In Part I, I wrote about the some more conceptual changes in how I believe medical school admissions could be improved. Here I'll give an outline for an admissions process I'd like to see. It won't be perfect - there are certainly important aspects I may have overlooked or addressed poorly - but it's an attempt. I welcome any criticisms or suggestions.
Introduction
I would still want to look at many of the same things current admissions committees look at, namely:
Introduction
I would still want to look at many of the same things current admissions committees look at, namely:
- Undergraduate marks
- MCAT
- Extra-curriculars
- Letters of Reference
- Essays
- Interviews
What differs is how I would use these factors. All these factorss are proxies for the attributes we actually want in physicians - intelligence, work ethic, empathy, communication skills, etc. They're imperfect proxies, but they have some overlap. I think admissions processes should capitalize on that overlap to better get at the underlying attributes rather than treating the proxies as sufficient measures alone.
Step 1: Is this person academically intelligent enough?
An applicant passes this stage if:
- They have alright marks and a very strong MCAT (~75% and 12/11/12 minimum)
- They have very high marks and a mediocre MCAT (~90% and 8/8/8 minimum)
- They have good marks and a good MCAT (~80% and 10/10/10 minimum)
Rationale: The idea here is to capture a lot of people with the intellect necessary to be physicians. The numbers can be played with a bit depending on the applicant pool, Not trying to get the smartest people here, just a good number who are all likely to be smart enough.
Step 2: Does this person have a strong enough work ethic?
An applicant passes this stage if:
- They have stellar marks (~90% minimum) and ECs that show some productivity outside of their curriculum
- They have good marks (~80% minimum) and ECs that show a plenty of productivity outside of their curriculum
- They have alright marks (~75% minimum) and ECs that show extensive productivity outside of their curriculum
Rationale: We want hard-working physicians, whether they're working hard at school or hard outside of school. In evaluating ECs at this stage, the focus should be on the quantity of hours worked, not necessarily the quality (though effort involved should play a factor). Anything and everything should count here - jobs of any sort (including fast food or retail), child-rearing, taking care of family members - literally anything. Medical school admissions don't give enough credit to people who are struggling just to keep life going and thereby give preference to those who are fortunate enough not to have that struggle - this step could help to level the playing field, even slightly.
Step 3: Has this person explored the medical field?
An applicant passes this stage if:
- They have any schooling or ECs with direct exposure to medicine, health care, or individuals with medical conditions
- They have any personal experiences with the medical system, either from their own medical conditions or those of loved ones
Rationale: Very easy to pass this step - just a quick check to make sure applicants have actually investigated medicine as a career. Being a physician should be an active choice, not a default position.
Step 4: Does this person work well with others?
An applicant passes this stage if:
- Their LOR has no red flags
Rationale: Again, an easy step to pass. Anything above a dismal or indifferent LOR will be fine. The main challenge with LORs is having people who know the applicant well enough to vouch for their competency. That's an important skill in itself, especially in the relationship-dependent field of medicine.
Step 5: Does this person bring something to the field of medicine?
An applicant passes this stage if:
- Their ECs and essays demonstrate a good average degree of achievement and skill-development in the 7 CanMEDS roles, with achievement above a certain level in at least 5 of the 7 roles.
Rationale: Here's where the quality and diversity of ECs factors in. Ideally we want physicians who are strong in all the CanMEDS competencies, but that's unrealistic for individuals just starting their career. Being good - but not great - at all aspects is a reasonable place to start. So is being incredible in a select few, as long as there is at least some development in most of the other competencies. The main goal here is to cut out the one-trick ponies who might be amazing in one way, but sorely lacking in the other aspects. Not everyone who would make a good physician is going to be a great scholar, or a great manager, or a great collaborator. Yet, individuals with no experience in scholarly activity, no experience managing others, and no experience collaborating are going to be in trouble, even if they happen to be superb health advocates and experienced communicators. This is intended to be the main EC cut-off.
Step 6: Can this person communicate?
An applicant passes this stage if:
- Their interview scores (MMI scores ideally) are in the top three quaters of those invited to interview
Rationale: Interviews suck. They're high stress and often fairly subjective. Unfortunately, so is medicine, so interviews have value. This is especially true in the margins, either in the very high end or very low end. The idea here is to eliminate the low end. I prefer the MMI to allow for increased, independent sampling of applicants' interview ability (though some MMI questions are just plain weird).
Step 7: Putting it all together
This is the final step. An applicant passes this stage if:
- Their combined score from all aspects of their application is high enough to be granted an invitation for admissions
Rationale: A final rating is necessary in just about any large-scale application scheme, so here it is. I picture the combined score comprising 50% of the interview score and 10% for each of the following: essays, ECs (evaluated for work ethic as was done in Step 2), ECs again (evaluated for achievement as was done in Step 5), undergraduate marks, and combined MCAT score. It's all a bit arbitrary at this point, but the idea is that the truly deficient are already out by this stage, so the specific metric shouldn't matter all that much. I put the additional emphasis on interview scores because intelligence is almost never lacking in medical students, but the same can't always be said about communication skills.
Conclusion
Again, I won't claim that the system I've presented is perfect. In many ways, it's quite similar to what many schools do now, maybe just a bit more complex in some respects. The main differences I'd like to emphasize are flexibility in academic requirements as well as an overall increase in the number of applicants passing the initial cutoffs and receiving interview invites. This would undoubtedly be an expensive, labour-intensive system. That's by design, but it's not a small consideration.
Would this be a better approach? I have absolutely no idea! If anyone has an opinion on this, please comment. I've treated this mostly as a mental exercise. What do I care about when looking at future colleagues and what would I like medical school to look at? Ultimately, my process above reflects my priorities: I want to see a greater emphasis on work ethic, communication skills and diversity of experiences than currently seems to exist, with perhaps a somewhat lower emphasis on raw intellect. Individuals with different priorities would undoubtedly design a system with an emphasis on different qualities. Nevertheless, I enjoy discussions about what it means to be a good physician, and I can think of no better way to focus that discussion than on the topic of medical school admissions, where the physicians of the future are chosen.
- They have alright marks (~75% minimum) and ECs that show extensive productivity outside of their curriculum
Rationale: We want hard-working physicians, whether they're working hard at school or hard outside of school. In evaluating ECs at this stage, the focus should be on the quantity of hours worked, not necessarily the quality (though effort involved should play a factor). Anything and everything should count here - jobs of any sort (including fast food or retail), child-rearing, taking care of family members - literally anything. Medical school admissions don't give enough credit to people who are struggling just to keep life going and thereby give preference to those who are fortunate enough not to have that struggle - this step could help to level the playing field, even slightly.
Step 3: Has this person explored the medical field?
An applicant passes this stage if:
- They have any schooling or ECs with direct exposure to medicine, health care, or individuals with medical conditions
- They have any personal experiences with the medical system, either from their own medical conditions or those of loved ones
Rationale: Very easy to pass this step - just a quick check to make sure applicants have actually investigated medicine as a career. Being a physician should be an active choice, not a default position.
Step 4: Does this person work well with others?
An applicant passes this stage if:
- Their LOR has no red flags
Rationale: Again, an easy step to pass. Anything above a dismal or indifferent LOR will be fine. The main challenge with LORs is having people who know the applicant well enough to vouch for their competency. That's an important skill in itself, especially in the relationship-dependent field of medicine.
Step 5: Does this person bring something to the field of medicine?
An applicant passes this stage if:
- Their ECs and essays demonstrate a good average degree of achievement and skill-development in the 7 CanMEDS roles, with achievement above a certain level in at least 5 of the 7 roles.
Rationale: Here's where the quality and diversity of ECs factors in. Ideally we want physicians who are strong in all the CanMEDS competencies, but that's unrealistic for individuals just starting their career. Being good - but not great - at all aspects is a reasonable place to start. So is being incredible in a select few, as long as there is at least some development in most of the other competencies. The main goal here is to cut out the one-trick ponies who might be amazing in one way, but sorely lacking in the other aspects. Not everyone who would make a good physician is going to be a great scholar, or a great manager, or a great collaborator. Yet, individuals with no experience in scholarly activity, no experience managing others, and no experience collaborating are going to be in trouble, even if they happen to be superb health advocates and experienced communicators. This is intended to be the main EC cut-off.
Step 6: Can this person communicate?
An applicant passes this stage if:
- Their interview scores (MMI scores ideally) are in the top three quaters of those invited to interview
Rationale: Interviews suck. They're high stress and often fairly subjective. Unfortunately, so is medicine, so interviews have value. This is especially true in the margins, either in the very high end or very low end. The idea here is to eliminate the low end. I prefer the MMI to allow for increased, independent sampling of applicants' interview ability (though some MMI questions are just plain weird).
Step 7: Putting it all together
This is the final step. An applicant passes this stage if:
- Their combined score from all aspects of their application is high enough to be granted an invitation for admissions
Rationale: A final rating is necessary in just about any large-scale application scheme, so here it is. I picture the combined score comprising 50% of the interview score and 10% for each of the following: essays, ECs (evaluated for work ethic as was done in Step 2), ECs again (evaluated for achievement as was done in Step 5), undergraduate marks, and combined MCAT score. It's all a bit arbitrary at this point, but the idea is that the truly deficient are already out by this stage, so the specific metric shouldn't matter all that much. I put the additional emphasis on interview scores because intelligence is almost never lacking in medical students, but the same can't always be said about communication skills.
Conclusion
Again, I won't claim that the system I've presented is perfect. In many ways, it's quite similar to what many schools do now, maybe just a bit more complex in some respects. The main differences I'd like to emphasize are flexibility in academic requirements as well as an overall increase in the number of applicants passing the initial cutoffs and receiving interview invites. This would undoubtedly be an expensive, labour-intensive system. That's by design, but it's not a small consideration.
Would this be a better approach? I have absolutely no idea! If anyone has an opinion on this, please comment. I've treated this mostly as a mental exercise. What do I care about when looking at future colleagues and what would I like medical school to look at? Ultimately, my process above reflects my priorities: I want to see a greater emphasis on work ethic, communication skills and diversity of experiences than currently seems to exist, with perhaps a somewhat lower emphasis on raw intellect. Individuals with different priorities would undoubtedly design a system with an emphasis on different qualities. Nevertheless, I enjoy discussions about what it means to be a good physician, and I can think of no better way to focus that discussion than on the topic of medical school admissions, where the physicians of the future are chosen.
Very interesting post...which school do you think most closely represents your proposed system of medical school admissions (if any)?
ReplyDeleteI'm a huge fan of the approach Queens takes, given its relatively low cutoffs and high number of people who get file reviews and then interviews. Their method is far from ideal, but it seems to catch a lot of people other schools miss, while raising expectations for softer factors like community involvement and communication skills.
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