This first part will focus on the more overarching principles I believe would be helpful to guide the admissions process, while the second part will present an algorithmic framework for admissions, that incorporates those overarching principles.
My Principles of Medical School Admissions
1) Admissions to medical school is arguably the single most important part of training physicians
2) There are numerous attributes we want in physicians - intellect, work ethic, communication skills, empathy - and it's more important that applicants be good in all attributes than great in some and deficient in others
3) Applicants should be willing to challenge themselves, even if it means making some mistakes or experiencing a degree of failure - as long as those mistakes or failures are not too great and were learned from
Principle #1 - Admissions Are Important
We need to have a rigorous approach to medical school admissions. In this post and in Part II, I will make some suggestions, suggestions I hope are based on a logical analysis of the current state of medical school admissions and, to the extent possible, have some grounding in available research. However, each one of these suggestions should be scrutinized and evaluated.
Additionally, we need to devote a significant amount of resources to the selection process, even if it somewhat reduces spending on actual medical education. Current admissions processes are often designed to minimize the work done by schools, typically by using somewhat arbitrary hard cutoffs to eliminate large swaths of applicants. To an extent, this is necessary, but it's become overused - weak applicants get cut out, but so too do a lot of strong applicants, applicants who may actually be better suited to being physicians than those admitted.
Spending large amounts on admissions seems like a waste - after all, wouldn't it be more productive to better educate those admitted? Yet admissions may be the most productive aspect of the whole process. A study on Ivy League schools in the US showed that these highly competitive schools did produce very good graduates - but so did second-tier schools when the students were able to get into an Ivy League school and simply didn't attend it. The Ivy League's greatest feat is selecting students who were good coming in, not necessarily in making those good students better. I see no reason the same situation isn't occurring in Canadian medical schools - where graduating medical students do well not because they received an amazing education, but because they had the capability to do well from the start and their medical schools merely succeeded in not screwing them up. Conversely, students who struggle as physicians may have been likely to do so from the beginning.
An even better admissions process could therefore lead to stronger graduating physicians. Since admissions is the major chokepoint between becoming a physician and not becoming a physician, it may be the only real point where our medical education system can meaningfully change the type of physicians in our workforce. It's worth spending some money on.
Principle #2 - Get Well-Rounded Candidates
The current admissions process is great at getting intelligent students. I've yet to meet a single person who is clearly not intelligent enough to be a physician - and more than a few who I wonder whether they're not too intelligent to be a physician.
Principle #1 - Admissions Are Important
We need to have a rigorous approach to medical school admissions. In this post and in Part II, I will make some suggestions, suggestions I hope are based on a logical analysis of the current state of medical school admissions and, to the extent possible, have some grounding in available research. However, each one of these suggestions should be scrutinized and evaluated.
Additionally, we need to devote a significant amount of resources to the selection process, even if it somewhat reduces spending on actual medical education. Current admissions processes are often designed to minimize the work done by schools, typically by using somewhat arbitrary hard cutoffs to eliminate large swaths of applicants. To an extent, this is necessary, but it's become overused - weak applicants get cut out, but so too do a lot of strong applicants, applicants who may actually be better suited to being physicians than those admitted.
Spending large amounts on admissions seems like a waste - after all, wouldn't it be more productive to better educate those admitted? Yet admissions may be the most productive aspect of the whole process. A study on Ivy League schools in the US showed that these highly competitive schools did produce very good graduates - but so did second-tier schools when the students were able to get into an Ivy League school and simply didn't attend it. The Ivy League's greatest feat is selecting students who were good coming in, not necessarily in making those good students better. I see no reason the same situation isn't occurring in Canadian medical schools - where graduating medical students do well not because they received an amazing education, but because they had the capability to do well from the start and their medical schools merely succeeded in not screwing them up. Conversely, students who struggle as physicians may have been likely to do so from the beginning.
An even better admissions process could therefore lead to stronger graduating physicians. Since admissions is the major chokepoint between becoming a physician and not becoming a physician, it may be the only real point where our medical education system can meaningfully change the type of physicians in our workforce. It's worth spending some money on.
Principle #2 - Get Well-Rounded Candidates
The current admissions process is great at getting intelligent students. I've yet to meet a single person who is clearly not intelligent enough to be a physician - and more than a few who I wonder whether they're not too intelligent to be a physician.
Most students I've met have a good work ethic, though there are certainly exceptions. There are more than a few stories floating out there of clerks, residents, or physicians who clearly don't put the effort into their work or learning. These are the exception, not the rule, and it's entirely possible for work ethics to change as students or physicians become overworked, jaded, or depressed, but some individuals with a poor work ethic could be identified from the start.
Communication skills are a point of major concern, something emphasized by current research and patient surveys. Physicians as a whole are not great at communicated with patients, with other healthcare professionals, or even with other physicians. That's troubling in a field that is so dependent on good communication - medical errors can and do occur when miscommunications occur. We could certainly use some stronger communicators in medicine. (As an aside, it's also a reason I want to keep going with this blog, to maintain and improve my communication skills!)
Empathy is the tricky element. It's something every patient wants in their physician. It's almost impossible to evaluate effectively or efficiently. It's certainly important during patient interactions in developing a rapport and establishing patient preferences. Yet, there's some research that indicates fake empathy produces much the same as genuine empathy. In that sense, an effort to be empathetic may be the important metric here - and to hope that a person's intelligence, work ethic, and communication skills can compensate where empathy might fail (as it does for everyone at some point).
Moving the focus off of simply getting smart medical students requires relaxing what most admissions committees consider "smart enough". This means relying less on hard cutoffs for academic attributes and taking a harder look at more candidates. As long as the cutoffs aren't lowered too much, we'll still get intelligent medical students - the reliably-intelligent students I've met so far have included people with rather low GPAs or MCAT scores, thanks to the different ways individual medical school evaluate applicants. It also means not letting academic strengths make up for weaknesses in other areas, at least not to the degree that they currently do at some medical schools.
Of course, we still want to get medical students who are as strong as possible with all these attributes, including intelligence. All other things being equal, I'd rather have someone with a 3.99 GPA and a 99th percentile MCAT than someone with a 3.70 GPA and a 30 MCAT. But if the second applicant always goes the extra mile and can communicate with patients exceptionally well while the first lounges around and can't connect with a patient to save their life, I'd rather have the second person. Finding that balance is tough, but doable.
Principle #3 - Mistakes are Acceptable, Challenges are Desirable
The main point I'd like to make here is that using GPA to evaluate candidates rather than a more fluid metric like a percentage average may not be the best idea.
GPA does have some advantages. Because a GPA system is very hard on low marks, it encourages consistency, which is a desirable trait in medical students. It also prevents significant difficulties in some courses from being masked by extreme strength in other courses. Under a percentage system, a 60% plus an 100% is equal to get two 80% marks, while in a GPA system those marks are equivalent to getting two low 70's. Since 60% is almost a fail, that probably indicates some degree of poor understanding or effort in that course and it's worth discouraging low performance.
However, the current standards take these principles too far. It's one thing to discourage a 60, but the current standards at many medical schools discourage even the odd 70. You basically need over 80% in everything to be competitive at many medical schools - some schools basically want almost every mark to be above 85%. Furthermore, hard shifts between what's considered good and what's not mean minor differences in candidates get exaggerated - a 79 is worth so much less than an 80 in a GPA format it's terrifying, even though these marks are essentially identical.
GPA systems encourages two undesirable phenomenon. First, grade inflation, which could be it's own full post. Second, it encourages prospective medical students to go for the easiest programs and courses. If there's a significant possibility of getting a 75 in a course, it's not worth taking, even though in some courses, a 75 demonstrates a very high level of intellect and work ethic.
Schools have recognized this and have often put in place weighting schemes which allow for particularly bad courses or years to be dropped from consideration. These weighting schemes reduce some of downsides of using a GPA, but they're a kludge - they accomplish that goal in a relatively ineffective, inefficient manner. You still need exceptionally high marks within that weighting scheme just to get considered at these medical schools and these weighting schemes suffer from much the same problem a percentage system - namely that low marks can be compensated with high marks. Overall, I'd rather see these weighting systems used than the alternative, but their necessity speaks to the inherent weakness of using GPAs.
A percentage system is more fluid and less punitive for difficult programs. It can also be weighted in ways to try to regain some of the advantages of using GPAs. Very low marks can be punished by re-scaling marks below 70%. For example, keep a 70 worth 70%, but make a 50 worth 0% and scale everything in between linearly (so a 60 would be worth only 35%). Very high marks can be discounted to prevent them from having an undue influence - make everything over a 90 worth only 90%, effectively the same as what is done in a GPA system.
Overall, the point I'd like to make is that medical schools should be as critical of their application process as they are on their applicants. It's one thing to set high standards, but if those standards eliminate good applicants in favour of other who may not be as well suited to being a physician, it's a disservice to the applicants, to the school, and to the patients who will be relying on the selected medical students in the future.
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