More Rantings About Rankings
More Rantings About Rankings
A counterpoint to a previous Sensible Medicine post
There was a time when medical trainees knew their place. The never disagreed with their attendings, and if they did, they kept it to themselves. Those days seem to be gone.
Adam Cifu, MD
A few counterpoints to Dr. Cifu's excellent essay. His points are in bold.
(1) Kudos to Harvard. Nothing signals high status like claiming you do not care about status. Why congratulate a school for acting in their own self-interest? Harvard is not leading a charge to improve medical education. They are simply raising their status, perhaps indefinitely.
Don’t get me wrong—this is good news for the competition. I’m sure Doximity, and other ranking entrepreneurs are salivating right now. But how much can we really expect a new version of the US News & World Report to change things? The new list will look a lot like the current list.
(2) The rankings are idiotic. It's great to say 'we should live in a world without rankings' but does anyone believe premeds are going to stop googling “top 10 medical schools”?
People desire status. Schools desire status. Companies like USNWR are just responding to their consumers’ desires. Claims of holistic evaluation are generally a smoke-screen for less transparent, often worse methods of rankings.
(And to be clear, most people are smart enough to take these official rankings with a grain of salt. Read the comment section on reddit if you do not believe me.)
(3) If we are going to rank… As always, Dr. Cifu is constructive with his criticism and proposes an alternative ranking methodology. I actually like some of these ideas. However, my question for Dr. Cifu is: do you think your methodology will dramatically alter the USNWR rank list? I would argue no.
We know that standardized medical exams are extremely correlated. Whether we use the MCAT, an MCAT-USMLE composite, the NBME, or the PcMAE, high test scorers will continue to get higher scores, and the more elite schools will continue to get the higher scorers.
(An aside: if you believe that schools truly educate students differently, then of course you want to incentivize better teaching. If, on the other hand, you believe there are few differences between the educational experiences at top- and middle-tier medical schools, then the reason why people at Harvard score better on the USMLE is because Harvard accepts students who are already better at standardized tests. Everyone learns microbio from Sketchy and pathology from Pathoma anyway.)
I particularly liked the idea of having a debt burden index included in the ranking schema. Surely this would incentivize schools to become cheaper. As someone with a few hundred thousand dollars of medical school debt, I support this! Luckily, someone has already compiled a rank list based on this metric alone. And guess what? It looks a lot like the USNWR. (Turns out the more prestigious schools are wealthier, which means they can afford to remit students’ tuition.)
Concluding Thoughts:
Harvard pulling out of the USNWR (and other elite medical schools following suit) probably just entrenches current rankings. Moreover, there is a subtler—and sadder—takeaway from this sequence of events: medical schools are far too conformist. If you doubt this, why does every single medical school mission statement sound exactly the same?
Which medical school should I go to if I am interested in medical entrepreneurship? Which medical school is breaking new ground when it comes to health policy or understanding healthcare law? Where is the medical school trying its damnedest to make the next generation of medical educators or communicators?
I agree with Dr. Cifu that we need more diversity when it comes to rankings. However, the true problem facing medical schools is that they are excessively similar. Inadvertently, this actually makes them easier to rank along one single hierarchy. To create a different system, we need medical schools to be more distinct. That will require more experimentation, and more risk.
If medical schools want the decision of attending medical school to be “nuanced, and individualized” as they claim, it is time for the schools to actually differentiate themselves.
Daniel Belkin is currently a transitional year intern at Memorial Sloan Kettering Cancer Center after which he will do a diagnostic radiology residency at Johns Hopkins. Together with his brother, Mitch Belkin, he hosts the External Medicine Podcast (@exmedpod).
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I agree 100% with Dr. Belkin's response. It is not surprising that the bottom ranked schools are not the ones pulling out; this is virtue signaling without consequence. Frankly, I went to the school that 1) I could best afford and 2) admitted me. And I ended up being a physician-scientist, even though I went to medical school thinking I wanted to be a primary care doctor...so I probably should have gone to a different school. but it worked out ok.
This is all well and good. I would argue that the majority of people just are going to go where they get it. We are kidding ourselves if we think that the majority of people applying to medical schools are actually using these ranking to decide where they go because the admission process and probably geography and cost decide for them.
The biggest flaw in students and resident today is an inability to take feedback for improvement as a positive. Show me an application process that teaches resiliency and an ability to self reflect in order to improve and learn. I find that high scorers often have never had to face adversity and when told they did something wrong they fall apart. Students and residents are becoming harder and harder to train and rankings/standardized tests do nothing to distinguish these characteristics.
In response to comment above, I think DEI and representation is important. We know that for some patients having a physician who looks like them or who has some shared lived experience improves trust and improves outcomes.