On Dec 11, 2008 I posted information about how medical systems built around a strong primary care infrastructure enhance the health of everyone. In my Dec 14, 2008, I addressed the topic of medical student selection, arguing that if we as a society wish to decrease health disparities and increase the health of the entire population, we need to have doctors who practice among those populations who do not have access to doctors (“underserved communities”) in both rural and urban areas. Again, this will require many more physicians entering the specialties, mainly primary care, that are needed in those areas. However, our current practice of admissions tends to select for students who will not enter such practices; selecting students who overwhelmingly come from high income families (80% of medical students come from families in the top 20% of income) in the suburbs of major cities is not likely to produce physicians who will enter the lower-paid specialties of primary care and work in rural and underserved inner city areas.
Taking different types of students into medical school requires a different approach to and understanding of the concept of “qualified”. In the past there has been general consensus that “high scores on exams” was “qualified”, but, as I have noted, these scores only predict performance in the “pre-clinical” (= “courses just like college”) curriculum, not in the clinical; moreover, the students who are most likely to have the characteristics that would lead them to practice in areas of need also have characteristics (such as coming from rural or inner-city high schools, coming from families with lower socioeconomic status) that make their scores lower. The “qualified” student for medical school is one who is likely to make a difference in the health of the American people. These same standards should be applied to the curriculum and reimbursement of physicians – how do they impact on improving the health of the people.
It turns out, unsurprisingly, that medical schools are not the only schools concerned with these issues. The effort to create diverse student bodies in universities and professional schools is widespread. A conference on the “Future of Diversity and Opportunity in Higher Education” was held at Rutgers University Dec 3-5, 2008, co-sponsored by the Center for Institutional and Social Change based at Columbia University. (Website: http://www.groundshift.org/.) Speakers addressed the idea of redefining “merit” to understand context; business has long understood that people hired need to add to the overall value of the organization, often by bringing different backgrounds and complementary skill sets. Lee Bollinger, President of Columbia University and the respondent in the two earlier University of Michigan affirmative suits (Gratz v. Bollinger and Grutter v. Bollinger) notes that those decisions allow selection on characteristics such as socioeconomic deprivation, but also notes that pretending that using socioeconomic characteristics obviates the need for racial and ethnic diversity is wrong. Richard McCormick, President of Rutgers and formerly President of the University of Washington noted the impact of the anti-affirmative action “Initiative 200” in Washington state: in 1998 1/11 freshman was non-Caucasian, but in 1999 it was 1/18. However, by developing new standards, including a required essay on diversity/adversity, within 4 years the ratio was at pre-Initiative rates without explicit use of affirmative action. In a particularly important panel on “Redefining Merit”, Sheila O’Rourke of the University of California at Berkeley spoke to the need to look at the definition of “merit” as not just test scores, but achievement in the context of opportunity. Prof. Lani Guinier from Harvard referred to the work of Malcolm Gladwell, looking at the differences in approach in selecting applicants to modeling schools and to the US Marines. Modeling schools looks for beautiful people in order to enhance their brand; this is selectivity effect. The Marines take people with a basic level of aptitude and skill and make them into Marines. This is treatment effect. The concept of “Democratic Merit” measures people on how they contribute to the mission of the organization or institution, and characteristics should include not only race and gender but socioeconomic status and geography. Much of this work is discussed in the book Prof. Guinier and Prof. Susan Sturm, from Columbia and the Center for Institutional and Social Change, wrote in 2001 “Who’s Qualified?” (Beacon Press, Boston.)
This is a critical concept. It understands how people contribute to the overall mission of a school, workplace or society. It recognizes how such institutions benefit from the difference in background, perspective, and experience of different people – and even how they think. Such a comprehensive perspective has to be of more value than simply performance on a test measuring one slice of knowledge and aptitude. As a simplistic example presented, consider 3 applicants for 2 positions in a company. If the criterion is performance on a 10-question test, and applicants A, B, & C respectively score 7, 6 & 5, should we take A & B? What if A got all 6 of B’s correct answers plus one more, but C’s 5 correct included the 3 both A & B missed? Would not C bring another perspective of value?
Businesses are far ahead of academic institutions in such thinking, even among those attending such a conference. It was from the panel of business leaders responsible for diversity in their companies, that the boldest assertions were made, and I paraphrase: “If there are only 12 top African-American law school graduates, the issue is not whether I can recruit them to my firm, because they will get good jobs somewhere; the issue is growing the number and pool,” and “We want diversity because it is good for our company, and will help it survive in a competitive market, but ultimately even if our company doesn’t survive, it is necessary for the success of our society.” I didn’t hear anything like that from the academics.
We need outcome-based criteria. In medicine, this is not how high the scores of a cohort of students are on exams given after 2 years of “basic science” or even “medical boards” (the USMLE, US Medical Licensing Exam) as long as they are adequate. It is also not whether they “match” in high-status residency programs. It can only be how well they contribute to the improvement of the overall health of our people.
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