Are Medical Schools Finding the Best Future Physicians? |
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The current medical school selection process is potentially corrosive to the wellness of future physicians.
The selection paradigm may negatively impact personal diversity in our physicians.
Most students feel they must delay application to med school for one to four years to maximize their chances.
Heavily prescribed pre-medical requirements potentially limit students' adult psychosocial development.
Anyone seeking admission to medical school must put untold hours into assorted extracurricular activities such as research, experiential healthcare jobs and volunteerism, and "community service"—making sure they demonstrate “leadership accomplishment” in several or all of said activities. The medical schools give no clear indication of how much time should be invested in the activities other than providing fifteen spaces in the universal application to describe them in all their glory. The students fret incessantly about the worthiness of the activities they select and their time invested within them. In addition, of course, they must put huge amounts of time and effort into their studies, and more still into preparing for the MCATS.
When I say untold hours, I mean untold hours. The competition is so stiff that a bidding war has resulted where students feel compelled to log in one, two, four, perhaps six thousand hours in key arenas. Most students, now, are finding that they have to take one to four "gap" years beyond college to reach what they perceive to be adequate representations of their commitment to the said arenas.
The schools assert that this distills the field down to the “best of the best.” But one has to question the logic, the science, and the outcomes of such a rigorous and time-dependent war of attrition.
What Are We Selecting For?
What kind of doctor do we believe we are selecting for? After all, admission to medical school is really admission into “the guild,” into the profession of medicine. What should matter most then is the type of doctor that eventually comes out of the medical education shoot, right? Are we certain that this grueling, soul-sucking, process selects for those with the personal and intellectual qualities that make the best physicians?
One can certainly argue that it selects those with a lot of grit, determination, and perseverance. But doesn’t grit indicate a personality that drives on despite injury? Do we really want our doctors to persevere through physical and mental damage, to “play hurt.” I would argue this type of personality is ripe for burnout and its attendant psychosocial complications (depression, marital discord, disruptive behavior, self-denial—over-indulgence cycles, etc.).
Is it even possible that we are selecting for those harboring certain less-than-desirable personality and behavioral traits: unidimensionality, entitlement, social aversion, obsessive compulsiveness, narcissism, and so forth? And is it possible we are taking those with decent emotional intelligence and stunting their development at the precise period in their lives where related skills are crystalizing (through the social interfaces and interactions of young adulthood)? Is there any evidence that relentlessly heaving on the oars of the pre-med slave ships instills altruism and social conscience? Might better doctors come out of fraternity and sorority gatherings, dances, and tailgate parties than biomedical wet labs? Let’s remember that the grand majority of medicine revolves around doctors interacting with patients. Speaking with them. Listening to them. Reading them. I fear we in the admissions world sometimes forget that medicine is an intensely interpersonal profession and very much a service industry. Ask any patient what qualities they value in a physician and their answer will almost always focus on the doc’s “people skills.”
What about professional competence, though? Surely we want the intellectual superstars. But is that who we get? One might argue that the smartest students recognize the absurdity of the process and punch out early, if they enter into it at all. And the process seems to favor the rote memorizers. And boy do we get them: physicians able to quote the results of every biomedical study published in the last ten years but unable to step out of an algorithm and adjust to a rapidly changing clinical setting. In other words, many seem to lack clinical “street smarts” (adaptive intelligence). Indeed, beyond scoring better than others on standardized exams, I’m unaware of any evidence that the current paradigm results in higher quality physician performance. And I have seen many a brilliant, kind, caring, critically thinking, emotionally intelligent future doctor struck down by organic chemistry, physics, or the MCATS.
Burning Out Our Future Physicians
What are the downstream ramifications of this gruesome grudge match? Many medical students tell me that they are so depleted by the process, that they see themselves practicing for maybe fifteen years, making bundles of money, and then “getting the hell out.” This is burnout. Severe burnout, before day one of actual practice. Beyond this, I have to question whether the process breeds narcissism/selfishness (I deserve the most spoils because I suffered so much for so long to get here), judgmentalism (who else has put this amount of effort into their lives), “misery Olympics” (veneration of those sacrificing the most for the profession), trivialization (what I have had to face eclipses the stressors of all others), hyper-competitiveness, loneliness, disillusion, and more. The degree of mercenary self-serving, self-enriching behavior I have witnessed in many docs out there argues that something about the process could definitely be improved.
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I assign my undergrads to come up with a system, different from our current one, that would select for the best physicians. They find that this is no easy task. Personally, I would love to see medical schools set a reasonably-attainable bar for grades and MCAT scores, and prescribe limited hours of well-defined extracurricular activities, and then to say to the applicants: “with the rest of your time, go be typical college students (at least semi-typical). Find what you are interested in. Explore. Take some risks. Meet all kinds of people and learn to get along with them. Take jobs as construction workers, and farm hands, and box store greeters. Got to parties. Date. Read some books, watch some movies, dive into pop culture. Get in great shape. Learn who you are.” At selection time, all who have cleared the requirements are put into a lottery rather than a cage match. Or, limit the number of schools each student can apply to but guarantee them all in-depth interviews at each selected school. I would bet that we would select no worse, and probably better, more diverse, future physicians.
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