Today’s Medical School Admissions Committees Won’t Pick Tomorrow’s Best Doctors.
It’s time for medical school candidates to start applying: Are the people who will choose our next doctors the right ones?
Janie knows applying to medical school is a long and complicated process. She will submit her primary applications for admission to medical school next month. If she’s lucky and is admitted somewhere, she won’t matriculate until fall of 2019.
Hopefully, Janie will receive secondary applications shortly after her primary materials are submitted next month. She will celebrate getting “secondaries” because receiving them means schools are interested in her. She’ll write many short essays in response to the schools’ questions. Her answers will be crafted (or so we hope) to grab admissions committees’ attention. With luck, she’ll be invited to interviews sometime between August 2018 and late March, 2019.
Admissions offices see scores, grades, recommendations, resumes, and personal statements in primary applications, with more essays written in the school-specific secondaries. Hopefully, they use all of this information.
Unfortunately, the hundreds of students with whom I’ve worked have learned that scores and grades are filters that all too often screen out people who had to overcome the real-world problems millions of patients struggle with daily.
Buy food? Or meds. Make time to earn needed income? Or take mom to the doctor.
These choices literally shape students’ futures and/or the lives and deaths of people they love.
What do scores, grades, recommendations, and carefully crafted essays say about whether Janie is able to deal with difficult patients, or crises, or death? My diverse experience suggests that until recently, they didn’t say much… and say little more even now.
The American Medical College Application Service (AMCAS) has realized that Janie’s understanding of real world factors that affect disease is as important as her knowledge of biology, chemistry or physics. However, the “new” MCAT, which adds fields like demographics, ethics, and sociology to the sciences, only evaluates her book knowledge… and often only the information test prep companies tell her will raise her score.
Janie is understandably focused on keeping her grades and scores high. She also does things (like research), that good candidates “need” to do. As a result, she has little time to get real world exposure to how patients experience disease and disability while living, loving, working and yes, dying. Experience she needs to be effective in an era when patients spend almost all of our time and energy on managing our health outside of the clinical setting; or so the data on in -and-out patient care, the physician workforce, and chronic disease indicate.
Recently, the Federal Government has moved far ahead of medical school admissions committees in recognizing the need for ongoing engagement with patients’ needs outside of the clinic. Much of this new policy is based on a rapidly growing supply of data in the literature and elsewhere.
As of this coming January, Medicare Advantage providers will be allowed to pay for services like assistance with getting to and from the grocery store and other low-skilled services meant to prevent health emergencies while generally improving patient longevity and outcomes. Aetna’s CEO has also recognized that insurance will need to facilitate preventative and social care more than it has in the past, and yet, medical schools (and in fact many health professions programs) seem, in my experience, to be far less focused on ensuring all of their candidates have spent enough time exposing themselves to these essential patient interactions and services.
Most recommendations for students like Janie focus on their performance in the lab or classroom. These letters usually don’t say whether candidates can empathize with the lives of patients who are statistically sicker, older, poorer, less well educated, and more ethnically diverse than they are.
As a Ph.D. trained geneticist, I can say students usually don’t work with patients in the lab. Work as a CNA or EMT for example, does provide this experience. Because it often pays better than undergraduate lab research, home health or emergency services work can let students start health professions training with less college debt than they carry now while getting far broader real-world experience of healthcare than they get doing lab research (invaluable though it can be), or volunteering in the hospital (where they may well not work with patients in that highly artificial environment).
Unfortunately, most candidates have relatively little experience of caring for patients relative to the time they’ve spent doing research.
Students often don’t get this experience because their advisors and friends who applied in previous years tell them that admissions committees strongly prefer research to other work. This is particularly true for candidates from Ivy-type schools. State university students are, in my experience, likelier to work with patients because they have fewer opportunities to do research.
Most students have to spend large amounts of time on lab courses in order to complete the majors many still feel are best suited to application for medical school. This very significant time commitment is one of many barriers to students getting real experience of how patients live, work, and manage their health in the real world. The four-to-six year-long biology, (sometimes followed by molecular biology) chemistry (add one-year organic and biochemistry courses here) and physics courses most need to complete to be considered potential candidates for admission to medical school generally have accompanying lab courses. Courses that may require up to ten hours each per week in order to complete assignments. Are these courses necessary to understand the principles taught in lecture or the basic science students will need to know when starting medical school? Generally, yes, but they do take time away from students’ ability to gain experience outside of the highly protected campus setting.
Even though their training doesn’t teach the empathy young people often lack, I’ve had to tell the hundreds of candidates for medical school admission whom I’ve mentored that a great “story” includes outstanding scores, grades, recommendations, extra-curriculars, and research. Doing well in most of these areas requires lots of study but only limited interpersonal skills. Almost every pre-medical student I have mentored complains that earning outstanding scores, grades, and recommendations rewards competitive behaviors, not compassionate ones.
Many full-time pre-health advisors and most pre-medical students believe admission to “dream” medical schools like Harvard, Stanford, or Washington University requires lots of time doing laboratory research. This is supported by data from the American Association of Medical Colleges showing that “good” research is particularly attractive to these schools that ideally train academic physicians; but even here most of their graduates will primarily work with patients.
Doing “good” research requires competition to get noticed by the “right” lab director. Once in a lab, undergraduates earning their bachelor’s degrees often get credit for time spent in basic science labs doing every kind of animal, bacteria and plant focused research imaginable for ten to fifteen hours a week during the year. They may work forty or more hours a week in summer if the lead researcher or college has money to support them. Their co-workers in the lab are socioeconomically similar to them (i.e., they are generally far younger, better educated, healthier, wealthier, and statistically less ethnically diverse than most patients are.) Lab work, therefore, doesn’t offer much interaction with patients whose life experiences are very different than those of our future doctors.
Unfortunately for millions of patients who depend on our healthcare system, most students who earn degrees from primary care focused schools like the Medical College of Georgia also shoot for “dream” schools like Emory. Emory therefore shapes the applicant pool of MCG, whose faculty recognizes that training students to manage the chronically ill and the caregivers who give 40 billion hours a year helping patients, is likely to decrease costs and suffering more than Emory’s arcane research will.
My mentees (many of whom later sat on admissions committees) also report that many medical school admissions committee members haven’t practiced in years — if they have done so at all. In many cases, committee members are scientists or other academics who don’t have any healthcare training or experience. As a patient myself, I can’t see how someone who doesn’t regularly work with patients, do procedures, diagnose colds, or live with a chronic disease or disability is qualified to decide who America’s future physicians should be. I also don’t see how physicians who spend half of their time on patients can fully connect with students wanting to focus on people, not Petri dishes. This is of particular concern since academic physicians make up about 15 percent of our physician workforce and yet make the majority of decisions about who our future physicians should be.
It is therefore likely that today’s admissions committees themselves are a barrier to selecting physicians with the empathy we now know is essential in selling patients and their caregivers on behaviors that are emotionally challenging, often time consuming, and frequently physically or psychologically unpleasant.
We can change this by giving patients an overt, full, and equal voice in the admissions process. Helping vet candidates would let thousands of volunteer patient interviewers feel their life experience and personal awareness of the strengths and weaknesses of today’s healthcare system have value.
If students knew patients would decide their futures, they would seek experiences to help them bond with patient interviewers, much as they now do research to connect with today’s admissions committee members.
Patient interviewers would ask themselves: “Would I be comfortable with this person as my physician in ten years?” Their answers to this question would have value because they account for the real-world experience of illness and impairment that shape patients’ health more than grades, scores, and committee members’ connections to academic recommenders.
In my view, medical school candidates should also be required to have a thousand hours of direct patient contact before applying and one patient recommendation: most have neither of these today.
Finally, nurses, therapists and other healthcare team members who do not hold MDs should also sit — and vote — on medical school admissions committees. This would help ensure accepted candidates have attitudes and experience these invaluable individuals feel will support teamwork rather than uncaring behaviors. Indifference that may exacerbate medical errors that causes 400,000 deaths and unnecessary suffering for millions every year.
In my view, long-standing patients should hold twenty-five percent of the votes, non-physician health professionals another twenty-five percent, and MDs the remaining half of the votes for students on the MD track, with each student interviewed by at least one non-physician.
Changing who chooses are future physicians can help open opportunities to people more socioeconomically and experientially like tomorrow’s patients than many of today’s medical students are. This will improve communication, patient welfare, outcomes and professional longevity for people selected for their emotional intelligence and capacity to deal with diverse patients and difficult workmates rather than their ability to experiment on fruit flies.
Author’s note: An earlier version of this blog was posted to the Huffington Post in 2016.