Medical student attrition is associated with underresourced ethnic background and lower family income in the United States

1. Medical students in the United States who were from racial or ethnically underresourced backgrounds, or from families with lower income, were more likely to drop out from medical school.

2. The attrition rate increased linearly with the number of risk factors identified in this study.

Level of Evidence Rating: 2 (Good)

Study Rundown: Despite efforts in recent years to increase diversity amongst medical school matriculants in the United States (US), there remains a significant difference between the racial and socioeconomic makeup of the US population and that of the physicians who serve it.  Admissions to medical school have been well-studied in the past, particularly from a diversity and inclusion lens, however little is known about attrition from medical school. This study sought to describe the racial/ethnic and sociodemographic factors associated with medical school attrition.

A total of 33,389 students were included. 12.9% were considered underrepresented in medicine (URiM) by race and ethnicity, 24.5% had grown up in low-income families and 17.7% in under-resourced neighborhoods. The overall attrition rate from medical school was 2.8%. The attrition rate was higher amongst URiM students than non-Hispanic White students and was highest amongst non-Hispanic American Indian/Alaska Native/Native Hawaiian/ Pacific Islander students (11%).  Low-income students had a significantly greater rate of attrition compared to non-low-income students, as did students from under-resourced neighborhoods compared to others. Furthermore, the risk of attrition increased proportionally with the number of risk factors experienced by a student.

This retrospective cohort study identified several factors associated with attrition from medical school amongst US students, making the argument that diversification does not end with broadening admissions. Some strengths of this study include its large sample size and considerable follow up period of five years. A major limitation of this work is that data collection is limited to self-reported data which can be collected retrospectively. Future work in this area should address ground level interventions to understand the driving factors for attrition amongst these groups of higher-risk students and any interventions which could better support them through their studies.

Click here to read this study in JAMA Internal Medicine

Relevant reading: Implicit racial bias in medical school admissions

In Depth: [retrospective cohort]: A retrospective cohort study was performed. All medical school matriculants from MD programs in the United States in 2014-2015 and 2015-2016 were included using de-identified data from several relevant databases. Self-reported race/ethnicity was divided into 1 of 7 categories: Hispanic, non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander, non-Hispanic Asian, non-Hispanic Black/African American, non-Hispanic White, and unknown or other; some students were otherwise classified as multiracial. The following groups of students were considered URiM: Hispanic only, non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander only, or non-Hispanic Black/African American. Family income was assessed by student self-report as well as receipt of financial assistance. Finally, underserved neighborhoods were classified based on access to healthcare services. This analysis was adjusted for students’ performance on standardized test scores and sex.

Of these students, 6079 (18.2%) identified as non-Hispanic Asian, 18213 (54.5%) as non-Hispanic White, and 4318 (12.9%) as URiM by race and ethnicity (2096 [6.3%] Hispanic, 118 [0.4%] non- Hispanic American Indian/Alaska Native/Native Hawaiian/ Pacific Islander, and 2104 [6.3%] non-Hispanic Black/African American). The attrition rate was significantly higher in URiM students (5.6%) compared to non-Hispanic White students (2.3%, p< 0.001). In the adjusted model, the odds ratio for attrition amongst URiM groups versus non-Hispanic White students were 1.41 for Hispanic students (95% confidence interval 1.13-1.77), 3.20 (1.76-5.80) for non-Hispanic American Indian/Alaska Native/Native Hawaiian/Pacific Islander students and 1.31 (1.13-1.77) amongst non-Hispanic Black/African American students.

The adjusted odds ratio for experiencing attrition in low-income students versus non-low income students was 1.33 (1.15-1.54). Finally, the adjusted odds ratio for attrition amongst students from under-resourced neighborhoods compared to others was 1.35 (1.16-1.58), indicating that this was another significant risk factor for attrition from medical school.

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