I agree that we could do medical school and residency selections better than we so. You already had some good suggestions in your book, "Ending Medical Reversal". I wholeheartedly endorse the idea of selecting candidates that have acquired good customer-service skills, and those who have been out in the "real world" before embarking on a career in medicine.
The first is admittedly really hard to measure, but in my decades as a physician (I graduated medical school in 1989), I have learned that my most important skill has been relating with patients. I think I'm much better at such relationships now than when I was in my 20's and 30's, but I don't think I was a slouch then, either. That should be something that is measurable, or at least subjectively detectable, by some means.
The second is easier to determine, but a bit harder to know if it is relevant. I went right from college to medical school, but only after starting first in architecture, then graduating with a degree in psychology, before getting my pre-med requirements met. That circuitous route was good for me, and I think made me a bit more interesting as a candidate. That should be the case even more for someone who served in the military as a medic, first worked as a nurse, or actually anyone who embarked upon one career path before redirecting themselves into medicine.
I believe that the combination of both, good people skills, and a commitment to medicine after prior experiences, would yield the best medical school and residency candidates.
We would all benefit if there was a reasonable ‘bar’ set, then all schools randomly select a certain number of in state and out of state students. I think that is the only method that would result in the possibility of more well rounded and healthier students
The selection process is also why there is a primary care shortage, I think. It skews towards academia and accolades so much that the people making it through seem to view being your standard hometown doc as a let down or “beneath” them.
Also, as an FP doc I feel most of my job is negotiating- negotiating with patients to get screenings done, to take their medicine, whether to have tests done, to quit bad habits. Then negotiating with insurance companies to get tests and medicines covered (ugh- do not get me started) , negotiating with workplaces about light duty/FMLA etcetcetc etc
When I tell premed students to take interpersonal communication/ negotiating classes they look at me like I am nuts- “but I must learn my anatomy and micobiology! How can I fit that in?”Then the med students that get rotations in real FP/ gen int med clinics are amazed and many are disillusioned that is not like an episode of House everyday with crazy diagnoses and whacky tests. Instead I spend much of my day discussing diet, smoking cessation, convincing people they do not need a zpack for every sniffle etc. (and the students are amazed people do not instantly follow our guidance and that the actual practice of medicine is,yes, an ongoing negotiation between patient and practitioner), they have quite unrealistic expectations as to what a doctor actually does. (I blame Grays Anatomy-ha!)
I think we have eliminated many of the students/ residents that would enjoy that sort of day to day personal interaction by the stress on research and perfect grades and having to look like this perfect person on paper. I worry Folks that probably would be great primary care docs just don’t even apply to med school because they would rather work with people than test tubes and feel they cannot compete against those with CVs a mile long etc. Selection bias.
I'm not sure a focus on how to select "better" residents is what is needed. It does not seem as if there is some extremely high-up, over arching and all-seeing body that decides what qualities best suit someone for a career in medicine. Market competition seems to have driven this current shift in requirements (and no, I would not imagine today's current residents are any better than those in the past!) To me it doesn't seem like any very high-level organization of the medical work force is going on or has ever gone on! The bigger change in all of this is the job we end up asking these people to do. The practice of medicine has become an assembly-line of "productivity". We are essentially line workers pumping out widgets - speed and efficiency being the priority. People are living longer with more complex conditions and more complex treatment options. To require these high-level professionals to accomplish what should legitimately take 45-60 minutes in a 15-minute time slot is the crux of the problem. Why don't we hear/see the statistics of the current medical work force and look at things like how long a career the average physician has - who "retires early"; who is working part time; who is "stressed" or "burnt out"? Where do PAs and ARNPs fit into the scheme of things? To spend the time, money, energy on training a physician, only to have them "retire early" at 39 y/o is ridiculous! But that is what is happening for many - they want out as soon as financially possible because the job is eating them up. It seems the bottom line of what you really need in a doctor is the skill and efficiency to see a patient every 15 minutes, do it so the patient feels "heard" and attended to, document it all in a very timely fashion, and not let it eat away at your psyche. What sort of process will select for people who can do that? So when we contemplate how to select those who will make good physicians, we should focus on the job they will eventually be asked to do for the next 30 years.
Let's select better medical school and residency teaching faculty... people who will be willing to set an example of honoring the Hippocratic Oath and advocating for good medical science and for patients.
That seems to be sorely lacking in the academic world right now as evidenced by the bumbling cooperation of so many in academia with the poor guidance of public health from the CDC and FDA during the pandemic as well as the recent too many examples of fraudulent research reported at Stanford and Harvard...
Yes! Let's take down the credential bloated meritocracy! Agree on many points and yes, I think we should have "better" residents, but we must start with some agreement on what we mean by better.
The educational dominance of this system glorifying research and scientific certitude above all other would-be valued pillars of medicine all started with the Flexner Report. There was a problem with the quality of trainees, and there was agreement among an influential group about that problem: there wasn't enough scientific rigor. From this agreement on how to make physicians better came the Report and, 100+ years later, it seems we've gone off the deep end in that direction.
So we need to dismantle the system that incentivizes (or requires and coerces) our trainees to spend their time checking all these boxes, but in order to do that, we must decide what we mean by "better". We have to move towards something, not just away from where we are.
This isn't as simple as just increasing slots, as someone suggests. (Here insert separate post on the complicated financing and politics of residency slots and growth through Medicare). Even if increasing slots were simple, we need different med students (or differently trained?) to fill them. The budding dermatologists, ophthalmologists and orthopedists I've taught in medical school won't be going into GIM or Family Medicine just because there are more slots.
To my mind, it's a question of our healthcare workforce. Our healthcare workforce should be built to meet our population healthcare needs, and there are so many. Someone mentioned primary care, someone else chronic disease, and I think we're all aware mental health is top of that list. More generally, it doesn't take a brain surgeon to realize that people want (need?) a doctor who listens, tries to know them, and seems to care. So how do we rebuild medical education, Flexner style, to do this? That's not an 850 word post, that's a big ass report, and a lot of (thankless) work after that.
Any admission criteria will be subject to Goodhart's law: "When a measure becomes a target, it ceases to be a good measure". Motivated applicants will naturally game the system and check whatever box needs checking. As they are rewarded for doing so, they are less likely to have the sought-after qualities associated with each criteria, and more likely to possess whatever traits are associated with checking boxes as a means to an end.
It would be nice if a lottery for those meeting threshold criteria worked. It seems so intuitively fair. But the Dutch experience does not bear that out. In 2017, they phased out the lottery system they had in place since the 1970’s (which was being criticized as unfair!) in favour of a more comprehensive selection process. The literature (for instance this systematic review: https://pubmed.ncbi.nlm.nih.gov/26695465/) seems to support their move.
I have to admit my heart sank a little reading this, as I have one of those high achieving kids currently in college and working at double speed to meet the modern-day requirements to get into a good MD/PhD program. I worry every day that it is not worth the toll it is exacting from her, but also want her to pursue a career that, honestly, she would be phenomenal at not just because of her intellect or work ethic but because of her innate compassion for people in distress.
It should be by no means easy to become a doctor - people's actual lives are at stake! - but the articles and side research as an UNDERGRAD that have no bearing on qualifications required just to keep up appearances borders on the ridiculous. I look down the road 10 years for her and wonder if it is worth it, particularly coupled with the double whammy of the DEI focus in medicine and the rift brought by C19 mandates within the profession.
Rote memorization needed for MCAT's, maintaining GPA etc. are nothing more than indicator of your willingness to grind. Being a doctor, 'scuse me - a MEDICAL doctor, should and must be damn hard. Your patients lives depend on it. So yes, the system is never perfect, but I actually FEAR what's happening in the name of DEI. Drop MCATs, Drop GPA, Drop this or that and use a "holistic approach" scares me. Somethings in life should never be easy. You should weed out those who don't belong ,don't have the heart etc. Also, until Insurance and Pharma's stranglehold on the medical establishment is solved, all of this will be a moot point. Patients get serviced by doctors but doctors get paid by insurance. It's feedback loop that's broken. What incentive is there for the doctor to go the extra mile with the patient (except for the goodness of his/her heart?) Ever wonder why elective plastic surgery and LASIK are sooooo different than any other doctor's experience.
As I finish up my second year of medical school, there's an overwhelming pressure from my peers and mentors to "play the game" by hopping on projects, only focusing on the "high yield" activities that will look good for residency applications, and other things like this. I think my classmates and I avoided this mindset for about a month before we were all poisoned (or wised up depending on your perspective). Whenever I do feel like I'm getting sucked up into the rat race though, I usually talk to a much older, calmer, and wiser healthcare provider and they remind me what actually matters and my perspective shifts.
Great article. Expectation to do panoply of superficial meaningless stuff to prove one's worth rather than passionately engage in something of in an activity real interest isn't going to distinguish between mediocre and awesome.
I’d like to see better selection. I’m an RN have been since ‘95. I work with Residents and Interns in an ICU. I feel this current way of selecting Doctors, has really changed and been ruined over time. The human connection between Residents and Interns and their patients really suffers. Since covid, and especially these last few years, young doctors have learned to treat the patients by sitting in front of a computer screen and not in person. They barely see the patients or interact with them. It’s so sad. The competition and also demand from the schools to “do more” and “to be the best” has ruined bedside care.
Why not dramatically increase the number of available slots? As things currently stand most people i know can NOT find a new primary care doc.
Maybe also make doctors commit to at least 5 years of primary care or something along those lines. And do so while making the cost of education nearly free.
Can we select better residents? Under the current system, probably not. Admission to and success in medical school is mostly predicated on rote learning abilities---memorization and regurgitation on tests. Certainly a lot of rote learning is necessary but skill at that doesn't require much critical thinking or interpersonal skills. Achieving the latter usually requires maturity and real life experience. If I had dictatorial powers, no one would go to college straight out of secondary school. This would mean that those who went on would at least have some real world experience. As dictator I would also get the government out of education and eliminate much of the "social science" that passes for education today. In my opinion, a system that shunts relatively immature children directly into higher education where they have many of their unrealistic childhood illusions reinforced by teachers who also have no real life experience has led to many of the problems we experience today.
“We are ruining people’s childhoods and young adult lives, forcing them to do things that they do not enjoy and do not prepare them for their futures.”
What a perfect descriptor of the article in one sentence. Not that I’m any good at work life balance... heck I’m not even any good at balance as a recovering addict - but I love living in the real with its beauty and its tragedy and finding joy when I can. Workaholism, perfectionism, and supermanism are not traits that I look for in a physician or any healthcaregiver. I want the Doc who says he or she makes a mistake every surgery, and knows when good enough is indeed good enough. I want to know they are HUMAN, too.
I agree that we could do medical school and residency selections better than we so. You already had some good suggestions in your book, "Ending Medical Reversal". I wholeheartedly endorse the idea of selecting candidates that have acquired good customer-service skills, and those who have been out in the "real world" before embarking on a career in medicine.
The first is admittedly really hard to measure, but in my decades as a physician (I graduated medical school in 1989), I have learned that my most important skill has been relating with patients. I think I'm much better at such relationships now than when I was in my 20's and 30's, but I don't think I was a slouch then, either. That should be something that is measurable, or at least subjectively detectable, by some means.
The second is easier to determine, but a bit harder to know if it is relevant. I went right from college to medical school, but only after starting first in architecture, then graduating with a degree in psychology, before getting my pre-med requirements met. That circuitous route was good for me, and I think made me a bit more interesting as a candidate. That should be the case even more for someone who served in the military as a medic, first worked as a nurse, or actually anyone who embarked upon one career path before redirecting themselves into medicine.
I believe that the combination of both, good people skills, and a commitment to medicine after prior experiences, would yield the best medical school and residency candidates.
We would all benefit if there was a reasonable ‘bar’ set, then all schools randomly select a certain number of in state and out of state students. I think that is the only method that would result in the possibility of more well rounded and healthier students
The selection process is also why there is a primary care shortage, I think. It skews towards academia and accolades so much that the people making it through seem to view being your standard hometown doc as a let down or “beneath” them.
Also, as an FP doc I feel most of my job is negotiating- negotiating with patients to get screenings done, to take their medicine, whether to have tests done, to quit bad habits. Then negotiating with insurance companies to get tests and medicines covered (ugh- do not get me started) , negotiating with workplaces about light duty/FMLA etcetcetc etc
When I tell premed students to take interpersonal communication/ negotiating classes they look at me like I am nuts- “but I must learn my anatomy and micobiology! How can I fit that in?”Then the med students that get rotations in real FP/ gen int med clinics are amazed and many are disillusioned that is not like an episode of House everyday with crazy diagnoses and whacky tests. Instead I spend much of my day discussing diet, smoking cessation, convincing people they do not need a zpack for every sniffle etc. (and the students are amazed people do not instantly follow our guidance and that the actual practice of medicine is,yes, an ongoing negotiation between patient and practitioner), they have quite unrealistic expectations as to what a doctor actually does. (I blame Grays Anatomy-ha!)
I think we have eliminated many of the students/ residents that would enjoy that sort of day to day personal interaction by the stress on research and perfect grades and having to look like this perfect person on paper. I worry Folks that probably would be great primary care docs just don’t even apply to med school because they would rather work with people than test tubes and feel they cannot compete against those with CVs a mile long etc. Selection bias.
I'm not sure a focus on how to select "better" residents is what is needed. It does not seem as if there is some extremely high-up, over arching and all-seeing body that decides what qualities best suit someone for a career in medicine. Market competition seems to have driven this current shift in requirements (and no, I would not imagine today's current residents are any better than those in the past!) To me it doesn't seem like any very high-level organization of the medical work force is going on or has ever gone on! The bigger change in all of this is the job we end up asking these people to do. The practice of medicine has become an assembly-line of "productivity". We are essentially line workers pumping out widgets - speed and efficiency being the priority. People are living longer with more complex conditions and more complex treatment options. To require these high-level professionals to accomplish what should legitimately take 45-60 minutes in a 15-minute time slot is the crux of the problem. Why don't we hear/see the statistics of the current medical work force and look at things like how long a career the average physician has - who "retires early"; who is working part time; who is "stressed" or "burnt out"? Where do PAs and ARNPs fit into the scheme of things? To spend the time, money, energy on training a physician, only to have them "retire early" at 39 y/o is ridiculous! But that is what is happening for many - they want out as soon as financially possible because the job is eating them up. It seems the bottom line of what you really need in a doctor is the skill and efficiency to see a patient every 15 minutes, do it so the patient feels "heard" and attended to, document it all in a very timely fashion, and not let it eat away at your psyche. What sort of process will select for people who can do that? So when we contemplate how to select those who will make good physicians, we should focus on the job they will eventually be asked to do for the next 30 years.
Am I reading correctly that you are in favor of a “gap year” before medical school? Why? We were nearly all freshly out of college.
Let's select better medical school and residency teaching faculty... people who will be willing to set an example of honoring the Hippocratic Oath and advocating for good medical science and for patients.
That seems to be sorely lacking in the academic world right now as evidenced by the bumbling cooperation of so many in academia with the poor guidance of public health from the CDC and FDA during the pandemic as well as the recent too many examples of fraudulent research reported at Stanford and Harvard...
Yes! Let's take down the credential bloated meritocracy! Agree on many points and yes, I think we should have "better" residents, but we must start with some agreement on what we mean by better.
The educational dominance of this system glorifying research and scientific certitude above all other would-be valued pillars of medicine all started with the Flexner Report. There was a problem with the quality of trainees, and there was agreement among an influential group about that problem: there wasn't enough scientific rigor. From this agreement on how to make physicians better came the Report and, 100+ years later, it seems we've gone off the deep end in that direction.
So we need to dismantle the system that incentivizes (or requires and coerces) our trainees to spend their time checking all these boxes, but in order to do that, we must decide what we mean by "better". We have to move towards something, not just away from where we are.
This isn't as simple as just increasing slots, as someone suggests. (Here insert separate post on the complicated financing and politics of residency slots and growth through Medicare). Even if increasing slots were simple, we need different med students (or differently trained?) to fill them. The budding dermatologists, ophthalmologists and orthopedists I've taught in medical school won't be going into GIM or Family Medicine just because there are more slots.
To my mind, it's a question of our healthcare workforce. Our healthcare workforce should be built to meet our population healthcare needs, and there are so many. Someone mentioned primary care, someone else chronic disease, and I think we're all aware mental health is top of that list. More generally, it doesn't take a brain surgeon to realize that people want (need?) a doctor who listens, tries to know them, and seems to care. So how do we rebuild medical education, Flexner style, to do this? That's not an 850 word post, that's a big ass report, and a lot of (thankless) work after that.
Any admission criteria will be subject to Goodhart's law: "When a measure becomes a target, it ceases to be a good measure". Motivated applicants will naturally game the system and check whatever box needs checking. As they are rewarded for doing so, they are less likely to have the sought-after qualities associated with each criteria, and more likely to possess whatever traits are associated with checking boxes as a means to an end.
It would be nice if a lottery for those meeting threshold criteria worked. It seems so intuitively fair. But the Dutch experience does not bear that out. In 2017, they phased out the lottery system they had in place since the 1970’s (which was being criticized as unfair!) in favour of a more comprehensive selection process. The literature (for instance this systematic review: https://pubmed.ncbi.nlm.nih.gov/26695465/) seems to support their move.
I have to admit my heart sank a little reading this, as I have one of those high achieving kids currently in college and working at double speed to meet the modern-day requirements to get into a good MD/PhD program. I worry every day that it is not worth the toll it is exacting from her, but also want her to pursue a career that, honestly, she would be phenomenal at not just because of her intellect or work ethic but because of her innate compassion for people in distress.
It should be by no means easy to become a doctor - people's actual lives are at stake! - but the articles and side research as an UNDERGRAD that have no bearing on qualifications required just to keep up appearances borders on the ridiculous. I look down the road 10 years for her and wonder if it is worth it, particularly coupled with the double whammy of the DEI focus in medicine and the rift brought by C19 mandates within the profession.
Rote memorization needed for MCAT's, maintaining GPA etc. are nothing more than indicator of your willingness to grind. Being a doctor, 'scuse me - a MEDICAL doctor, should and must be damn hard. Your patients lives depend on it. So yes, the system is never perfect, but I actually FEAR what's happening in the name of DEI. Drop MCATs, Drop GPA, Drop this or that and use a "holistic approach" scares me. Somethings in life should never be easy. You should weed out those who don't belong ,don't have the heart etc. Also, until Insurance and Pharma's stranglehold on the medical establishment is solved, all of this will be a moot point. Patients get serviced by doctors but doctors get paid by insurance. It's feedback loop that's broken. What incentive is there for the doctor to go the extra mile with the patient (except for the goodness of his/her heart?) Ever wonder why elective plastic surgery and LASIK are sooooo different than any other doctor's experience.
As I finish up my second year of medical school, there's an overwhelming pressure from my peers and mentors to "play the game" by hopping on projects, only focusing on the "high yield" activities that will look good for residency applications, and other things like this. I think my classmates and I avoided this mindset for about a month before we were all poisoned (or wised up depending on your perspective). Whenever I do feel like I'm getting sucked up into the rat race though, I usually talk to a much older, calmer, and wiser healthcare provider and they remind me what actually matters and my perspective shifts.
Great article. Expectation to do panoply of superficial meaningless stuff to prove one's worth rather than passionately engage in something of in an activity real interest isn't going to distinguish between mediocre and awesome.
I’d like to see better selection. I’m an RN have been since ‘95. I work with Residents and Interns in an ICU. I feel this current way of selecting Doctors, has really changed and been ruined over time. The human connection between Residents and Interns and their patients really suffers. Since covid, and especially these last few years, young doctors have learned to treat the patients by sitting in front of a computer screen and not in person. They barely see the patients or interact with them. It’s so sad. The competition and also demand from the schools to “do more” and “to be the best” has ruined bedside care.
Why not dramatically increase the number of available slots? As things currently stand most people i know can NOT find a new primary care doc.
Maybe also make doctors commit to at least 5 years of primary care or something along those lines. And do so while making the cost of education nearly free.
Can we select better residents? Under the current system, probably not. Admission to and success in medical school is mostly predicated on rote learning abilities---memorization and regurgitation on tests. Certainly a lot of rote learning is necessary but skill at that doesn't require much critical thinking or interpersonal skills. Achieving the latter usually requires maturity and real life experience. If I had dictatorial powers, no one would go to college straight out of secondary school. This would mean that those who went on would at least have some real world experience. As dictator I would also get the government out of education and eliminate much of the "social science" that passes for education today. In my opinion, a system that shunts relatively immature children directly into higher education where they have many of their unrealistic childhood illusions reinforced by teachers who also have no real life experience has led to many of the problems we experience today.
“We are ruining people’s childhoods and young adult lives, forcing them to do things that they do not enjoy and do not prepare them for their futures.”
What a perfect descriptor of the article in one sentence. Not that I’m any good at work life balance... heck I’m not even any good at balance as a recovering addict - but I love living in the real with its beauty and its tragedy and finding joy when I can. Workaholism, perfectionism, and supermanism are not traits that I look for in a physician or any healthcaregiver. I want the Doc who says he or she makes a mistake every surgery, and knows when good enough is indeed good enough. I want to know they are HUMAN, too.