.
Obtaining of funding: F. Mullan.
Administrative, technical, or logistic support: G. Kolsky.
Collection and assembly of data: C. Chen, S. Petterson, G. Kolsky, M.
Spagnola.
W-310 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 www.annals.org
CORRECTION
In the recent article by Mullan and colleagues (1), several insti-
tutions were named incorrectly. Morehouse College should be listed
as Morehouse School of Medicine. Baylor University should be listed
as Baylor College of Medicine. Michigan State University should be
listed as Michigan State University College of Human Medicine.
University of Medicine and Dentistry of New Jersey should be listed
as University of Medicine and Dentistry of New Jersey—NJ. Asso-
ciation of American College of Osteopathic Medicine should be
listed as American Association of Colleges of Osteopathic Medicine.
University at Albany, State University of New York should be listed
as Albany Medical College. Universidad de Puerto Rico en Ponce in
Table 1 and Ponce Medical College in Appendixes 4 and 5 should be
Ponce School of Medicine.
The online version has been corrected.
Reference
1. Mullan F, Chen C, Petterson S, Kolsky G, Spagnola M. The social mission of
medical education: ranking the schools. Ann Intern Med. 2010;152:804-11. [PMID:
20547907]
www.annals.org 15 June 2010 Annals of Internal Medicine Volume 152 • Number 12 W-311
... _ analysis ). In a supplementary analysis, we collected additional statements from U.S. medical schools identified in the top 20 ranking by "social mission," as described by Mullan et al. [8] ( Appendix ). ...
... All included hopeful language. In the supplementary analysis, U.S. medical schools ranked according to "social mission" [8] compared favorably on some metrics (e.g., mention of the police, use of words indicating active support) but compared equivalently or unfavorably on others (e.g., explicitly naming racism, reference to the Black community) ( Appendix ). ...
... It is possible that our focus on medical schools labeled as leading institutions according to ranking systems that are widely used but are of arguably limited relevance to social mission [ 8 , 18 ] could have biased our quality assessments toward the null. However, in the supplementary analysis of U.S. medical schools with top rankings according to "social mission" [8] , no clear pattern of improvement was observed. It should be noted here that the schools ...
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