Abstract
This study explores US medical students’ intent to practice in underserved areas, analyzed by demographic characteristics.
Unequal access to health care contributes to health disparities.1,2 A suggested approach to improving access to care is to increase the diversity of the workforce1,2 because minority physicians disproportionally practice in underserved areas. Studies conducted before 2013 reported racial and ethnic minority medical students were more likely to primarily intend to care for underserved populations.3,4 No recent study has explored medical students’ intent to practice in underserved areas, and previous analyses combined racial and ethnic identities and did not include sexual orientation or an intersectional lens.3,5,6 We analyzed medical students’ intent to practice in underserved areas from 2019 to 2021 by demographic characteristics.
Methods
The Association of American Medical Colleges (AAMC) administers a web-based questionnaire to individuals graduating from an allopathic US medical school. The AAMC linked survey responses from 2019, 2020, and 2021 to AAMC sources that included demographic factors previously provided by responders. We obtained a deidentified data set that included demographics and response to the item “Do you plan to work primarily in an underserved area?” Medical schools without all 3 years of data were excluded. The study was deemed exempt by the Mayo Clinic and University of Colorado institutional review boards.
Responses were pooled across years. Analysis included summary statistics, χ2 tests, and a logistic regression model for intent to practice in an underserved area that included age at graduation, race, ethnicity, sexual orientation, and debt (premedical school, medical school, and consumer). All tests were 2-sided, with a type I error of .05. All comparisons were performed using SAS version 9.4 (SAS Institute).
Results
The total number of respondents was 48 885 (response rate, 80.7%) from 139 (of 148) medical schools. Of these, 45 687 (93.4%) answered the item about intent to practice in an underserved area (Table). Among the latter cohort, 51.4% were women, 8.1% were Hispanic, 63.9% were White, and 91.9% were heterosexual. Overall, 27.6% indicated they planned to work primarily in an underserved area. Considering demographics, 33.1% of female, 46.2% of American Indian or Alaska Native, 54.9% of Black or African American, 43.6% of Hispanic, 37.5% of Native Hawaiian or Other Pacific Islander, and 43.6% of bisexual students intended to practice in an underserved area. After controlling for other factors, women had higher odds of intent to practice in an underserved area than men (odds ratio [OR], 1.80; 95% CI, 1.72-1.88) (Table). American Indian or Alaska Native (OR, 1.82; 95% CI, 1.44-2.29); Black or African American (OR, 2.09; 95% CI, 1.87-2.33); Hispanic, Latino, or of Spanish origin (OR, 1.71; 95% CI, 1.56-1.86); and Native Hawaiian or Other Pacific Islander (OR, 1.65; 95% CI, 1.14-2.39) students had higher odds of intent to practice in an underserved area than those who did not identify with each of those respective racial and ethnic groups. Bisexual (OR, 1.86; 95% CI, 1.67-2.06) or gay or lesbian (OR, 1.46; 95% CI, 1.31-1.62) students had higher odds of intent to practice in an underserved area than heterosexual or straight students.
Table. Demographics of 2019-2021 Association of American Medical Colleges’ Graduation Questionnaire Responders and Intent to Practice in an Underserved Area.
| 2019-2021 Responders who answered the item on intent to practice in an underserved areaa | ||||
|---|---|---|---|---|
| No. (%) | Intent to practice in underserved area, No. (%) | Multivariable logistic regressionb | ||
| Odds ratio (95% CI) | P value | |||
| Sexc | <.001 | |||
| Male | 22 190 (48.6) | 4809 (21.7) | 1 [Reference] | |
| Female | 23 497 (51.4) | 7785 (33.1) | 1.80 (1.72-1.88) | |
| Race and ethnicityd | ||||
| American Indian or Alaska Native | 355 (0.8) | 164 (46.2) | 1.82 (1.44-2.29) | <.001 |
| Asian | 11 508 (25.2) | 2657 (23.1) | 0.67 (0.61-0.74) | <.001 |
| Black or African American | 3146 (6.9) | 1726 (54.9) | 2.09 (1.87-2.33) | <.001 |
| Hispanic, Latino, or of Spanish origin | 3720 (8.1) | 1622 (43.6) | 1.71 (1.56-1.86) | <.001 |
| Native Hawaiian or Other Pacific Islander | 144 (0.3) | 54 (37.5) | 1.65 (1.14-2.39) | .008 |
| White | 29 197 (63.9) | 7194 (24.6) | 0.65 (0.59-0.70) | <.001 |
| Other | 1566 (3.4) | 441 (28.2) | 0.87 (0.76-0.99) | .04 |
| Sexual orientation | <.001 | |||
| Heterosexual or straight | 41 128 (90.0) | 10 911 (26.5) | 1 [Reference] | |
| Bisexual | 1780 (3.9) | 776 (43.6) | 1.86 (1.67-2.06) | |
| Gay or lesbian | 1859 (4.2) | 593 (31.9) | 1.46 (1.31-1.62) | |
The total number of respondents to the Association of American Medical Colleges’ (AAMC) Graduation Questionnaire from 2019 to 2021 was 48 885 (response rate, 80.7%). Of these respondents, 45 687 (93.4%) answered the item about intent to practice in an underserved area and 12 594 (27.6%) reported intent to practice in an underserved area.
Model adjusted for age at graduation, premedical school debt, medical school debt, and consumer debt. For race and ethnicity, each racial and ethnic group is compared with everyone else not in that group.
The sex variable in the data set stems from individuals’ responses to the American Medical College Application Service, which collected one’s sex with male/female options during this period.
The race and ethnicity data in the data set stem from multiple AAMC sources (eg, electronic residency application service, American Medical College Application Service, Medical College Admission Test). In this table, priority is given to the most recent, self-reported race and ethnicity information. “Other” race was an actual response option that individuals could select either alone or in combination with other response options. Respondents were able to select multiple race and ethnicity categories. The percentage indicates the proportion of respondents who selected this race category compared with those not selecting that category. N will exceed total respondents. P values reflect comparison with all other categories. For example, the P value for “Asian” reflects comparison with all other race and ethnicity categories.
Discussion
In this cohort, differences in intent to practice in an underserved area were reported by sex, race, ethnicity, and sexual orientation, with results consistent with3,6 and building on previous studies, particularly in separating racial and ethnic groups underrepresented in medicine and presenting results by sexual orientation. Study limitations include unknown predictive validity of the intent to practice in an underserved area item, although results are consistent with minority physicians being more likely to practice in underserved areas.4 The study did not include all factors previously shown to relate to practice in an underserved area, schools in Puerto Rico or those with fewer than 3 years of data, and identities beyond sex, race, ethnicity, and sexual orientation. Future studies should examine whether continued efforts to diversify the medical student body improve access to health care among individuals living in underserved areas.
Section Editors: Jody W. Zylke, MD, Deputy Editor; Karen Lasser, MD, and Kristin Walter, MD, Senior Editors.
Data Sharing Statement
References
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Supplementary Materials
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