Sunday, August 7, 2022

Who should we take in medical school? What should be the criteria? Who will be a good doctor?

There are many serious inequities in our society, and they tend to build upon one another. People with more advantages have more opportunities to do well themselves, and those with fewer have less. Those advantages (or, conversely, disadvantages) include wealth, white race, male  gender, suburban or urban (but not poor areas) location, and education. All these feed one another. For example, coming from a well-to-do family and being white dramatically increase the odds of success in a chosen field. Even if there were no discrimination against people based on race and color (and this is a long way from being true), there is still the fact that people of color are grossly over-represented in low-income communities and families. This is a clear example of structural racism, so that effective discrimination based on class disproportionately falls on people of color.

An important manifestation of this exists in healthcare, and in particular the production of healthcare professionals (but also in other professional fields). In medicine specifically, we have a physician workforce that does not reflect the population of the US in terms of class (or family income), race, gender (although this is the area in which the greatest progress has been and continues to be made), geographic location (rural vs. urban), and specialty choice. Our doctors overwhelmingly are from upper-middle-class backgrounds, are white, are from suburban (or well-to-do urban) communities, and largely male. They practice in urban and suburban areas in even greater proportion than they come from them, in part because they also practice in specialties and subspecialties that cannot survive in smaller communities, rather than in family medicine and other primary care specialties that are in shortage. This exacerbates the other inequities by making healthcare something that is less accessible to many Americans based on geography (where are the doctors located?) and culture, as well as because of cost, the absence of a universal affordable healthcare system being an almost uniquely American phenomenon.

Not having a medical workforce that looks like America, or practicing in the areas and specialties where there is most need, goes beyond the admissions process to medical school. It is impacted by the curriculum (both formal and informal, or “hidden”) in medical school, by role models and mentors, and very much by the potential income from practice. The systemic characteristics of society greatly influence who is considered a “good” candidate for medical school, and even who applies. These are considerations addressed in a recent blog post on LinkedIn®, a professional networking site, by Dr. Heidi Chumley, dean of the Ross University School of Medicine (RUSM). Dr. Chumley focuses on the challenges faced by students from backgrounds underrepresented in medicine (URiM), and in particular on the emphasis on performance on the Medical College Admission Test (MCAT) for deciding who gets into medical school, since URiM students perform less well on that test. She notes that what seems like a small difference in scores makes a significant difference in admission: “There remains an unexplained gap in average MCAT scores between White (503.1), Black (494.9), and LatinX (497.1) test-takers. This gap matters as 29% of applicants with a score of 502-505 are accepted compared to 10% with a score of 494-49.”

Dr. Chumley also address two other critical points. First, that the lower MCAT scores are likely tied to many of the social and educational disadvantages faced by URiM students, thus reflecting, and compounding, the other factors that these students have to overcome. Second, that efforts implemented by many medical schools (and endorsed by the Association of American Medical Colleges, AAMC) to have a more “holistic” admissions process mostly changes the selection of which high-scoring students are admitted. Yes, it is great that students who have a social conscience and have done volunteer work in the US and abroad are selected over those who are selfish and not so involved, but this rubric, as she points out, ignores the fact that many lower-income (and URiM) students need to work at paying jobs to support themselves (and often their families), and devalues such employment in comparison to the voluntarism that is more accessible to those from privileged backgrounds.

Added to this is the financial component of the cost of medical school itself, which, in the US and in the US (and Canadian) serving Caribbean medical schools (of which Ross is one of the largest and most prominent), is staggering. Students typically graduate from medical schools with debt loads of $250,000 or more. In addition to being outrageous to start with, add the fact that compound and accrued interest makes the total to be repaid much higher, and this encourages students to choose higher-paid specialties even when that is not where the greatest need is (you may make, over a lifetime, $7M more practicing as, say, an anesthesiologist compared to a primary care doctor) or even where the student’s personal interest lies.

Dr. Chumley describes some of the efforts to increase access for URiM students at RUSM, and they are indeed impressive. They include “pipeline” relationships with HBCUs (Historically Black Colleges and Universities) and HSIs (Hispanic-Serving Institutions) and  re-thinking what criteria for admission are essential, valuing the life experience (including work experience) of applicants and putting less emphasis on the absolute score students get on the MCATs. As she points out, the MCAT predicts performance on similar multiple-choice tests of knowledge including most “pre-clinical” tests in medical school, and the licensing exam, the USMLE (particularly Part I, which covers basic science). It definitely does not predict performance as a good or excellent clinician. Also, while there are significant differences in the first-time pass rates on USMLE in those who score “over-500” (> 95%) and “just under 500” (> 80%) groups on the MCAT, the medical school curriculum should be addressing those differences.

The two points I would like to emphasize are the criteria for who is likely to become a good doctor (and thus should preferentially be admitted to medical school) and the enormous cost burden on medical students that obviously falls hardest on those with the least wealth. As I have said before (The high cost of medical education: Who should be trained to become doctors?, Dec 10, 2019; Free tuition in medical school is only one step toward producing the doctors America needs, Aug 26, 2018), those who should be given the opportunity to become doctors (ie., be admitted to medical school) should be those most likely to make a positive difference in the health of our population. This includes a sense of community over self, a willingness to serve where needed, and interest in (preferably commitment to) practicing the specialties most in need in the areas most in need of them. Since URiM doctors are more likely to practice with patients from similar backgrounds (and those patients are often more comfortable seeing them), and a comparable correlation exists with those from rural backgrounds, these characteristics should be very important criteria. As should coming from a family with lower than average wealth and income, which requires addressing the second point. Higher income does correlate with better education and higher MCAT scores, and maybe higher scores on basic science tests in medical school (which are very like undergraduate science tests) and USMLE Part I scores, but not (and almost inversely) with practicing the specialties most needed and caring for the people most in need. So this should at best be a neutral, not positive, criterion.

And the money is a big one. You can admit a student from a low-income family who will be a great doctor, but they should not have to go into absolutely crushing debt and certainly not to enter the highest-income specialties to pay it off. This can partially be addressed by medical schools offering scholarships and states and localities offering loan-repayment programs, but it would be most effective if the federal government could subsidize the cost to make it far lower, and in conjunction with requirements that schools (state or private, stateside or Caribbean) to produce the physicians America needs.

Of course, as well, and even more important for all our people, to have a free or very low cost universal health system.


Disclosure: Dr. Chumley and I have known each other for many years and previously worked together.

1 comment:

don said...

Great insights, Josh. We have a bloated health care system that is increasingly being staffed with products of a bloated and disconnected medical education system. As you've pointed out, the "measures" used as selection criteria are not serving the needs of our most vulnerable patients. A fine article.

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