Variables Associated with Attrition from Uniformed Services University of the Health Sciences Medical School

Military Medicine, Feb 2004 by Stetto, Jayne E, Gackstetter, Gary D, Cruess, David F, Hooper, Tomoko I

Attrition among medical students is a concern for the institution, the individual, and the profession. Disenrollment has an impact on the institution, in terms of academic reputation and resources expended, and the individual, in terms of self-esteem, personal finances, and opportunity costs. This study summarizes the results of an epidemiologic study of student attrition conducted at the only federal medical school in the United States-the Uniformed Services University of the Health Sciences in Bethesda, Maryland-and describes the association between demographic and selected quantitative variables for those students who graduated or remained enrolled and those who disenrolled. Both sex (female) and a decelerated curriculum were predictive of attrition in this medical student population. The records of the students who left Uniformed Services University of the Health Sciences without graduating were examined to ascertain the presence of noncognitive issues surrounding disenrollment; over one-half of the students who disenrolled left voluntarily and for nonacademic reasons.

Introduction

The F. Edward Hebert School of Medicine at the Uniformed Services University of the Health Sciences (USUHS) was established by Congress in 1972 (Public Law 92-426) with the mandate to train uniformed physicians for the U.S. Army, Navy, Air Force, and the public health service.1 The school enrolled its first 32 medical students in 1976 and increased class size every year until 1985, when enrollment reached its current level of approximately 165 students per class. Twenty-four classes have matriculated at USUHS, and as of May 2000, only 97 of 3,550 students have left medical school without graduating. This study examines both demographic and other possible predictor variables and their association with student attrition. Additionally, specific qualitative or noncognitive characteristics of the 97 students who left medical school without graduating are described.

The Liaison Committee on medical education defines attrition as: (1) dismissal for academic failure; (2) withdrawal in poor academic standing; (3) dismissal or withdrawal for other reasons; and (4) transfer to another school.2 Attrition remains a concern for many medical schools; it impacts the school in terms of institutional competitiveness, prestige, and resource costs and impacts the student in terms of self-esteem and basic economic and opportunity costs. Although attrition rates would likely be of concern to administrators, educators, and medical professionals, as well as potential applicants, medical schools do not openly publish information about their individual attrition rates. Instead, national medical school enrollment and graduation statistics have been published annually in JAMA since 1973.3 By means of the data from JAMA and other published sources,4"6 the national attrition rate was estimated using the following formula: 1 - number in cohort by graduation year/number of first-year enrollments in cohort, 4 years prior to graduation year � 100. The national attrition rate for graduation years 1984 to 1999 is estimated at 6.4%. Applying the same formula, the USUHS attrition rate for graduation years 1984 to 1999 is 3.0%. The four graduating classes before 1984 were not included in the attrition rate calculation because class sizes were very small. Even though the estimated attrition rate for USUHS is well below the estimated national rate for the same time period, one of the school's quality improvement initiatives calls for an evaluation of students who do not successfully graduate.

A MEDLINE literature search was conducted through 1999 using the keywords medical school attrition, medical education, premedical education, medical schools, student attrition, and admission criteria. According to the published literature, U.S. medical schools emphasize undergraduate academic achievement as reflected by grade point averages (GPAs) and standardized Medical College Admission Test (MCAT) scores as the primary basis for admission consideration.7'8 In addition to these quantitative measures, a survey by Puryear and Lewis9 noted that 99% of all U.S. medical schools use the admission interview as a foundation for final selection and that the one-on-one interview is used by 74%. Also, according to Edwards et al.,10 the vast majority of schools use either a semistructured or unstructured interview format.

The processes and criteria used for admission into the USUHS medical school are similar to other U.S. schools of medicine. Students are rated according to several criteria that include undergraduate grades, standardized test scores, and two personal interviews with staff physicians. The USUHS interview is conducted one-on-one and is classified as unstructured, according to the interview format criteria developed by Edwards et al.10

Unique to USUHS, every prospective student must also meet uniformed service (i.e., military and public health service) accession standards. In other words, all candidates must be U.S. citizens and fulfill physical, medical, security, and character requirements to hold a commission in one of the U.S. uniformed services. Also unique to USUHS is the cost. Tuition and other fees are fully funded for each student by the Department of Defense. In 1995, Gardner et al.,1 calculated the cost per USUHS medical student for 4 years of medical school at an estimated $571,000, whereas the average cost per student at other U.S. medical schools was estimated at $1,282,000.1 Students are obligated to "pay back" the cost of their education through active duty service in their chosen branch of service. In fact, all USUHS graduates are required to fulfill at least a 7-year uniformed service obligation upon graduation. Successful completion of the 4-year curriculum and graduation from USUHS includes maintaining an acceptable medical school GPA, passing steps I and II of the U.S. Medical Licensing Examination, satisfactorily completing the core clinical clerkships, and maintaining military standards of conduct, bearing, and physical fitness.