Editorial  |   April 2019
Growth, Debt, and Diversity Driving Innovation in Medical Education
Author Notes
  • Dr McClain is the associate editor for the JAOA/AACOM Medical Education section and oversees the content in the annual osteopathic medical education theme issue of the JAOA. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Elizabeth K. McClain, PhD, EdS, MPH, Arkansas Colleges of Health Education, 7000 Chad Colley Blvd, Fort Smith, AR 72916. Email:
Article Information
Medical Education
Editorial   |   April 2019
Growth, Debt, and Diversity Driving Innovation in Medical Education
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 221-223. doi:10.7556/jaoa.2019.036
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 221-223. doi:10.7556/jaoa.2019.036
The osteopathic medical profession is experiencing growth in the number of student applicants and matriculants and in the expansion of medical schools in both number and class size. Yet, the cost of training to become a physician in the United States continues to increase. During the 2017-2018 academic year, the median debt reported by the Association of American Medical Colleges (AAMC) for medical school graduates was $195,000,1 which represented an 8.3% increase over the previous year. The American Association of Colleges of Osteopathic Medicine (AACOM) reported that the debt average for osteopathic medical school graduates in 2017 was $240,000, which was an increase of 2.9% over the previous year.2 As medical school debt grows, however, there remains a consistent narrative of a predicted physician shortage. The 2017 annual AAMC report3 estimated that by 2030, there would be a physician shortage of 14,800 to 49,300 primary care physicians and 33,800 to 72,700 non–primary care specialists, aligning with previous reports. 
Despite the reported financial burden, students are answering the call to enter medical school. As AACOM noted: 

For the first time in history, osteopathic medical students make up more than 25 percent of the U.S. medical student population. Fall 2018 new (first-year) student enrollment at the nation's colleges of osteopathic medicine (COMs) increased by 5.7 percent from fall 2017.4

There is also increased interest in finding ways to ease the financial burden of medical school. According to the AAMC survey,1 45.7% of students who responded to the survey planned to enter a loan forgiveness program to help with their medical school debt.1 Federal incentives and programs such as the National Health Service Corps, Public Service Loan Forgiveness, the Conrad 30 Waiver, and Title VII and Title VIII are all designed to increase the diversity of the workforce, to encourage physicians to train in identified shortage specialties, and to encourage physicians to practice in underserved communities. 
In this edition of The Journal of the American Osteopathic Association (JAOA), Sheckel et al5 revisit this concern with a deeper dive into osteopathic graduate medical education (GME) by looking at primary care trends and whether medical school debt is associated with practice patterns. The study found that increased educational debt directly influenced graduates’ practice choices. Specifically, “Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs.”5 Additionally, “graduates with high debt burden who did not use loan forgiveness/repayment programs” were less likely to choose primary care.5 
The continued growth in medical school matriculants demonstrates a positive trend for the osteopathic medical profession. However, the profession has a responsibility to investigate and address the impact of increased debt load on the diversity of osteopathic medical school applicants. To provide culturally competent care, it is important to train a culturally diverse medical student population. The financial cost, coupled with the length of training and access to academic preparation, can reduce the diversity of our qualified applicant pool, especially when considering factors such as rural and underrepresented minority groups. For more than a decade, accrediting bodies (both the Liaison Committee on Medical Education and the Council on Osteopathic College Accreditation) have pushed to institute standards supporting diversity in medical school matriculants. Recent data have demonstrated an increase in the percentage of underrepresented minorities in line with the growing diversity of the US population, but it is still not adequate. In the 2016-2017 academic year, 13,851 underrepresented minorities were enrolled in US medical schools, representing 12% of total enrollment. Of that total, 6717 (5.8%) were Hispanic, 6696 (5.8%) were African American, 303 (0.26%) were Native American/Alaska Native, and 135 (0.12%) were Hawaiian/Pacific Islander.6 When compared with the United States 2017 Census data,7 medical school representation fell short of the growing diversity of the US population. Of the total reported US population, 18.1% of individuals self-reported as Hispanic/Latino, 13.4% as black or African American, and 1.3% as American Indian/Alaska Native.7 
Many schools have organized efforts to attract and retain students from diverse backgrounds by incorporating programs, such as pipeline, academic enrichment, and bridge programs, to address the need to increase the diversity of qualified applicants. Organizations such as the Student National Medical Association have served as a driving force of change focused on providing support for underrepresented minority medical students, underserved communities, and communities of color.8 The importance of academic enrichment programs focusing on prematriculation preparation is highlighted by Shipley et al.9 A 16-week comprehensive course for undergraduate students had 70% of participants reporting their ethnicity as Hispanic. The program included preparation for the Medical College Admission Test, medical school applications, and interviewing workshops, as well as an introduction to the osteopathic medical school experience. Initial outcomes noted increased awareness of osteopathic medical education and rural medicine, increased confidence in the medical school application process, and increased preparedness to take the admission test. This study9 provides a nice overview of a program that falls in line with many pipeline and academic enrichment programs developed by osteopathic medical schools to support rural medicine and underrepresented populations. 
As educators, we are driven to do more than merely educate; we hope to develop future leaders in medicine, whether it be clinical or academic. Physician leaders demonstrate a broad and diverse range of skill sets and abilities. Beyond clinical training and expertise, approaches to organization, internal motivation, stress management, and effective communication are added layers to successful leadership. In the field of professional education, researchers continue to explore a variety of methodologies in teaching and assessing skill development and skill attrition of learners throughout the educational process. However, the density and rate of the curricular process can be a daunting and overwhelming task for educators and students alike. 
Stanco et al10 took a novel approach, providing a pathway to integrate preclinical basic science concepts with clinical ICD-10 coding. The study describes an interesting approach to introduce ICD-10 codes that are common in clinical documentation into the curriculum. The codes were integrated in basic biomedical science lectures, and material was revisited during clinical rotations using patient encounters. Innovative focuses such as this, on the cognitive skill development and fund of knowledge in biomedical and clinical sciences, can provide a pathway to guide the development of quality patient care. 
Likewise, it is important to foster training of well-rounded physician leaders who are empathetic, emotionally intelligent, and skilled in patient-centered quality care. Emotional intelligence (EI) is a construct that has persisted in educational and leadership research. Mintle et al11 explore the change in EI between the first and second year of medical school. The study used the Six Seconds Emotional Intelligence Assessment and found that overall EI scores declined, as did scores on 6 of the 8 core competency scales between the first and second year of medical school. Take-home points from this study and avenues for additional research suggest that identifying opportunities to enhance EI in the preclinical years are appropriate next steps. 
As we look to the future of osteopathic medicine, we are in a time of change in certification, accreditation, and training. Williams12 provides an update of osteopathic board certification, taking a historical look at where it started and where the new trends will take it. Buser et al13 provide updates on the single accreditation system for GME as the June 30, 2020, completion date nears. They also include a discussion of policy changes and enhancements to facilitate successful transitions to the single accreditation system. An appendix of osteopathic GME data for the 2017-2018 academic year categorized by distribution, number of positions, and program are provided by the American Osteopathic Association's Department of Education.14 
As the profession continues to keep up and work to stay ahead of trends in medical education, I look forward to further innovations and reflections from those in the osteopathic medical profession. I thank the authors featured in this issue and throughout the past and future JAOA/AACOM Medical Education section installments for their dedication and commitment to strengthening the future of the osteopathic medical profession through medical education research. 
Medical School Graduation Questionnaire: 2018 All Schools Summary Report. Bethesda, MD: Association of American Medical Colleges; 2018. Accessed February 24, 2019.
AACOM 2016-17 Academic Year Survey of Graduating Seniors. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; 2017. Accessed February 23, 2019.
The Complexities of Physician Supply and Demand: Projections from 2016 to 2030. Washington, DC: Association of American Medical Colleges; 2018. Accessed February 24, 2019.
Latest figures spotlight continued growth in osteopathic medical school enrollment [news release]. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; January 9, 2019. Accessed February 20, 2019.
Scheckel CJ, Richards J, Newman JR, et al.   Role of debt and loan forgiveness/repayment programs in osteopathic medical graduates’ plans to enter primary care. J Am Osteopath Assoc. 2019;119(4):227-235. doi: 10.7556/jaoa.2019.038
Data on the current state of diversity in osteopathic medical education. American Association of Colleges of Osteopathic Medicine website. Accessed February 18, 2019.
Quick facts 2017. United States Census Bureau website. Accessed February 10, 2019.
Our mission. Student National Medical Association website. Accessed March 12, 2019.
Shipley TW, Phu N, Etters AM, Kadavakollu S. Comprehensive medical college admission test preparatory course as a strategy to encourage premedical students to pursue osteopathic medicine in rural areas. J Am Osteopath Assoc. 2019;119(4):243-249. doi: 10.7556/jaoa.2019.041
Stanco KM, Prater MR, Wubah A, Sumpter C, Rawlins F, Garner HR. Improving medical education by coupling basic science lectures with ICD-10 codes. J Am Osteopath Assoc. 2019;119(4):251-256. doi: 10.7556/jaoa.2019.042
Mintle LS, Greer CF, Russo LE. Longitudinal assessment of medical student emotional intelligence over preclinical training. J Am Osteopath Assoc. 2019;119(4):236-242. doi: 10.7556/jaoa.2019.039
Williams D. The evolution of osteopathic board certification. J Am Osteopath Assoc. 2019;119(4):224-226. doi: 10.7556/jaoa.2019.037
Buser BR, Swartwout J, Lischka T, Biszewski M. Single accreditation system for graduate medical education: transition update. J Am Osteopath Assoc. 2019;119(4):257-262. doi: 10.7556/jaoa.2019.043
Martinez B, Biszewski M. Appendix: osteopathic graduate medical education, 2019. J Am Osteopath Assoc. 2019;119(4):268-272. doi: 10.7556/jaoa.2019.044