How Admissions Process Fail

I wrote briefly about a somewhat common argument in defense of current medical school admissions that doesn't quite hold up to scrutiny. Put simply, because there are so many qualified applicants to medical schools in Canada, it's not hard to design a system that selects mostly qualified applicants.

What is much harder to do is select the most qualified candidates and to do so fairly such that people aren't looked over for factors largely out of their control. Right now most medical schools' admissions processes do a reasonable job - the highly qualified candidates seem to get in with relative reliability and no one seems completely unqualified to be a future physician among the medical students I've met. Yet, there's a huge swath of applicants who are neither incredibly competent nor clearly inept. It's selecting between these candidates where the challenge lies and where I believe our current systems fall flat.

How Admissions Are Unfair

The admissions process gets accused of unfairness often, quite frequently for spurious reasons related to individual applicants not getting in (and then calling the system unfair because of it). One way in which there appears to be a clear level of unfairness, however, is in socioeconomic status.

Today's medical students come from predominantly upper-middle or upper class families. Many have physicians as parents. Being rich and connected doesn't get you into medicine - no one cares in an interview if your dad is the Head of Neurosurgery or something - but not being rich or connected can certainly play a role in keeping you out.

Medical schools obviously don't ask for your parent's income when you apply, but the factors they do look at can be greatly influenced by income and connections. In Canada, schools generally consider four major factors in granting admission: GPA, MCAT, extra-curriculars (ECs), and interviews.

GPA requires consistently high marks. Sometimes a single bad mark can ruin an applicant's chances at select schools. Even at schools that have relatively low GPA requirements, you need pretty close to straight-A's. That level of consistency requires time and energy. That's reasonable if you have nothing to do aside from school, but becomes a real challenge if you're commuting from home, working significant hours (even 10+ per week has been shown to decrease academic performance), or have domestic responsibilities. Money can also buy some extra help - hiring a tutor or doing some difficult courses part-time during the summer when you can afford to put some extra time in (or when schools don't consider them in your GPA) are all pathways unavailable to lower-income students. Not to mention that undergraduate education isn't exactly cheap...

ECs are much the same - they take time and energy. Some ECs also take money, such as travel abroad or high-level sports. There is a push to better consider activities and experiences that reflect life for lower-income students, such as valuing work experience or time spent caring for family members. There is also a trend against ECs that are clearly bought, not earned, such as travelling abroad for so-called "voluntourism" initiatives. Still, there is plenty of room for bias. A job in a research lab looks much better than a job in retail, yet lab jobs often don't have enough hours or sufficient flexibility for some students to manage. They also tend to require high marks. Connections make a difference too - those who have physicians as parents are more likely to be aware of opportunities in undergrad and may have an advantage in obtaining those coveted positions.

The MCAT also requires time and money, though I'd argue less than maintaining a high GPA or developing strong ECs. The financial cost for me to write my MCAT, including prep materials, was somewhere in the range of $500, plus about 4 weeks of dedicated studying, compared to tens of thousands of dollars and 4 years needed for an undergrad. Still, my experience may not be universal and there are definitely individuals who spend exorbitant amounts to prepare for the MCAT, or who write it multiple times to get a better score. If these expenses are even modestly helpful, it's yet another barrier for low-income students.

Interviews are probably the one chance to equal out the field a bit. People are persuaded by stories of struggle and interviews are the perfect opportunity for lower-income applicants to put what they've done in proper context. Yet, interviews come only after all the other factors are considered. Interviews do have some barriers as well - clothing and travel. Suits and other forms of formal wear are expensive! So is travelling to interviews, which can be halfway across our rather large country for some. For many students, it's a small expense, but when you're living paycheque-to-paycheque, it's not.

Admittedly, factors related to competence are likely at play here. Intelligence correlates with income and has a hereditary component meaning the offspring of wealthy individuals are more likely to be sufficiently intelligent than those from non-wealthy families. However, the disparity is striking. In light of the financial barriers to entering medical school, I'm doubtful that these sort of correlations explain the whole picture.

All of the factors medical schools consider have support as mechanisms to evaluate qualifications. Yet, because they reflect more than qualifications, particularly personal circumstances, they tend to cut out those with challenges beyond their control to overcome.

How Admissions Fail To Capture The Best Candidates

In providing unintentional preference to wealthy applicants, medical schools automatically miss out on some very capable individuals. Yet even among those from similar socioeconomic backgrounds, there are ways in which the current system selects candidates who may not be the best qualified.

Schools want the smartest, hardest working, most responsible candidates. Patients want physicians who are ethical, caring, and who have strong communication skills. I'd argue these six attributes are essentially what admissions committees are trying to measure.

GPA and the MCAT largely cover what schools wants - intelligence and work ethic. ECs can hit everything somewhat depending on the types of ECs done. Interviews are primarily meant to assess ethics and communication skills.

Ideally, we want applicants to be exceptionally strong in all these attributes. If they are, they tend to do quite well in all the admission criteria - stellar GPA, high MCAT scores, varied and unique ECs, plus a solid interview. Very few people fit this mold. Deciding between individuals who are not stellar in all categories is trickier. Is someone with a 4.0 GPA but a 50th percentile MCAT more qualified than someone with a 99th percentile MCAT but a 3.5 GPA? Some schools in Canada say yes. Others say no.

I'd argue both are probably smart enough to be a physician and it's the other factors that should be analyzed. Unfortunately, most schools in Canada don't allow for strength in one category to make up for strength in another, even when measuring roughly the same metrics. This leaves a lot of individuals cut out of consideration relatively arbitrarily. It's one thing to take a look at an applicant and ultimately decide against them - it's another to dismiss an applicant without looking at them at all. Yet, that's what virtually every medical school does. In Canada, the main barrier to entry into medical school is having high enough stats (GPA and MCAT) for schools to bother looking at the rest of your application. Once that bar is cleared, entry into medical school is very likely, even if it takes a few application cycles. In effect, this means that GPA and MCAT dictate entry into the profession, even though ECs and interview scores are considered.

In some respects, the variation in criteria for medical schools in Canada does allow for a bit of a bigger net to be cast. Ottawa, for example, has crazy-high GPA requirements, but doesn't care about the MCAT at all. Western, by contrast, has insane MCAT requirements, but fairly lax GPA cutoffs. Individually these two schools ignore a lot of qualified applicants, but together they're at least looking at wider number of qualified applicants.

Nevertheless, GPA and MCAT still reign king. ECs and interviews seem to matter only when exceptionally deficient. This leads to schools largely getting the students they want - smart, hard-working ones. Patients, who want ethical, caring, communicative individuals tend to lose out. Looser requirements for GPA and MCAT, looking at more applicants' non-academic qualifications, may allow those qualifications to matter a bit more.

I've yet to meet a medical student or physician too dumb for the job, but I've met plenty who lacked the soft skills to be capable. Our admissions process is part of that.