From the Schools and Programs of Public Health 637
CHARACTERISTICS AND CAREER INTENTIONS OF MD-MPH PROGRAM GRADUATES: A NATIONAL COHORT STUDY Dorothy A. Andriole, MD Donna B. Jeffe, PhD Robert H. Tai, EdD
U.S. Liaison Committee for Medical Education-accredited medical schools offer many joint advanced-degree programs, including doctor of medicine (MD)-master of public health (MPH) programs.1 During the past 20 years, the number of MD-MPH programs has increased substantially. In 1992–1993, MD-MPH programs were offered at 31 of 126 (24.6%) medical schools.2 By 2004–2005, the number of programs had risen to 64 of 125 medical schools (51.2%),3 and by 2012–2013, the most recent year for which data are available, to 81 of 136 (59.6%) medical schools (Personal communication, Sylvia Etzel, American Medical Association, March 2014, April 2014, and May 2014). National tracking data from the Association of American Medical Colleges (AAMC) indicate that the annual number of MD-MPH program graduates doubled from 2002–2003 to 2012–2013, from approximately 100 graduates to more than 200 graduates.4 Only a few studies have described MD-MPH-program graduates’ career plans. Recent studies included a descriptive study of a single-institution’s MD-MPH program participants with comparative demographic data for MD program participants;5 a study of medical students from several institutions who completed the MPH program either as MD-MPH program participants or independently with MD and MPH degrees awarded by different institutions;6 and another single-institutional, retrospective cohort study of medical-school graduates that compared characteristics and careers of MD-MPH program graduates and MD graduates who subsequently completed the MPH program with MD-only or MD-other degree graduates, but without MPH degrees.7 To date, no national studies have been reported. To address this gap in the literature, we conducted a retrospective, national cohort study of Medical College Admission Test (MCAT) examinees who enrolled in medical school to (1) determine the extent of MD-MPH program participation and graduation from U.S. medical schools and (2) compare demographic characteristics, attitudes, academic achievement, and career plans of MD-MPH program and MD program graduates.
METHODS Our study sample included graduates from MD and MD-MPH programs identified in the AAMC Student Records System. The cohort included graduates who had entered medical school in 2003–2007 and who had graduated by the end of 2012. During 2012–2013, 81 of 136 (60%) medical schools offered MD-MPH programs (Personal communication, Sylvia Etzel, American Medical Association, March 2014, April 2014, and May 2014). We obtained data on these graduates from the AAMC, including data from the Pre-MCAT Questionnaire (PMQ), the Graduation Questionnaire (GQ), the AAMC Student Records System, and the National Board of Medical Examiners. The PMQ was offered to all MCAT examinees in 2001–2006 before their initial MCAT attempt. The PMQ included many items about the areas of medicine that examinees found most interesting and the importance of various items in their decision to study medicine.8 Responses to the item “Indicate the area of medicine in which you are most interested” included public health aspects of disease, biomedical research, or patient management. Response options on the importance of 15 different items in a student’s decision to study medicine ranged from 1 (not important) to 4 (extremely important). As previously described,9 we derived three of these factors—altruism, status, and research/finding cures—from 10 of the 15 items for use in our study. We derived the altruism factor from the mean of responses to three items: “profession offers the opportunity to serve community needs,” “coworkers share desire to help people,” and “profession offers opportunity to make a difference in people’s lives.” We derived the status factor from the mean of responses to five items: “profession offers opportunity to satisfy personal desire for authority,” “profession represents achievement higher than any other profession,” “physicians receive immediate status and prestige,” “profession offers the possibility of a high income,” and “physicians are rarely unemployed.” We derived the research/finding cures factor from the mean of responses to two items: “profession provides chance to pursue interest in research” and “profession offers opportunity to discover a great cure.” The GQ is offered to all medical students during the spring of their final year and is completed voluntarily.10 We analyzed responses to items about graduates’ career intentions (full-time university faculty; other, including response options of state/federal or medical/ health-care administration, part-time faculty, part-time practice, and other; undecided; and missing [i.e., no response to the GQ item] or full-time, non-academic clinical practice); total debt at graduation; age at
Public Health Reports / July–August 2016 / Volume 131
638 From the Schools and Programs of Public Health
graduation; and plan for specialty-board certification. Based on responses to the specialty-board certification and specialty-choice items, we created a nine-category specialty-choice variable (internal medicine, family medicine, obstetrics-gynecology, pediatrics, surgical specialties, emergency medicine, no/undecided about specialty-board certification plans, missing [no response to the GQ item(s)], and all other specialties). The AAMC provided data on sex, race/ethnicity, matriculation and graduation dates, degree program at matriculation, and graduation. We used self-reported PMQ or AAMC Student Records System data, as available, for sex and race/ethnicity (categorized as underrepresented racial/ethnic groups in medicine [i.e., black, Hispanic, and Native American/Alaska Native], Asian/Pacific Islander, other/multiple races/ unknown, and non-Hispanic white). The AAMC also provided first-attempt scores on four standardized tests: MCAT (sum of verbal reasoning, biological sciences, and physical sciences sub-scores), National Board of Medical Examiners’ U.S. Medical Licensing Examination (USMLE) three-digit Step 1 and Step 2 Clinical Knowledge (CK) scores, and pass-fail USMLE Step 2 Clinical Skills (CS) results. USMLE sequence completion is required for U.S. medical licensure.11 Our outcome of interest was which degree program, MD or MD-MPH, the student was in at the time of graduation. We compared MD-MPH program graduates with MD program graduates (including MD, bachelor of arts-MD, and bachelor of science-MD). We excluded all other MD-advanced-degree program graduates (e.g., MD-master of science, MD-master of arts, MD-juris doctorate, MD-master of business administration, and MD-doctor of philosophy) from analysis. We report descriptive statistics for each variable examined in association with degree program at graduation (i.e., MD, MD-MPH). We used Pearson’s χ2 tests and analysis of variance to measure between-group differences. We used multivariate logistic regression to identify independent predictors of MD-MPH program vs. MD program graduation, reporting adjusted odds ratios (aORs) and 95% confidence intervals (CIs) and controlling for all predictor variables shown in the tables. In addition to the overall model, we stratified the logistic regression analysis by sex and by race/ ethnicity. We performed all statistical tests using SPSS® version 22.0,12 and considered two-sided p,0.05 to be significant. Study sample derivation Of 262,813 PMQ respondents in 2001–2006, a total of 100,440 (38.2%) respondents entered medical school. Of these respondents, 77,718 (77.4%) matriculated
during 2003–2004 through 2007–2008, comprising 91.1% of all 85,312 matriculants in U.S. LCMEaccredited medical schools during the cohort years of interest.13 Of these 77,718 matriculants, 72,674 (93.5%) had graduated by the end of 2012, including 69,787 (96.0%) in MD programs, 972 (1.3%) in MD-MPH programs, 904 (1.2%) in MD programs combined with other advanced degrees, and 1,011 (1.4%) in MDPhD programs. Of the 70,759 MD program and MDMPH program graduates eligible for study inclusion (100% of whom had completed the PMQ, at least in part), we excluded 10,717 (15.1%) graduates without complete data for all PMQ items of interest and 245 (0.3%) graduates who were missing standardized test data. Our final sample of 59,797 graduates included 58,975 MD program graduates (84.5% of 69,787 MD program graduates) and 822 MD-MPH program graduates (84.6% of 972 MD-MPH program graduates) who met the inclusion criteria and had complete data for all PMQ items and standardized tests of interest (Figure). RESULTS Of the 59,797 medical-school graduates included (Figure), 822 (1.4%) were MD-MPH program graduates and 58,975 (98.6%) were MD program graduates. We found significant between-group differences in all variables except Step 2 CK scores and Step 2 CS results (Table 1). Not shown, of 294 MD-MPH program enrollees at matriculation, 262 (89.1%) completed the MD-MPH program and comprised 31.9% of all 822 MD-MPH program graduates in the sample. The mean (standard deviation [SD]) duration of medical school enrollment was longer for MD-MPH program graduates than for MD program graduates (MD-MPH: 4.9 [0.5] vs. MD: 4.2 [0.4] years; p,0.001); and, based on data available for 41,875 graduates, MD-MPH program graduates were older than MD program graduates (MD-MPH: 28.0 [2.3] vs. MD: 27.3 [2.7] years of age; p,0.001). Also, based on GQ data available for 33,840 graduates, mean (SD) total debt at graduation did not differ significantly between MD-MPH program and MD program graduates overall (MD-MPH: $145,161 [$90,787] vs. MD: $142,224 [$86,890]; p50.516) or only graduates of private schools (MD-MPH: $153,562 [$101,444] vs. MD: $158,827 [$96,805]; p50.480) or public schools (MD-MPH: $138,049 [$80,249] vs. MD: $132,406 [$78,827]; p50.311). Graduates who were female or from underrepresented racial/ethnic groups in medicine (i.e., black, Hispanic, and Native American/Alaska Native) reported public health aspects of disease as the most interesting area of medicine on the PMQ; attributed
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From the Schools and Programs of Public Health 639
Figure. Flow diagram of Pre-Medical College Admission Test Questionnaire (PMQ) respondents during 2001–2006 in an analysis of MD program graduates and MD-MPH program graduates in the United States through 2012
• • • • •
MD 5 doctor of medicine MPH 5 master of public health PhD 5 doctor of philosophy
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640 From the Schools and Programs of Public Health
Table 1. Characteristics of medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD program graduation in the United States through 2012a
Characteristicb Total Sex Male Female Race/ethnicity Non-Hispanic white Other/multiple races/ no response Non-Hispanic black, Hispanic, Native American/Alaska Native Asian/Pacific Islander Graduates’ most interesting area of medicinef Patient management Public health aspects of disease Biomedical research Graduates’ career intention Full-time clinical practice Full-time faculty Other (state/federal or medical/ health-care administration, part time faculty, part-time practice, and other [not specified]) Undecided Missing (no response) Specialty choice for board certification Internal medicine No/undecided about specialty board certification Emergency medicine Family medicine Obstetrics-gynecology Pediatrics Surgical specialties All other specialties Missing (no response) USMLE Step 2 Clinical Skillsg Pass Fail School ownership Private Public Unknown (information not provided for graduate)
All graduates N (percent)c
MD program MD-MPH program graduates graduates P-valued N (percent)c N (percent)c
59,797 (100.0)
58,975 (100.0)
822 (100.0)
29,704 (49.7) 30,093 (50.3)
29,382 (49.8) 29,593 (50.2)
322 (39.2) 500 (60.8)
aOR (95% CI)e
P-value
Ref. 1.30 (1.12, 1.51)
0.001
,0.001
0.001 38,508 (64.4) 1,747 (2.9)
38,023 (64.5) 1,714 (2.9)
485 (59.0) 33 (4.0)
Ref. 1.32 (0.92, 1.90)
0.128
8,804 (14.7)
8,651 (14.7)
153 (18.6)
1.68 (1.37, 2.05)
,0.001
10,738 (18.0)
10,587 (18.0)
151 (18.4)
1.04 (0.86, 1.26)
0.696
Ref. 2.96 (2.52, 3.49) 1.14 (0.83, 1.58)
,0.001 0.415
,0.001 50,316 (84.1) 5,642 (9.4) 3,839 (6.4)
49,753 (84.4) 5,428 (9.2) 3,794 (6.4)
563 (68.5) 214 (26.0) 45 (5.5)
14,697 (24.6) 12,964 (21.7) 5,102 (8.5)
14,626 (24.8) 12,753 (21.6) 4,995 (8.5)
71 (8.6) 211 (25.7) 107 (13.0)
Ref. 3.23 (2.44, 4.29) 3.40 (2.51, 4.62)
,0.001 ,0.001
7,543 (12.6) 19,491 (32.6)
7,483 (12.7) 19,118 (32.4)
60 (7.3) 373 (45.4)
1.47 (1.04, 2.08) 1.83 (0.73, 4.56)
0.030 0.196
Ref. 1.53 (1.10, 2.12)
0.011
1.05 1.92 1.55 1.21 0.64 0.65 1.40
1.61) 2.90) 2.30) 1.75) 0.95) 0.91) 3.25)
0.824 0.002 0.030 0.319 0.027 0.013 0.437
Ref. 0.95 (0.57, 1.57)
0.833
Ref. 0.87 (0.72, 1.05) 1.49 (0.93, 2.38)
0.140 0.100
,0.001
,0.001 5,501 (9.2) 5,836 (9.8) 3,014 2,166 2,454 3,557 6,272 11,272 19,725
(5.0) (3.6) (4.1) (5.9) (10.5) (18.9) (33.0)
5,436 (9.2) 5,742 (9.7) 2,981 2,124 2,410 3,503 6,233 11,198 19,348
(5.1) (3.6) (4.1) (5.9) (10.6) (19.0) (32.8)
65 (7.9) 94 (11.4) 33 42 44 54 39 74 377
(4.0) (5.1) (5.4) (6.6) (4.7) (9.0) (45.9)
(0.68, (1.27, (1.04, (0.83, (0.42, (0.46, (0.60,
0.327 58,318 (97.5) 1,479 (2.5)
57,512 (97.5) 1,463 (2.5)
806 (98.1) 16 (1.9) ,0.001
15,754 (26.3) 26,132 (43.7) 17,911 (30.0)
15,535 (26.3) 25,882 (43.9) 17,558 (29.8)
219 (26.6) 250 (30.4) 353 (42.9)
continued on p. 641
greater importance to altruism as a reason to study medicine on the PMQ; had higher MCAT and Step 2 CK scores; listed GQ specialty category as “family medicine,” “obstetrics-gynecology,” or “no/undecided about specialty-board certification plans;” and reported
“full-time faculty,” “other,” or “undecided” GQ career intentions were more likely to be MD-MPH program graduates than to be MD program graduates. Graduates who attributed greater importance to the status of medicine and to research/finding cures on the PMQ as
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From the Schools and Programs of Public Health 641
Table 1 (continued). Characteristics of medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD program graduation in the United States through 2012a
Characteristicb Importance of factors in graduates’ decision to study medicinej Status Altruism Research/finding cures MCAT scorek USMLE Step l scorel USMLE Step 2 Clinical Knowledge scorem
All graduates Mean (SD)
2.2 3.7 2.7 29.1 222.8 230.9
(0.7) (0.4) (0.8) (4.9) (21.5) (21.8)
MD program MD-MPH program graduates graduates Mean (SD) Mean (SD) P-valueh
2.3 3.7 2.7 29.0 222.8 230.9
(0.7) (0.4) (0.8) (4.9) (21.5) (21.8)
2.1 3.8 2.6 30.5 221.2 232.0
(0.7) (0.4) (0.9) (4.5) (20.2) (21.0)
,0.001 0.003 ,0.001 ,0.001 0.039 0.138
aOR (95% CI)i
0.80 1.29 0.86 1.10 0.99 1.01
(0.72, (1.07, (0.78, (1.08, (0.98, (1.00,
0.89) 1.56) 0.94) 1.12) 0.99) 1.01)
P-value
,0.001 0.008 0.001 ,0.001 ,0.001 0.009
a The study sample comprised U.S. Liaison Committee for Medical Education-accredited medical school MD-MPH and MD program graduates who had completed the Association for American Medical Colleges Pre-MCAT Questionnaire during 2001–2006, entered medical school during 2003–2007, and graduated by the end of 2012.
Data sources included the Association of American Medical Colleges Student Records System, Pre-MCAT Questionnaire, and Graduation Questionnaire; and the National Board of Medical Examiners.
b
Percentages may not total to 100 because of rounding.
c
Tests of significance were Pearson’s χ2 tests comparing each categorical variable with degree program at graduation (MD-MPH program graduates vs. MD program graduates). d
Hosmer and Lemeshow goodness-of-fit test p50.209.
e
Response options to the item “Indicate the area of medicine in which you are most interested” included public health aspects of disease, biomedical research, or patient management. f
USMLE Step 2 Clinical Skills is a standardized patient examination testing information-gathering, physical examination, and communication skills; scores are reported on a pass/fail basis.
g
Tests of significance were one-way analysis of variance testing differences in scores by degree program at graduation (MD-MPH program vs. MD program).
h
i For each unit increase, aOR ,1.00 indicates a lower likelihood and aOR .1.00 indicates a greater likelihood of MD-MPH program graduation vs. MD program graduation. j Response options about the importance of each item in graduates’ decision to study medicine ranged from 1 (not important) to 4 (extremely important).
MCAT is a multiple-choice examination on verbal reasoning, biological sciences, and physical sciences, with scores ranging from 0 to 45.
k
USMLE Step l is a multiple-choice examination on basic medical sciences, with scores ranging from 1 to 300.
l
m
USMLE Step 2 Clinical Knowledge is a multiple-choice examination on clinical medical sciences, with scores ranging from 1 to 300.
MD 5 doctor of medicine MPH 5 master of public health aOR 5 adjusted odds ratio CI 5 confidence interval Ref. 5 reference group USMLE 5 U.S. Medical Licensing Examination SD 5 standard deviation MCAT 5 Medical College Admission Test
reasons to study medicine, had higher Step l scores, and whose GQ specialty category was “surgical specialties” or “all other specialties” were less likely to be MD-MPH program graduates than to be MD program graduates (Table 1). Seventy percent of graduates in the sample had completed the GQ, at least in part; for each GQ item analyzed, findings for graduates who were miss-
ing data for the item did not differ significantly from findings for the reference group. We grouped descriptive statistics by degree program at graduation and ran multivariate logistic regression models separately for women (Table 2) and men (Table 3) to determine if variables independently associated with MD-MPH program (vs. MD program)
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642 From the Schools and Programs of Public Health
Table 2. Characteristics of all female medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD-program graduation in the United States through 2012a
Characteristicb
Total N (percent)c
Total 30,093 Race/ethnicity Non-Hispanic white 18,357 Other/multiple races/no response 960 Non-Hispanic black, Hispanic, Native 5,135 American/Alaska Native Asian/Pacific Islander 5,641 Graduates’ most interesting area of medicinef Patient management 25,269 Public health aspects of disease 3,239 Biomedical research 1,585 Graduates’ career intention Full-time clinical practice 6,693 Full-time faculty 6,634 Other (state/federal or medical/health-care 3,033 administration, part-time faculty, part-time practice, and other [not specified]) Undecided 4,305 Missing (no response) 9,428 Specialty choice for board certification Internal medicine 2,529 No/undecided about specialty-board 3,741 certification Emergency medicine 1,233 Family medicine 1,266 Obstetrics-gynecology 2,113 Pediatrics 2,682 Surgical specialties 1,967 All other specialties 5,044 Missing (no response) 9,518 USMLE Step 2 Clinical Skillsg Pass 29,738 Fail 355 School ownership Private 8,235 Public 13,191 Unknown (information not provided for 8,667 graduate)
MD program graduates N (percent)c
MD-MPH program graduates N (percent)c
(100.0) 29,593 (100.0)
500 (100.0)
(61.0) (3.2) (17.1)
18,077 (61.1) 935 (3.2) 5,027 (17.0)
280 (56.0) 25 (5.0) 108 (21.6)
(18.7)
5,554 (18.8)
87 (17.4)
P-valued
aOR (95% CI)e
P-value
0.003 Ref. 1.60 (1.05, 2.44) 0.029 1.78 (1.38, 2.28) ,0.001 1.01 (0.79, 1.31)
0.913
,0.001 (84.0) (10.8) (5.3)
24,941 (84.3) 3,087 (10.4) 1,565 (5.3)
328 (65.6) 152 (30.4) 20 (4.0)
Ref. 3.19 (2.61, 3.90)
CHARACTERISTICS AND CAREER INTENTIONS OF MD-MPH PROGRAM GRADUATES: A NATIONAL COHORT STUDY Dorothy A. Andriole, MD Donna B. Jeffe, PhD Robert H. Tai, EdD
U.S. Liaison Committee for Medical Education-accredited medical schools offer many joint advanced-degree programs, including doctor of medicine (MD)-master of public health (MPH) programs.1 During the past 20 years, the number of MD-MPH programs has increased substantially. In 1992–1993, MD-MPH programs were offered at 31 of 126 (24.6%) medical schools.2 By 2004–2005, the number of programs had risen to 64 of 125 medical schools (51.2%),3 and by 2012–2013, the most recent year for which data are available, to 81 of 136 (59.6%) medical schools (Personal communication, Sylvia Etzel, American Medical Association, March 2014, April 2014, and May 2014). National tracking data from the Association of American Medical Colleges (AAMC) indicate that the annual number of MD-MPH program graduates doubled from 2002–2003 to 2012–2013, from approximately 100 graduates to more than 200 graduates.4 Only a few studies have described MD-MPH-program graduates’ career plans. Recent studies included a descriptive study of a single-institution’s MD-MPH program participants with comparative demographic data for MD program participants;5 a study of medical students from several institutions who completed the MPH program either as MD-MPH program participants or independently with MD and MPH degrees awarded by different institutions;6 and another single-institutional, retrospective cohort study of medical-school graduates that compared characteristics and careers of MD-MPH program graduates and MD graduates who subsequently completed the MPH program with MD-only or MD-other degree graduates, but without MPH degrees.7 To date, no national studies have been reported. To address this gap in the literature, we conducted a retrospective, national cohort study of Medical College Admission Test (MCAT) examinees who enrolled in medical school to (1) determine the extent of MD-MPH program participation and graduation from U.S. medical schools and (2) compare demographic characteristics, attitudes, academic achievement, and career plans of MD-MPH program and MD program graduates.
METHODS Our study sample included graduates from MD and MD-MPH programs identified in the AAMC Student Records System. The cohort included graduates who had entered medical school in 2003–2007 and who had graduated by the end of 2012. During 2012–2013, 81 of 136 (60%) medical schools offered MD-MPH programs (Personal communication, Sylvia Etzel, American Medical Association, March 2014, April 2014, and May 2014). We obtained data on these graduates from the AAMC, including data from the Pre-MCAT Questionnaire (PMQ), the Graduation Questionnaire (GQ), the AAMC Student Records System, and the National Board of Medical Examiners. The PMQ was offered to all MCAT examinees in 2001–2006 before their initial MCAT attempt. The PMQ included many items about the areas of medicine that examinees found most interesting and the importance of various items in their decision to study medicine.8 Responses to the item “Indicate the area of medicine in which you are most interested” included public health aspects of disease, biomedical research, or patient management. Response options on the importance of 15 different items in a student’s decision to study medicine ranged from 1 (not important) to 4 (extremely important). As previously described,9 we derived three of these factors—altruism, status, and research/finding cures—from 10 of the 15 items for use in our study. We derived the altruism factor from the mean of responses to three items: “profession offers the opportunity to serve community needs,” “coworkers share desire to help people,” and “profession offers opportunity to make a difference in people’s lives.” We derived the status factor from the mean of responses to five items: “profession offers opportunity to satisfy personal desire for authority,” “profession represents achievement higher than any other profession,” “physicians receive immediate status and prestige,” “profession offers the possibility of a high income,” and “physicians are rarely unemployed.” We derived the research/finding cures factor from the mean of responses to two items: “profession provides chance to pursue interest in research” and “profession offers opportunity to discover a great cure.” The GQ is offered to all medical students during the spring of their final year and is completed voluntarily.10 We analyzed responses to items about graduates’ career intentions (full-time university faculty; other, including response options of state/federal or medical/ health-care administration, part-time faculty, part-time practice, and other; undecided; and missing [i.e., no response to the GQ item] or full-time, non-academic clinical practice); total debt at graduation; age at
Public Health Reports / July–August 2016 / Volume 131
638 From the Schools and Programs of Public Health
graduation; and plan for specialty-board certification. Based on responses to the specialty-board certification and specialty-choice items, we created a nine-category specialty-choice variable (internal medicine, family medicine, obstetrics-gynecology, pediatrics, surgical specialties, emergency medicine, no/undecided about specialty-board certification plans, missing [no response to the GQ item(s)], and all other specialties). The AAMC provided data on sex, race/ethnicity, matriculation and graduation dates, degree program at matriculation, and graduation. We used self-reported PMQ or AAMC Student Records System data, as available, for sex and race/ethnicity (categorized as underrepresented racial/ethnic groups in medicine [i.e., black, Hispanic, and Native American/Alaska Native], Asian/Pacific Islander, other/multiple races/ unknown, and non-Hispanic white). The AAMC also provided first-attempt scores on four standardized tests: MCAT (sum of verbal reasoning, biological sciences, and physical sciences sub-scores), National Board of Medical Examiners’ U.S. Medical Licensing Examination (USMLE) three-digit Step 1 and Step 2 Clinical Knowledge (CK) scores, and pass-fail USMLE Step 2 Clinical Skills (CS) results. USMLE sequence completion is required for U.S. medical licensure.11 Our outcome of interest was which degree program, MD or MD-MPH, the student was in at the time of graduation. We compared MD-MPH program graduates with MD program graduates (including MD, bachelor of arts-MD, and bachelor of science-MD). We excluded all other MD-advanced-degree program graduates (e.g., MD-master of science, MD-master of arts, MD-juris doctorate, MD-master of business administration, and MD-doctor of philosophy) from analysis. We report descriptive statistics for each variable examined in association with degree program at graduation (i.e., MD, MD-MPH). We used Pearson’s χ2 tests and analysis of variance to measure between-group differences. We used multivariate logistic regression to identify independent predictors of MD-MPH program vs. MD program graduation, reporting adjusted odds ratios (aORs) and 95% confidence intervals (CIs) and controlling for all predictor variables shown in the tables. In addition to the overall model, we stratified the logistic regression analysis by sex and by race/ ethnicity. We performed all statistical tests using SPSS® version 22.0,12 and considered two-sided p,0.05 to be significant. Study sample derivation Of 262,813 PMQ respondents in 2001–2006, a total of 100,440 (38.2%) respondents entered medical school. Of these respondents, 77,718 (77.4%) matriculated
during 2003–2004 through 2007–2008, comprising 91.1% of all 85,312 matriculants in U.S. LCMEaccredited medical schools during the cohort years of interest.13 Of these 77,718 matriculants, 72,674 (93.5%) had graduated by the end of 2012, including 69,787 (96.0%) in MD programs, 972 (1.3%) in MD-MPH programs, 904 (1.2%) in MD programs combined with other advanced degrees, and 1,011 (1.4%) in MDPhD programs. Of the 70,759 MD program and MDMPH program graduates eligible for study inclusion (100% of whom had completed the PMQ, at least in part), we excluded 10,717 (15.1%) graduates without complete data for all PMQ items of interest and 245 (0.3%) graduates who were missing standardized test data. Our final sample of 59,797 graduates included 58,975 MD program graduates (84.5% of 69,787 MD program graduates) and 822 MD-MPH program graduates (84.6% of 972 MD-MPH program graduates) who met the inclusion criteria and had complete data for all PMQ items and standardized tests of interest (Figure). RESULTS Of the 59,797 medical-school graduates included (Figure), 822 (1.4%) were MD-MPH program graduates and 58,975 (98.6%) were MD program graduates. We found significant between-group differences in all variables except Step 2 CK scores and Step 2 CS results (Table 1). Not shown, of 294 MD-MPH program enrollees at matriculation, 262 (89.1%) completed the MD-MPH program and comprised 31.9% of all 822 MD-MPH program graduates in the sample. The mean (standard deviation [SD]) duration of medical school enrollment was longer for MD-MPH program graduates than for MD program graduates (MD-MPH: 4.9 [0.5] vs. MD: 4.2 [0.4] years; p,0.001); and, based on data available for 41,875 graduates, MD-MPH program graduates were older than MD program graduates (MD-MPH: 28.0 [2.3] vs. MD: 27.3 [2.7] years of age; p,0.001). Also, based on GQ data available for 33,840 graduates, mean (SD) total debt at graduation did not differ significantly between MD-MPH program and MD program graduates overall (MD-MPH: $145,161 [$90,787] vs. MD: $142,224 [$86,890]; p50.516) or only graduates of private schools (MD-MPH: $153,562 [$101,444] vs. MD: $158,827 [$96,805]; p50.480) or public schools (MD-MPH: $138,049 [$80,249] vs. MD: $132,406 [$78,827]; p50.311). Graduates who were female or from underrepresented racial/ethnic groups in medicine (i.e., black, Hispanic, and Native American/Alaska Native) reported public health aspects of disease as the most interesting area of medicine on the PMQ; attributed
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Figure. Flow diagram of Pre-Medical College Admission Test Questionnaire (PMQ) respondents during 2001–2006 in an analysis of MD program graduates and MD-MPH program graduates in the United States through 2012
• • • • •
MD 5 doctor of medicine MPH 5 master of public health PhD 5 doctor of philosophy
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640 From the Schools and Programs of Public Health
Table 1. Characteristics of medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD program graduation in the United States through 2012a
Characteristicb Total Sex Male Female Race/ethnicity Non-Hispanic white Other/multiple races/ no response Non-Hispanic black, Hispanic, Native American/Alaska Native Asian/Pacific Islander Graduates’ most interesting area of medicinef Patient management Public health aspects of disease Biomedical research Graduates’ career intention Full-time clinical practice Full-time faculty Other (state/federal or medical/ health-care administration, part time faculty, part-time practice, and other [not specified]) Undecided Missing (no response) Specialty choice for board certification Internal medicine No/undecided about specialty board certification Emergency medicine Family medicine Obstetrics-gynecology Pediatrics Surgical specialties All other specialties Missing (no response) USMLE Step 2 Clinical Skillsg Pass Fail School ownership Private Public Unknown (information not provided for graduate)
All graduates N (percent)c
MD program MD-MPH program graduates graduates P-valued N (percent)c N (percent)c
59,797 (100.0)
58,975 (100.0)
822 (100.0)
29,704 (49.7) 30,093 (50.3)
29,382 (49.8) 29,593 (50.2)
322 (39.2) 500 (60.8)
aOR (95% CI)e
P-value
Ref. 1.30 (1.12, 1.51)
0.001
,0.001
0.001 38,508 (64.4) 1,747 (2.9)
38,023 (64.5) 1,714 (2.9)
485 (59.0) 33 (4.0)
Ref. 1.32 (0.92, 1.90)
0.128
8,804 (14.7)
8,651 (14.7)
153 (18.6)
1.68 (1.37, 2.05)
,0.001
10,738 (18.0)
10,587 (18.0)
151 (18.4)
1.04 (0.86, 1.26)
0.696
Ref. 2.96 (2.52, 3.49) 1.14 (0.83, 1.58)
,0.001 0.415
,0.001 50,316 (84.1) 5,642 (9.4) 3,839 (6.4)
49,753 (84.4) 5,428 (9.2) 3,794 (6.4)
563 (68.5) 214 (26.0) 45 (5.5)
14,697 (24.6) 12,964 (21.7) 5,102 (8.5)
14,626 (24.8) 12,753 (21.6) 4,995 (8.5)
71 (8.6) 211 (25.7) 107 (13.0)
Ref. 3.23 (2.44, 4.29) 3.40 (2.51, 4.62)
,0.001 ,0.001
7,543 (12.6) 19,491 (32.6)
7,483 (12.7) 19,118 (32.4)
60 (7.3) 373 (45.4)
1.47 (1.04, 2.08) 1.83 (0.73, 4.56)
0.030 0.196
Ref. 1.53 (1.10, 2.12)
0.011
1.05 1.92 1.55 1.21 0.64 0.65 1.40
1.61) 2.90) 2.30) 1.75) 0.95) 0.91) 3.25)
0.824 0.002 0.030 0.319 0.027 0.013 0.437
Ref. 0.95 (0.57, 1.57)
0.833
Ref. 0.87 (0.72, 1.05) 1.49 (0.93, 2.38)
0.140 0.100
,0.001
,0.001 5,501 (9.2) 5,836 (9.8) 3,014 2,166 2,454 3,557 6,272 11,272 19,725
(5.0) (3.6) (4.1) (5.9) (10.5) (18.9) (33.0)
5,436 (9.2) 5,742 (9.7) 2,981 2,124 2,410 3,503 6,233 11,198 19,348
(5.1) (3.6) (4.1) (5.9) (10.6) (19.0) (32.8)
65 (7.9) 94 (11.4) 33 42 44 54 39 74 377
(4.0) (5.1) (5.4) (6.6) (4.7) (9.0) (45.9)
(0.68, (1.27, (1.04, (0.83, (0.42, (0.46, (0.60,
0.327 58,318 (97.5) 1,479 (2.5)
57,512 (97.5) 1,463 (2.5)
806 (98.1) 16 (1.9) ,0.001
15,754 (26.3) 26,132 (43.7) 17,911 (30.0)
15,535 (26.3) 25,882 (43.9) 17,558 (29.8)
219 (26.6) 250 (30.4) 353 (42.9)
continued on p. 641
greater importance to altruism as a reason to study medicine on the PMQ; had higher MCAT and Step 2 CK scores; listed GQ specialty category as “family medicine,” “obstetrics-gynecology,” or “no/undecided about specialty-board certification plans;” and reported
“full-time faculty,” “other,” or “undecided” GQ career intentions were more likely to be MD-MPH program graduates than to be MD program graduates. Graduates who attributed greater importance to the status of medicine and to research/finding cures on the PMQ as
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From the Schools and Programs of Public Health 641
Table 1 (continued). Characteristics of medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD program graduation in the United States through 2012a
Characteristicb Importance of factors in graduates’ decision to study medicinej Status Altruism Research/finding cures MCAT scorek USMLE Step l scorel USMLE Step 2 Clinical Knowledge scorem
All graduates Mean (SD)
2.2 3.7 2.7 29.1 222.8 230.9
(0.7) (0.4) (0.8) (4.9) (21.5) (21.8)
MD program MD-MPH program graduates graduates Mean (SD) Mean (SD) P-valueh
2.3 3.7 2.7 29.0 222.8 230.9
(0.7) (0.4) (0.8) (4.9) (21.5) (21.8)
2.1 3.8 2.6 30.5 221.2 232.0
(0.7) (0.4) (0.9) (4.5) (20.2) (21.0)
,0.001 0.003 ,0.001 ,0.001 0.039 0.138
aOR (95% CI)i
0.80 1.29 0.86 1.10 0.99 1.01
(0.72, (1.07, (0.78, (1.08, (0.98, (1.00,
0.89) 1.56) 0.94) 1.12) 0.99) 1.01)
P-value
,0.001 0.008 0.001 ,0.001 ,0.001 0.009
a The study sample comprised U.S. Liaison Committee for Medical Education-accredited medical school MD-MPH and MD program graduates who had completed the Association for American Medical Colleges Pre-MCAT Questionnaire during 2001–2006, entered medical school during 2003–2007, and graduated by the end of 2012.
Data sources included the Association of American Medical Colleges Student Records System, Pre-MCAT Questionnaire, and Graduation Questionnaire; and the National Board of Medical Examiners.
b
Percentages may not total to 100 because of rounding.
c
Tests of significance were Pearson’s χ2 tests comparing each categorical variable with degree program at graduation (MD-MPH program graduates vs. MD program graduates). d
Hosmer and Lemeshow goodness-of-fit test p50.209.
e
Response options to the item “Indicate the area of medicine in which you are most interested” included public health aspects of disease, biomedical research, or patient management. f
USMLE Step 2 Clinical Skills is a standardized patient examination testing information-gathering, physical examination, and communication skills; scores are reported on a pass/fail basis.
g
Tests of significance were one-way analysis of variance testing differences in scores by degree program at graduation (MD-MPH program vs. MD program).
h
i For each unit increase, aOR ,1.00 indicates a lower likelihood and aOR .1.00 indicates a greater likelihood of MD-MPH program graduation vs. MD program graduation. j Response options about the importance of each item in graduates’ decision to study medicine ranged from 1 (not important) to 4 (extremely important).
MCAT is a multiple-choice examination on verbal reasoning, biological sciences, and physical sciences, with scores ranging from 0 to 45.
k
USMLE Step l is a multiple-choice examination on basic medical sciences, with scores ranging from 1 to 300.
l
m
USMLE Step 2 Clinical Knowledge is a multiple-choice examination on clinical medical sciences, with scores ranging from 1 to 300.
MD 5 doctor of medicine MPH 5 master of public health aOR 5 adjusted odds ratio CI 5 confidence interval Ref. 5 reference group USMLE 5 U.S. Medical Licensing Examination SD 5 standard deviation MCAT 5 Medical College Admission Test
reasons to study medicine, had higher Step l scores, and whose GQ specialty category was “surgical specialties” or “all other specialties” were less likely to be MD-MPH program graduates than to be MD program graduates (Table 1). Seventy percent of graduates in the sample had completed the GQ, at least in part; for each GQ item analyzed, findings for graduates who were miss-
ing data for the item did not differ significantly from findings for the reference group. We grouped descriptive statistics by degree program at graduation and ran multivariate logistic regression models separately for women (Table 2) and men (Table 3) to determine if variables independently associated with MD-MPH program (vs. MD program)
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642 From the Schools and Programs of Public Health
Table 2. Characteristics of all female medical-school graduates in the sample, by degree program at graduation, and results of the multivariate logistic regression model predicting MD-MPH program graduation vs. MD-program graduation in the United States through 2012a
Characteristicb
Total N (percent)c
Total 30,093 Race/ethnicity Non-Hispanic white 18,357 Other/multiple races/no response 960 Non-Hispanic black, Hispanic, Native 5,135 American/Alaska Native Asian/Pacific Islander 5,641 Graduates’ most interesting area of medicinef Patient management 25,269 Public health aspects of disease 3,239 Biomedical research 1,585 Graduates’ career intention Full-time clinical practice 6,693 Full-time faculty 6,634 Other (state/federal or medical/health-care 3,033 administration, part-time faculty, part-time practice, and other [not specified]) Undecided 4,305 Missing (no response) 9,428 Specialty choice for board certification Internal medicine 2,529 No/undecided about specialty-board 3,741 certification Emergency medicine 1,233 Family medicine 1,266 Obstetrics-gynecology 2,113 Pediatrics 2,682 Surgical specialties 1,967 All other specialties 5,044 Missing (no response) 9,518 USMLE Step 2 Clinical Skillsg Pass 29,738 Fail 355 School ownership Private 8,235 Public 13,191 Unknown (information not provided for 8,667 graduate)
MD program graduates N (percent)c
MD-MPH program graduates N (percent)c
(100.0) 29,593 (100.0)
500 (100.0)
(61.0) (3.2) (17.1)
18,077 (61.1) 935 (3.2) 5,027 (17.0)
280 (56.0) 25 (5.0) 108 (21.6)
(18.7)
5,554 (18.8)
87 (17.4)
P-valued
aOR (95% CI)e
P-value
0.003 Ref. 1.60 (1.05, 2.44) 0.029 1.78 (1.38, 2.28) ,0.001 1.01 (0.79, 1.31)
0.913
,0.001 (84.0) (10.8) (5.3)
24,941 (84.3) 3,087 (10.4) 1,565 (5.3)
328 (65.6) 152 (30.4) 20 (4.0)
Ref. 3.19 (2.61, 3.90)
