Sunday, July 31, 2022

Medical School Admission Criteria: a discussion

 It is very difficult to get admitted to a medical school.   At UBC, only about 10% of applicants are accepted.   

This leads to extreme competition.  Students admitted to the program  have average university grades just under 90%, and average standardized test scores (from the MCAT) just under the 90th percentile.  

Even if you have average university grades above 90%, it is no guarantee of admission.  Only 26% of applicants with such high grades are accepted.  

Therefore, there are other factors which increase the likelihood of admission, aside from grades and standardized test performance.  These are so-called "extracurriculars" such as history of volunteering and "leadership activities," reference letters, and performance in a "multiple mini-interview," which involves responding in a desired fashion, within a time limit, to various hypothetical scenarios with a sequence of 10 different interviewers.  

I understand the need to have multiple criteria to judge applicants.  But I would like to make the case here that the current selection process is not particularly efficient or fair, it has a very strong bias against people with particular personality types, despite those people being very well-suited to be excellent physicians, and also leads to years of unhealthy, expensive, and wasteful frenzied competition before starting medical school.  There is also a bias in favour of people from wealthier families, since such people would more easily be able to afford years of volunteering, cultural exploration, club leadership, MCAT prep courses, tutoring, etc. instead of having to work long hours for years near minimum wage to support educational expenses.  

Imagine who the best future surgeons would be.  They would likely have excellent hand-eye coordination, tactile skills, mastery of fine details such as of anatomy, immense patience with meticulous tasks, and ability to remain calm and focused for long periods of time.  Some of them might be not be "neurotypical."   Many of the most talented such people would not necessarily have great social skills, would not be inclined to volunteer at Big Brothers or at nursing homes, would not be on the executive of university clubs, would not have a history of musical or drama performances, would not seem impressive in rapid interviews, and also may not have high grades in biochemistry or English.  I don't believe that any of the relevant surgical talents described above are assessed at all in the medical school admissions process.  

The current medical school admissions process therefore excludes many of the best future surgeons.  For many other future surgeons who are fairly accepted, they would have spent perhaps years of extra time padding their CVs with life activities that they were not really interested in, just to keep up with the pre-med competition game.  This is a waste not only for these individuals, but for society as a whole (we have budding surgeons who have several fewer years of professional life due to them having spent these years doing CV padding activities).  

Another result of the pre-med competition process is that candidates will be well-motivated to pad their academic transcript with easier courses, so-called "grade boosters," while avoiding difficult or challenging courses which tend to have a low class average.   The challenging courses would lead to improved scholarship and wisdom, but people have to avoid them because they could drag their grades down.  Most medical colleges do not take into account the difficulty of the courses that people take.  In any case, one of the advantages of a standardized exam such as the MCAT is that everyone in the world takes the exact same exam, so there is no selective avoidance of difficult material.  

The competition to show extracurricular volunteering and "leadership activities" also creates a bias against introverts.  Many of us are quiet, shy, with relatively solitary habits.  Such gentle, quiet people often would make excellent physicians: people who are calm, good listeners, patient, kind, intelligent, sensitive, and skilled.  But for a person with this personality style, group involvement, group leadership, and many types of volunteering, are just simply unpleasant or impossible.   I am an example of such a quiet, shy, relatively solitary person.  

We should have a selections process that chooses people who are likely to be competent, skilled, and stable.  We should have a process that makes it hard for a psychopathic person to get admitted.  The existing process does select for competence, stability and skill indirectly through grades, even though most of the actual grades have little to do with skills that would be of clinical use during a medical career.   A psychopathic person is less likely to have consistently high grades and a good volunteer record.  But many psychopaths could present themselves very well in cross-sectional interviews, while many non-psychopaths who are simply shy or reserved would bomb the interviews.  

What would be reasonable to change the process?  I don't think there's an easy answer.  I think that grades and MCAT should continue to have a prominent impact on admissions, despite some of the biases involved. Maybe this is unavoidable.   People should be rewarded, rather than penalized, for taking difficult courses that may have lower average grades.  It would seem very reasonable and practical to be rewarded in the admissions hierarchy if you have proven experience or skill in health care work or in relevant skills; for example, people who have worked in nursing or other allied health fields, as a paramedic, in an anatomy lab, as a technician, doing other work requiring long hours of meticulous focus, veterinary work, or psychotherapeutic work.  I think that much less weight should go to performance in a cross-sectional interview process, since this is extremely prone to biases which are not relevant to future medical performance (this reminds me of Kahneman's descriptions of biased and meaningless selection interviews from "Thinking Fast and Slow").  I think that showing "leadership skills" should have minimal impact on admissions, and people should not be penalized in the process for not showing "leadership skills."   Furthermore, those who are most ambitious to show such "leadership" are often the worst leaders.