Can We Select “Better” Residents?

An invitation to brainstorm

Two things are clear about the internal medicine residents I get to work with. First, their qualifications are spectacular: academic accolades, research, publications, clinical medicine experiences prior to residency, even real-life professional experiences. When they enter internship, their CVs dwarf those of my residency colleagues (’93 - ’96). Second, although they are excellent residents -- smart, knowledgeable, dedicated, hard-working -- they are no better than my peers were.

Why are the residents so much more qualified, on paper, today than we were 30 years ago?

Because it is more competitive to get to where they are. There are many more people competing for slots in medical school and residency and the number of “slots” have increased at a slower pace than the applicants. Competition for the slots in “premier” (frou-frou?) programs is even stiffer.

This all raises an obvious question. If applicants are more impressive on paper, but no more impressive in the clinics and hospitals, aren’t we doing something wrong?

You could argue that no, we are doing just fine. We are, and have always been, at “peak resident.” We can’t get any better. Our selection system guarantees trainees who are not only smart, but will do anything that is asked of them. Get straight A’s; done. Ace the MCAT; check. Publish a journal article; OK. Volunteer in a free clinic; anything else sir? We can’t expect more than what we have always had: intelligent, hardworking, young people who can make the most of their training.

This seems defeatist. What we ask of our applicants has negative consequences.

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. They fill journals with articles that do nothing for medicine but only add a line to a CV. They spend money on test prep courses and needle their teachers into inflating grades.

Maybe we are also enriching the population of trainees with people who are likely to be unhappy. A nice article that I found while writing this made the point that many of the characteristics that are rewarded in our selection process make for unhappy learners and doctors. We seek the workaholic (whose only response to challenges is to work harder), the superhero (who feel like every challenge is hers alone), the perfectionist (who can't stand the thought of them or their colleagues ever making a mistake).

Maybe, we are also missing an opportunity to judge our applicants differently, in ways which could have made today’s young doctors better than those of a generation ago.[i]

Are their alternatives? I have always been a fan of random selection. To some extent, I think this is mostly what we already do in admission/selection committees.[ii] Set a standard; invite applicants that meet the standard to get a sense of the institution so they know that it provides what they want and that they will fit into the culture; and then randomly select a class. For medical school, I would randomly select from college graduates who have achieved a minimum MCAT score and succeeded during at least a year of work in food service or the military.[iii] Some of the best trainees and doctors I have ever worked with met these criteria. They were dedicated, followed directions, worked hard, were skilled at the “customer service” side of medicine, and were mature enough to know that medicine was for them.

One could also follow the lead of the tech industry and invest in the selection process. Right now, we mostly beg people to squeeze admissions work into their already ridiculously busy lives. We have not designed an process that evaluates applicants’ abilities to perform their future job. We should offer salary support and train those interested in working in admission and require applicants do designed, structured interviews. Require applicants to do tasks that predict whether they will succeed. If Meta or Alphabet or all of fintech can ask their applicants to do coding tests for jobs that don’t deal with life and death, maybe medicine could up its game?

I know what you are thinking, we don’t need this process for residencies because we have medical schools to train and evaluate our applicants. Have you considered what has been going on in medical school evaluations recently?

Obviously, this essay is meant to be a bit provocative. Please comment or send us a piece on the topic (sensiblemedicine2022@gmail.com). This was about 850 words, just keep it to that length if you do write something.

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[i] I’m being kind to myself by writing “a generation” rather than “several generations”.

[ii] I am no longer involved in admissions. I served some time on medical school admissions committees, served on a couple of residency internship selection committees, and even did a few “alumni interviewers” for my college. The fact that I no longer serve in any of these roles should tell you something, I didn’t like it much and I was not very good at it.

[iii] For food service, I would include working in your family’s grocery/butcher shop. You know, so I might still have a chance.