Imagination is more important than knowledge. Albert Einstein
Human salvation lies in the hands of the creatively maladjusted. Martin Luther King, Jr.
The reasonable man adapts himself to the conditions that surround him... The unreasonable man adapts surrounding conditions to himself... All progress depends on the unreasonable man. George Bernard Shaw
It will take more than knowledge and students fitting current high expectations to improve the health of all Americans in the next century. No area impacts health care, access to care, and health care quality as much as medical school admissions committees. Various studies have noted problems in the selection of medical students. Admissions committee work involves much time and effort with lots of blame and very little credit given. Few, if any, faculty work full time in the area despite the importance of selecting good candidates.
Schools vary greatly in the training done to prepare admissions members for their work. Admissions committees attempt to balance the various characteristics of candidates, but clearly favor qualities with perhaps easier measurements, such as the intellectual. It is also a challenge to get representation from clinicians, private practitioners, those involved in primary care, and those from rural or minority backgrounds due to distance and scarcity. A variety of perspectives and experience is helpful.
Therefore, the authors caution that the use of only a few personality traits to predict personal suitability on all medical school performance measures is not realistic. The authors suggested that cross-validation studies are warranted due to the relative small sample size of their study. http://www.aamc.org/students/mcat/research/bibliography/shen001.htm
Why Do We Continue to Choose Students Who Are Less Likely To Be Needed, especially for underserved areas?
"There are two tragedies in life: one is not to get your heart's desire. The other is to get it." George Bernard Shaw
Short term measures are grossly inefficient and distracting. Institutions have to face alumni, accreditation, and faculty. More intellectual candidates make it easier to pass first semester grades http://www.aamc.org/students/mcat/research/bibliography/webbc001.htm , but long term outcomes such as performance on Boards or in Clinical Experiences are not as easily predicted with MCAT and GPA http://www.aamc.org/students/mcat/research/bibliography/hojat001.htm
3. Perhaps it is fear of lawsuits
Admissions committees face well publicized lawsuits. They also have had challenges regarding the competency of those admitted who in someone's future view, should never have become a doctor (shredded and concealed records and reduced access to admissions research a problem). The most recent assaults have been lawsuits against affirmative action Character, Color, Admissions, and Physicians Now powerful people or alumni or those with greater resources can recruit legal help to their previous political and social pressures.
In a perfect world, all of us would like to choose the brightest medical students. Most of us in medical education are, or consider ourselves among the best and brightest. While there is no question that the brightest are the easiest to teach, look the best in board scores, and are less likely to raise the ire of accreditation committees, they are also often the wrong students for certain situations. They may also not be the best for performance.
CONCLUSION: The "noncognitive," or psychosocial, measures increased the magnitude of the relationships between the predictive and criterion measures of the students' academic performances, beyond the magnitude attained when only the conventional admission measures were used. Therefore, psychosocial measures should be considered as significant and unique predictors of performance in medical school. http://www.aamc.org/students/mcat/research/bibliography/hojat001.htm
Most members are familiar with the usual scores and many are familiar with recent history regarding students who did not make it. As in most of medicine, there is a benefit to risk ratio. If students have a lower GPA or MCAT, they are at more risk of academic failure. Committees are willing to risk 10% or sometimes 20% probabilities of failure, but are they willing to risk more to get students with different characteristics?
Are Likely to Leave the State. The best and brightest are likely to want the Harvards, and Mayos. They might not want to stay in Nebraska or any state of origin.
May not fit the state and nation’s needs for care of the elderly and mentally ill. The sharp ones who leap to conclusions are often ill suited for careers in geriatrics, mental health, or primary care. We will need many more skilled in geriatrics with estimates of 70 million such Americans in only a few years. Where will they come from? Thank God for folks like Tim Malloy who trains our UNMC residents and has taken geriatrics from one of our worst scores to one of our best. Grateful rural communities should also than him since 60% of our family medicine residency graduates choose rural Nebraska towns.
May be more likely to face malpractice claims. Family physicians in Florida who had the highest board scores were also the most likely to face malpractice charges. Intellect and Malpractice
Are Not Likely to Choose Rural Practice and much needed primary care. The higher the MCAT, the less likely rural practice (Dona Harris study in Utah). Osteopathic students have much lower MCAT scores and choose primary care and rural practice in far greater percentages.
This does not mean that rural physicians are not as smart. NO, it just means that physicians for primary care and service to the underserved need to have a broader range of qualities to fit their career needs and that of the populations they will serve. Their expertise needs to be broad. Their people skills need to superb. It is possible that they need as much or more emotional IQ to go with a good level of Intellectural IQ. Underserved practice takes a person with a good tolerance of uncertainty and devotion to service and qualities of versatility beyond the ability of most physicians.
Studies of medical schools that reduced class size noted that the family practice match diminished in subsequent years. Could it be that we look intellectual first, and other qualities last, especially in 2003 as compared to over 16 years ago? Declines basically cut into this pool. Selecting for this pool would have significant improvements in qualities we deem important for future physicians of all types, beyond primary care (Fahey, Saches, Bauer Declining Class Site and the Decline in Graduates Choosing Family Medicine Academic Medicine 67 10 oct 1992 p 680-684).
While some may worry about years with fewer applications, others may rejoice at the more motivated students that apply.
It is possible for the brightest (but not necessarily the ones most motivated toward medicine) to crowd out the best. In lean application years, the ones with greater motivation toward medicine will apply. In years were economic or career conditions do not look as good for other professions, medicine looks better.
RESULTS: The results indicated that acceptance rates for both
underrepresented minorities and other applicants increased as numbers of
applications from both groups declined, then decreased as application numbers
again increased. Underrepresented minorities were accepted at substantially
higher rates when compared with other applicants within the same ranges of
grades and MCAT scores.
CONCLUSIONS: The author concluded that these results indicated medical schools
were generally acting affirmatively in selecting applicants from
underrepresented minority groups. In addition, the author reported that concerns
of underrepresented minorities being accepted at lower rates than other
applicants were unfounded. Jolly, P. Academic Achievement and Acceptance Rates
of Underrepresented-Minority Applicants to Medical School. Academic Medicine,
67;765-769, 1992.
http://www.aamc.org/students/mcat/research/bibliography/jolly001.htm
Also worth a review of this regarding academic vs non-academic even though only this involved only 2 schools and only first semester performance http://www.aamc.org/students/mcat/research/bibliography/webbc001.htm
Schools working with colleges and high schools can level these situations by encouraging more of those with true interest in medicine and serving to do better, prepare, and apply.
See Admissions Package Studies (Madison at UNC Chapel Hill) show that students with service motivation can be selected. Using only the information available to admissions members, the authors were able to select those that later did choose primary care careers. Many feel that the recent (and temporary) improvements in the primary care match rates were economically driven. A return to specialism confirms this view. Admissions did not make any changes. Students were merely responding to the market and will likely specialize at a later date. Choosing students better for service motivation could have impact that lasts. It is tougher to examine a broad range in individual students, but possible and helpful.
Data from the AAMC (1995 GQ questionnaire) also shows that those with rural interest were twice as likely to do volunteer work in nearby locations or overseas. Again there is a connection between primary care, rural interest, and service motivation. AAMC Data on Rural-Interested Seniors from 1995 GQ Survey
This brings a very important question
What Is the Risk If We Train Too Many To Serve the Underserved? The answer is very little risk and some major gains.
Studies by Rabinowitz (Physician Shortage Area Program Links and Info) have shown that only 1 % of a selected group of all Pennsylvania medical students has grown over 30 years to become 21% of the rural family physicians of the state. These are doctors that choose rural practice and stay in rural practice. He chooses some 15 students a year on the basis of rural background, rural interest, and family practice preference. Other medical education programs have had similar successes.
Data from the AAMC demonstrates that minority students (blacks, hispanics, natives) are 4 times as likely to choose underserved practices. Black and Hispanic physicians serve Medicaid and underserved populations as well as those of similar background Role of Black and Hispanic Physicians Volume 334
Older students also are more likely to choose primary care.
Cohen Encourages Admissions to Look Beyond MCAT
Major medical education conferences call for "thinking outside of the box" Millennium Conference on the Clinical Education of Medical Students but few with such thinking are included in the conferences or resulting activities. How can we have "thinking outside of the box" if we do not admit those from outside the box?
How can we have thinking outside the box if we grow more isolated in our centers and do not go out and visit a variety of communities and neighborhoods, especially those in great need of health care?
Those who have reflected upon technology and its impact on us, or various government programs and their impact on us, have basically called us to get out with the people and find out about their needs directly.
Quinten Schultze notes in Habits of the High Tech Heart, "It's actual communities that require us to think about the needs and interests of others. And it's in real communities, starting with the family, that character is formed. And for all the talk about Internet diversity, only a real community—one based on shared space, not just interests—can teach us how to live with people who are different from us." From Chuck Colson: As Schultze reminds us, this is the biblical model for community. Messy? Sure. But if our goal is real virtue, then there is no avoiding real people." Technology Character and Family Medicine
John McKnight notes the problems of government programs, noting that it is people that are able to care, not programs. John McKnight: Servant and Facilitator
Few admissions committees know the down side of ignoring those that are in the alternate or slightly below category.
What if NHSC participated in admissions using the criteria that they have developed over many years because they were stuck with what admissions committees selected, instead of selecting the candidates that they have found to be best for the underserved areas that they represent? What if the government truly held medical schools accountable for outcomes such as distribution, instead of giving money away to support high tuitions and programs that could be far more effective such as Title VII (GAO study on Title VII)?
Rural states suffer greatly through inequitable distributions of education and other resources Importance of Admissions for Nebraska
Minority education has many of the same deficits. Minorities and Education
Small towns can also contribute to the problem.
When they send gifted kids off to college, small towns expect to rarely see them again. When these students do come home, they are often treated as if they are failures, instead of the town feeling honored that one of their graduates thought that the small town experience was so valuable that they wanted to have it themselves and share it with their kids.
Recommendations
We need people on admissions committees that pick candidates that they hope will do a good job of taking care of them in of them in future years.
We need faculty members that take the time and effort to pick based on more than intellectual prowess.
We need to prioritize the admission of students who will be more likely to meet the needs of the rural and underserved parts of our state.
We need to have patient faculty that will work with the less than outstanding students to help them through the intellectual struggles of medical school.
We need to train admissions committee members to understand that rural background students may not have the same GPA and MCAT scores, but they do have the same potential to be great physicians.
We have to take the pressure of admission committees to produce great board scores and pristine accreditations, and hold them accountable for the needs of our citizen-patients, the state, and nation.
We need to stimulate the state to reverse the centralization process that threatens to cut off the flow of young professionals of all types to rural Nebraska. Admissions must reach out to small colleges and high schools to encourage the gifted to attend smaller colleges and apply to professional schools as Missouri, Minnesota, and Pennsylvania programs do.
Dona Harris, Ph.D., did studies at the University of Utah on MCAT and rural (Family Medicine 21 3 May-June 1989 p 187-90). The higher the scores, the less likely the choice of rural practice.
Other studies at U of KC (J Med Ed vol 56 sept 1981 p 717 726, studies in MN on RPAP students, studies on Jefferson students in PA (Rabinowitz), showed that students that took rural tracks (selected on basis of rural background, desire to return rural and desire to do FP) did poorer on MCAT and GPA when compared with traditional students.
Also J Med Ed Vol 51 Jan 1976 p 47-49 (Cullison, Reid, Colwill) showed poorer MCAT in rural background students.
Verby showed that RPAP students in MN (rural background and rural practice interested students doing 9 months rural rotation in M-3 year) were in the bottom half of the class, yet moved up the class rank and cognitive scores compared to traditional students upon graduation. They equalled or exceeded their traditional cohorts in 23 cognitive, behavioral, and procedural measures.
Centralization and Regionalization Bowman
Characteristics of Rural Interested Students AAMC GQ 1995 Bowman
Hope: Students From the Underserved, For the Underserved
Learn more about Dr. Schultze’s research. Quentin J. Schultze, Habits of the High-Tech Heart: Living Virtuously in the Information Age (Baker Books, 2002).
All physicians need good communications skills and service motivation, but clearly primary care physicians put a higher priority on these areas. Indications are that psychiatry, geriatrics, and primary care continue to lead the lists of the specialties most in demand (COGME studies), but despite the obvious needs for greater emphasis on communication, no response is heard from admissions committees.