PRESIDENTIAL, ADDRESS

Where Have All the Students Cone? Frederic C. Chang, MD, FACS, Wichita, K~IMS

I thank the Southwestern Surgical Congress for the honor and privilege of serving as the 41st president.

When I joined this organization 20 years ago, I did not envision this moment when I would be asked to make a presidential address. I thought my requirements would be to faithfully attend the meetings, present a few papers, and participate in the discussions. However, having been elected, I will make the most of this opportunity. In pre- paring for this presentation, I had the opportunity to review the papers of many of the past presidents. I noted that a variety of topics were discussed, which included historical events in surgery, current issues in medicine and surgery, and in-depth review of surgical advances. My presentation will deal with an area in which I have been involved for most of my career; namely, student education. More specifically, I will discuss the declining interest in our profession among young persons, the rami- fications of this change, and the possible solutions.

It is common knowledge that qualified college gradu- ates no longer look upon the medical profession with the same esteem as their predecessors. Most of you are aware that there has been a marked decline in the applicant pool to medical school and that there is a suspicion the matric- ulating classes are not what they used to be. In fact, I had the opportunity of attending a recent meeting of the American Association of Medical Colleges (AAMC) that dealt entirely with this issue. I will present the data that addresses the declining applicant pool.

In 1968, there were 18,724 applicants to medical school, and this number increased gradually to a high of 42,155 in 1977 [I]. To accomodate the increasing number of applicants and the perceived need for more physicians, there was a doubling of first-year medical school positions during this same time period. Since 1977, there has been a gradual but significant decrease in applicants. In 1988, there were 28,123 applicants, a decrease of 33 percent when compared with 1977 and slightly less than the num- ber for 1972. However, this still represents more appli- cants than in 1968. The number of first-year medical school positions decreased by 3 percent during this period of declining interest (Figure 1).

During the past 20 years, there have also been changes in the applicant-to-acceptance ratio. In 1977, the ratio was 2.7; this has decreased yearly to 1.7 in 1988. How- ever, the 1988 ratio is quite similar to the applicant- acceptance ratio for 1968. It should be mentioned, how- ever, that in some state universities, the acceptance ratio for in-state students has been even lower than 1.7, and

From the Department of Surgery, The University of Kansas School of Medicine, Wichita, Kansas.

Requests for reprints should be addressed to Frederic C. Chang, MD, 818 North Emporia, Suite 200, Wichita, Kansas 67214.

Presented at the 41st Annual Meeting of the Southwestern Surgical Congress, Monterey, California, April 23-26.1989.

there is considerable competition between medical schools for qualified applicants.

The quality of the matriculants to medical school has also been questioned by practicing physicians and medi- cal school faculty. There is concern that medical schools now must accept unqualified students. To date, this has not been borne out by data regarding the grade point averages and Medical College Admission Test scores of medical school matriculants. Though grade point aver- ages are slightly lower than 10 years ago, they are still quite high (3.45 in 1988), and Medical College Admis- sion Test scores in the sciences are higher than in 1978. However, having recently served on an admission com- mittee of a state medical school, I do have the impression that although the average scores remain high, some in- state students are being accepted with marginal scores. The scores of these students are being offset by out-of- state students with very high scores. State universities are accepting out-of-state students to maintain the overall quality of their classes. Obviously, this cannot continue if the applicant pool continues to decrease. Therefore, on summarizing the current data on medical school appli- cants, I believe that the overall quality of the current matriculants is high, although some schools are accepting students who would not have been considered in the past. However, we are at a critical point where a further de- crease in the number of applicants will indeed significant- ly affect the quality of our matriculants.

What are the reasons for this decline in the applicant pool? There are multiple contributing factors. A survey performed on the 1987 candidates by the Association of American Medical Colleges revealed that 984 accepted applicants to medical school decided not to enroll [Z]. I thought it was remarkable that almost 1,000 qualified and accepted applicants went through the arduous appli- cation procedure and then decided not to attend. This would have been unheard of only a decade ago. In this survey, the main reasons cited by the nonmatriculants were fmancial, discouraging statements by physicians, and that other fields would be more satisfying. I will address each of these factors.

The first of these deals with finances and was men- tioned as a primary concern by 42 percent of the respon- dents to the aforementioned survey. Financial concerns are indeed a major problem confronting persons entering the field of medicine. The cost of medical education and the indebtedness of medical school graduates have grave implications on recruitment, career choices of graduates, and patterns of care. Funds available for both public and private schools have changed significantly during the past decade. Federal funds have decreased and the states have had to bear a greater burden in health education. Though tuition has been a relatively small proportion of medical school revenues, the increase in tuition during the past decade has been significant for the individual student.

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# of Applicants

45,000

36,000

A/A Ratio

16.000 18,260

1967 1968 1972 19n 1978 1981 1982 1983 1964 1986 1986 1967 1988

Yearly in-state tuition at public schools ranges from 0 to $9,048 (average $4,960) and at private schools, from $8,000 to $22,500 (average $16,290). The Association of American Medical Colleges Graduation Questionnaire for 1987 noted that 83 percent of graduates were in debt and that the average debt burden was $35,621. Seventeen percent of all medical students who graduated in 1987 owed more than $50,000. This alone is a major deterrent to medical school recruitment and has had a major im- pact on recruitment of minority students and students from low and middle income families. Medicine is be- coming a profession for the sons and daughters of the elite.

Having identified financial concerns as a problem, it seems that reasonable solutions can be found. State and federal governments and the private sectors must contrib ute to medical education, including residency training because, in the long run, they will all suffer the conse- quences of inadequate health care.

The second factor contributing to the decline in medi- cal school applicants is the advice being given by current physicians. Prospective students to the medical profession have received increasingly negative feedback from physi- cians. I have commonly heard in doctors’ lounges, cafete- rias, and other social gathering sites the fact that they, as physicians, would not recommend the medical profession to young people. Twenty-nine percent of nonmatriculants accepted into medical school cited this as a major factor for not entering medical school [2]. A number of com- monly held notions have led to this disillusionment by fellow physicians. These views include the following: Changes in the health care delivery system will impair physicians’ independence, medicine will not be as finan- cially rewarding, demands on physicians preclude other interests, medicine is becoming highly technical, medi- cine is too socialized, malpractice makes it impossible to practice a reasonable form of medicine, and so on. Though all these concerns are indeed true to some extent, they only represent changes that occur in any profession. Paul Valere, a French poet and philosopher, said almost a

century ago that “the trouble with the future is that it is not what it used to be.” American medicine has not been without controversy, but to date we have been able to withstand and adjust to all external and internal pres- sures.

It is interesting to note that, in 1962, Dr. Edward Churchill, Emeritus Professor of Surgery at Harvard Medical School, entitled his Frank Lahey Memorial Lec- ture “Should I Study Medicine?” [3]. Among other prob lems of that time, there was a declining interest in medi- cine among students in some New England states. Churchill was particularly critical of physicians because of the “tarnished image” of the doctor that they were presenting to the public. However, in his conclusion he stated, “And so to the young man who is pondering ‘should I study medicine?’ I say, seek information and above all beware of misinformation. Doctors are still among the most important people of the world. Every bit of evidence points toward increasing importance of the responsibilities that they must assume in the future. Man- kind itself needs the wisdom of talented young men in medicine as never before.”

I also echo the sentiments of Dr. Carola Eiinberg, who wrote the controversial article “It is Still a Privilege to Be a Doctor” [4]. She stated, “It stands the world on its head to suggest that the liabilities of a career in medicine outweigh the assets. Of course there are major problems in the delivery of medical care, and we ought to be in the vanguard of those seeking solutions to them. But to lose sight of just how lucky we are to have a profession in which we do well for ourselves by doing well for others reflects a puzzling loss of perspective.”

Personally, my impression is that despite the current discontent of some physicians, medicine continues to be an attractive field. Nowhere else is there the opportunity to study the marvels of the human body and the impact of medicine and surgery on die. The satisfaction of see- ing a patient one has treated recover from ilhmss or injury can only be experienced by a physician. Physicians are still held in high esteem by their patients, and though

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fmancial rewards may be different than in the past, physi- cians will continue to be amply rewarded for their ser- vices. Therefore, in this particular area of negativism by doctors, I would like to quote that famous contemporary philosopher Pago, who stated, “We have met the enemy and he is us.” At this time, we are driving inquisitive and intelligent young men and women from medicine, and this will have a severe impact on new advances and the practice of medicine for many future generations.

Lastly, I would like to answer the question, where have all the students gone? The students have entered other occupations and professions, including engineering, law, computer sciences, and business, among others. Dur- ing the past 20 years, degrees awarded in engineering and business have doubled, law degrees have tripled, and computer sciences degrees have increased by twentyfold [5]. I will not try to explain these increases other than to say that these professions are also highly respected and are among the best paid. The absolute numbers are re- markable, and make the decline in medical school appli- cants seem quite small. When the total number of college graduates is considered, it would not take much to return the medical school applicant pool to its 1977 high. Medi- cal schools are actively recruiting in high schools and colleges, and we must assist them in this effort.

In summary, though the current practice environment may seem dark and unattractive, medicine has encoun- tered and overcome other crises in the past. We must not forget our patients and the patients for generations to come. Although the applicant pool to medical schools is not what it used to be, the applicants are still of high quality. As physicians, we have an obligation to care for the ill and injured, to teach, and to encourage intelligent and compassionate young men and women to become part of the medical profession. I urge you not to turn your back on the profession to which you have contributed so much and from which you have all benefitted.

REFERENCES 1. Jonas HS, Etzel SI. Undergraduate medical education. JAMA 1988; 260: 1063. 2. Lindley DW. Turning students on to medicine: changing the image of the profession. AAMC Invitational Conference. June 13- 14, 1988. 3. Churchill ED. Should I study medicine? N Engl J Med 1963; 268: 531. 4. Eiinberg C. Sounding board: it is still a privilege to be a doctor. N Engl J Med 1986; 314: 1113. 5. U.S. Dept of Education. Digest of education statistics 1988. Publication no. CSO88-600. Washington, DC: Oftice of Education- al Research & Improvement, 1988.

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