Fairness in Medical School Admissions

A favourite topic of mine is medical education and one of the more interesting aspects of medical education to me is admissions. In our current system, admission to Medical School is the major choke-point. Before you get that admission, you're not going to become a doctor. Once you get that admission, you are almost guaranteed to become a physician. It's a fairly important milestone.

It's also a very difficult milestone to get beyond. Medical school admissions, particularly in Canada, are insanely competitive. Just getting the GPA/MCAT combo to get looked at is a non-trivial task. Having the more subjective measures be up-to-par is an added challenge, your extra-curriculars, letters of reference, interview performance all can matter as well. Far more people apply than gain admissions and there's a large set of interested individuals who never bother to apply at all, knowing it would be futile.

Because admissions is the major choke-point to entering the profession, having an effective and fair admissions process is a meaningful concern. At some point, I'd like to dig into the nuances of this process in depth, probably over several posts. For now, I'll stick to commenting on one point that always bugs me: just because we have generally good physicians does not mean that we have a good admissions process.

The thing is, far more qualified individuals want to be physicians than are allowed to be physicians. Ontario takes approximately 1000 new medical students each year, most of whom will likely be very good physicians. Yet, there are several more thousand aspiring physicians who cannot gain admissions who would probably be good physicians as well. This leaves plenty of room for inefficiency, inequality, or in some cases, downright inequality in the selection process.

Here's a simple scenario - let's say you have three applicants for one medical school position, Jim, Bob, and Ray.

Jim is not qualified to be a physician, not even close. Both Bob and Ray, however, would probably make good physicians. Jim and Bob are both tall, but Ray is not.

A selection process that considers both height and qualifications would select Bob. Bob's qualified, so that's not a bad outcome for the system - at least we're not getting Jim! But it's not a fair system to Ray, who's also qualified, but doesn't happen to be tall, a factor which isn't relevant or within Ray's control.

The current admission systems are rarely so obviously preferential, but bias can still creep in. If there were 100 Jims and 100 Bobs and 100 Rays applying for 100 positions, without any stated preference for height, yet we ended up with 90 Bobs and 10 Rays, that's not likely to be a fair system. Sure, we didn't end up with any Jims, so height doesn't trump qualifications, but that's a small comfort to the many Rays who got passed over for Bobs when the only major difference between them is height.

With so many qualified applicants, it's not too hard to avoid the unqualified ones (though the odd one still slips through the cracks...). But that's not good enough, not for patients, and not for applicants who deserve a fair shot at the profession.

Stress Management

I took on too much this year. Not way too much, just a bit more than I should have, and at times it stretches me a bit thin. This causes some stress. Not a ton - I'm still staying on top of everything, I maintain some semblance of a social life and I do get to spend a fair bit of time at home with my significant other.

Stress management for me takes many forms, but the main one is just letting my brain sort through the dozens of thoughts in it. Sometimes this means some alone time, just bouncing ideas around. Sometimes this means discussing what's rattling around in my head with friends, family, colleagues, or even the dog (the dog is a very good listener when he's not stealing socks).

One of the main purposes of this blog is stress management. It lets me get those thoughts out without avoiding the world or overwhelming those around me. I find writing (well, typing) to be fairly relaxing as well. So, at times you'll see me writing about tiny, insignificant things that have little if anything to do with medicine. Sometimes I'll write diatribes about a very specific topic in health care. It all depends what's stuck up in my brain that needs to come out.

My hope is that between all these outpourings of random thoughts, there will be some useful bits for those reading, if there is anyone reading.

Webcomics

Like a lot of kids, I grew up reading comics. Not the superhero type comics (though I'm starting on those now), but the type found in the back of the newspaper, or in the funnies section. You know, back when newspapers were still a thing. Calvin & Hobbes and then Zits were the big ones.

Reading comics has stuck with me and I've been absolutely thrilled with the way comics have evolved. In the past, only a few comic strip writers could really make a career of it. Either you managed to get published in a large number of newspapers and had enough to live on, or you didn't and comics became, at most, a hobby.

These days, webcomics are supplanting the traditional print comics and it's nothing short of amazing. Most webcomics don't get their creators rich, but many provide enough to live on, particularly with the rise of crowd-funding. A couple thousand dedicated followers are enough to support an artist if they're willing to pony up a bit of cash for projects (usually books) every now and then.

The great thing about online comics is that they're relatively free of constraints. They can be about virtually anything, provided there's a natural reader base. They can take any format - and that format can change! They can publish on their own schedules, rather than what a publisher demands. This leads to some incredible of variety in the webcomic world.

I spend a bit too much time reading webcomics and draw on them frequently in life. I will likely post more than a few on this blog if they're relevant to the topic. I will try to reference them as explicitly and overtly as possible - these content creators deserve as much credit as they can get for the work they do. And I encourage anyone reading to visit their sites and check them out!

March Break Incoming

Just finished the exam I missed because I was attending a conference and with March Break coming up, I can finally take a breath.

This semester has flown by so far. After the Christmas Break, we had one fairly intense week of class, a week of exams and then a fairly intense (but worthwhile) MSK block. Two of my clubs have been extra-busy since the break and the workload from my involvement with the school's journal has stepped up in a big way. The demands from my research project intensified a bit, though I've been lucky to have an exceptionally competent, laid-back supervisor.

I still have a ton on my plate - and because apparently I like to suffer, I seem to keep taking on more - but having a week to put it all together really does help.

I hope to sign up for the USMLEs, get my active ECs in order, set up some observerships (I've been neglecting these and I find them very worthwhile), and get my research project going a bit.

Oh, and sleep. That'd be nice.

Paying For Healthcare

Recently, a number of events have happened - both in the wider medical community and in my little bubble - that involve how we pay for healthcare. It's a difficult subject, one that elicits a wide variety of opinions and positions.

The Fundamental Dilemma

Much of the controversy on healthcare funding comes from a relatively simple conflict, derived from two widely-held positions.

1) We value health and life more than money when it comes to us or our loved ones.

2) We value money (in the form of lower taxes and insurance premiums) more than health and life when it comes to the vast majority of people we haven't met.

Basically we care about individual health more than collective health, but since the collective is made up of individuals, we get stuck between a rock and a hard place - constant pressure to reduce total costs along with constant pressure to increase individual costs. Since many decisions on spending get made on the patient- or individual-level where the pressure to increase spending is greater, it tends to win. Hence, ever-increasing healthcare costs.

Affordability

The catch comes that many individuals can afford to pay more for healthcare. When they have the option to do so for themselves (but not others) they often do so. In the US, you see this in luxury care for those able to afford it, and medical bankruptcy for those unable to afford it. In Canada, you see this in the push for a dual-tier system, where the wealthy would be able to pay extra money for more care than provided for by the public system. For those concerned with more equal access for individuals of all socioeconomic backgrounds, the push is more for increased taxes to pay for higher-quality heathcare for all.

Mo' Money, Not Mo' Health?

I work in healthcare. I would stand to benefit significantly if we suddenly spent more on healthcare, whether through a private, dual-tier system or through increased government expenditures. Yet, more money devoted to healthcare doesn't necessarily mean better health.

The Canada-US disparity in funding expresses this fairly easily. The US pays far more for their healthcare than Canada does, yet has overall health outcomes which are, at best, equivalent. Part of that is having great care for those who can afford it, yet very low-quality care for a group who cannot afford reasonable care. Fixing that disparity could push the US ahead of Canada in standard health metrics, but even so, not by all that much (and it might not even do that).

The thing is, that much money could have a real, meaningful impact on people's health - but not if it's spent in the healthcare system. The further into this field I get, the more I realize how poor many of our diagnostic tests and therapeutic interventions are. Some are incredibly effective, but many of a middling efficacy, while a few other may not work at all. There are some interventions that we know work really well though - these are improved diet, increased exercise, quitting smoking, reducing stress, longer/improved sleep, and moderating alcohol consumption. The healthcare system is slowly beginning to focus on these highly important lifestyle factors, but because they're part of a person's lifestyle, they're affected by much more than just healthcare services.

The difference in healthcare spending between Canada and the US is about 6% of GDP. If Canada decided it could afford to spend an extra 6% of its GDP on improving health - roughly $100 billion each year - I'd much rather see it go to efforts to improve those metrics that we know work. Getting people to eat better or exercise more has always been a difficult challenge, but with $100 billion each year, I bet we could come up with a few things that'd have an impact.

This brings me to my main point - there's a reason to control costs in healthcare, because healthcare isn't the same as health and it's certainly not the same as life. We want good healthcare and I want to be part of providing it. But I want good healthcare because I want people (including myself!) to be happy and prosperous. If the costs of healthcare hinder those efforts by minimizing spending on other worthy pursuits more than they help directly by improving health, it's not really beneficial. There are diminishing returns when pumping more money into healthcare, especially when that additional money doesn't have a clearly established, useful purpose.

Bottom line - controlling health care costs, whether public costs paid through taxes or private costs paid through insurance premiums and out of pocket, is an important goal, even for those who want the healthiest people possible.

Match Day (well, not for me)

So, today was the CaRMS match day. Hundreds of graduating medical students just found out where they will spend the next 2-6+ years of their lives and what they'll be doing for the rest of their careers.

It's a day of very mixed emotions. For many, it's the best day of their lives. They get validation for 3-4+ years of hard work and learning. More importantly, they get a chance to help patients in the way they want to help patients, to have the career they wanted. Getting into medical school was a huge moment for me, but I'm not considering my career on track until I know my residency placement. I think a lot of students feel similarly, which is why getting a good result on Match Day is such a huge deal. It's a life-defining moment.

And yet, there are some who got less-than-stellar news today. There's always a percentage of people don't match each year in the first iteration. To them, it's a crushing moment, full of anxiety, fear, and uncertainty. Many will go through this whole process again with the unfilled spots left in the second iteration. By definition, these spots will be ones that had already rejected the unmatched applicants, or ones which those applicants chose not to apply to. That's a very tough pill to swallow - anything left that an applicant wants has basically already said "no", so they have to pursue programs they didn't want in the first place.

In the middle are people who matched, but went so far down their list of preferred programs that there's a major element of doubt. They'll be heading to a location or specialty they didn't fully expect to get, and have to make a major readjustment in mentality and life planning. That's a big curveball just when a career is starting to take off - and there's no backing out. CaRMS is a contract, so once you're matched, that's where you're going.

It's hard to know what to feel on days like today. Elation for some, cautious optimism for others, consolation for a few more.

Of course, being someone who will go through this all in a few short years, it's hard not to be a little scared of what's coming. Today's not about me - not even close - but it's tempting to put myself in the shoes of the current graduating class. To feel the unbridled excitement of matching to a first-choice program. To steel myself for the possibility that maybe I'll have to settle for a backup I never thought I'd end up with. To experience the dread of going unmatched and what I might do today to avoid that fate.

As I said - a day of mixed emotions.

Post-Conference Thoughts

Just returned from the conference, had a few thoughts.

1) Heated seats are possibly the best things in the world when you're driving for extended periods of time in the winter.

2) The conference was in Quebec and while it's been a while since I used it, I though my French was at least passable. It's not. Not even close.

3) A good portion of the conference was dedicated to a handful of topics and I found myself reminded of this comic:

(SMBC)

I don't mean to disparage the work of the conference attendees, most of whom had far more complex work to present than I did and generally presented it better as well, but there did seem to be a lot of energy devoted to one or two topics in medicine with little attention paid to other meaningful research pursuits.

Part of this is the nature of the conference of course, no conference is universal in scope even when restricted to certain disciplines, but it's true for research in general as well. Some topics seem to get an inordinate amount of attention and funding, even for relatively trivial aspects of that subject, while other fields are almost devoid of attention.

This would be reasonable if those areas of research with intense activity answered the key questions reliably, but that doesn't necessarily happen. There are a lot of low-quality studies out there, ones that address the question, but come with so many asterisks that the conclusions are not necessarily reliable. Such studies can be useful when first addressing a problem - they can provide descriptive information, generate hypotheses, and identify research areas clearly not worth pursuing. Yet, once a field has been established, these studies can only pick at the margins, rather than provide any real clarity.

For all the time, energy, and resources put into the research presented at the conference, one good RCT or high-quality cohort study would likely have been more meaningful. That would require concentrating resources, however, while the current model for research funding tends to spread out resources between groups. That means a lot of researchers producing necessarily flawed studies because none of them can afford to do a high-quality one.

In a lot of activities, I've found you get credit either for doing something exceptionally well, or doing something exceptionally unique. Research appears to be much the same. I do hope to get to do that high-quality, question-answering research in the future, when I have a bit more clout than I do as a pre-clerkship MD candidate. For now, doing relatively unique research has been quite interesting and, I hope, useful.

P.S. Oh yeah, this. An exaggeration? Yes. A huge exaggeration? Nope...

(Ari Friedman via The Incidental Economist)