Do higher scores alone predict success in medical school, or in clinical practice?
The medical school application process is grueling for most. An entire industry has been created around coaching students on how to achieve the best grades on examinations and how to negotiate the pathway through the application process.
Historically GPA and MCAT scores have been the principal criteria by which people are selected. There is little doubt that higher scores predict the intellectual ability necessary to succeed. But do higher scores alone predict success in medical school, or in clinical practice?
A study done in England showed that when acceptance was based 50% on academic achievements and 50% on structured interviews designed to assess interpersonal skills, passion, compassion, and flexibility, the group with lower academic credentials with higher interpersonal skills were more likely to complete the course than students with higher academic scores with lower interpersonal ratings. It is also well known that academic record provides information about breadth and depth of subject knowledge, but it does not usually indicate other cognitive skills.
However, medical schools get so many applications that they have to set baseline academic scores in order to triage students into the group to interview and the group to reject outright. They couldn’t possibly review and offer interviews to all applicants. Conducting proper interviews is also quite complicated and time intensive. Some schools conduct multiple interviews on the same day, so that the student is exposed to a variety of different interviewers. For most schools the interview is largely unstructured, and maybe perfunctory in some cases.
The problem with screening by academic performance is that this tends to select applicants who may be predisposed to be competitive, high achievers, not team players, and more rigid. In today’s medical environment, teamwork between medical professionals is essential to good care for patients. Most young graduates are entering into hospital groups or large groups where teamwork is essential.
Medical schools might learn from the research conducted by William Muir, PhD, at Purdue University in the 1990s. Muir was attempting to increase the egg laying productivity of chickens. He theorized that he could identify the best producers of chickens from the flock by counting how many eggs they laid. He took those super chickens and bred them over 6 generations thinking he could produce a colony of chickens with the ability to lay more eggs. He also took a control group of 9 average producing hens and bred them over 6 generations. The 2 groups shared similar living environments and food. Productivity was measured by counting the number of eggs produced by each group.
At the end of his study, the results were totally unexpected. The control group chickens were healthy, well feathered, and actually produced more eggs than they did at the start of the experiment. The super chicken group was in disarray and in fact only 3 of the original group survived because most were killed by fighting the other chickens.
President Franklin D. Roosevelt wrote, "competition has been shown to be useful up to a certain point and no further, but cooperation, which is the thing we must strive for today, begins where competition leaves off."
So how else should be evaluate potential doctors? Letters of recommendation are almost useless—95% of them are strongly supportive and only 5% actually say anything negative. The message is: letters of recommendation don’t help but can hurt an applicant.
Undergraduate choice of major does not predict who will succeed in medical school although some studies suggest that students who chose humanities were more successful in clinical practice.
While we need to maintain diversity of skills and personality, there are some characteristics which we demand in any doctor. Enough intellectual ability to do the job, plus honesty, integrity, and conscientiousness, must be at the heart of good practice. Helpfulness and willingness to cooperate are extremely important as are interpersonal skills and empathy. The mental health of the applicant is also important since doctors are more vulnerable than comparable professional groups to alcoholism, drug abuse, and suicide.
Coming from a background of stable childhood experiences, candidates are less likely to suffer from burnout. How do you assess the psychological health of potential doctors?
There is disconnect between what patients think a good doctor should be and what medical schools consider a future doctor to be. Patient's want their doctor to be a good communicator, who is compassionate, a good listener, and sensitive to their needs. These qualities are not easily measurable in potential applicants.
The solution has to be more emphasis on conducting meaningful interviews which are structured and conducted by several observers. A handful of schools use an approach where the candidate sees 5 or 6 interviewers on the same day for a rapid-fire series of interviews. This is a great idea because the opinions of 6 people probably provide more insight than the opinion of just 1 person.
Medical schools might look to industry which has invested heavily in predicting who will succeed in business. In general, they found that the most productive people are about 40% better than average, while the least are 40% worse than average These are not the only criteria for a decent doctor, but they matter. There is consistent evidence that students with higher IQ are more likely to complete medical school. Further factors consistently found to add to prediction of performance are integrity and conscientiousness: these do not correlate with IQ.
The good news here is that most medical schools have gotten the message: grades count, but only so far. The best students are those with better than average grades, who have high marks for integrity, honesty, curiosity, and are teachable and team players. These interpersonal qualities can’t be compromised if we expect to improve the quality of medical care our patients receive. The challenge is how we are going to measure these aspects. I think weighing both academic abilities and interpersonal qualities equally will improve the quality of doctors, decrease burnout rates, and will improve the health of society.