Thursday, 15 March 2018

Medical School. Who should be in and who should be out? Are we makng the right choices?

      When I decided I wanted to become a doctor, life was a lot simpler.  First one had to pass the entrance examination to University.  If one couldn't manage that, that was the end of the  story.  As far as I can  recall one was permitted three tries and if one failed three times, that was the end.   You weren't getting into University at all, let alone into Medical  School.  No-one thought, in those days that everyone should go to university.   No one considered that it was unfair discrimination or racism that all potential candidates were not accepted.  In fact, it was widely recognized that an applicant required a certain initiative and level of competence to be a suitable candidate for a university education.  In those distant days, applicants or their families had to pay their fees, so even the candidates did not want to waste their time and money entering a program that they were likely to fail.  This tended to weed out those who were not likely to ultimately gain a degree that would be an asset to their success  in later life.
      Getting into medical school in those days did not mean you were going to come out a physician.  If one failed to meet the standard one might easily be thrown out!  There were other standards that had to be met, as well as mastering the core content of knowledge.   There were standards of professionalism demanded of a prospective physician.  If the academic faculty. the professors and the Dean of Medicine felt a candidate did not meet the required standards, unless the situation was remediable that candidate  would not allowed to continue the program.  Although the years have clouded my memory, I believe about twenty per cent of the class I started with in Medical School  fell by the wayside.   Any appeal would be dealt with in-house and if it failed, no lawyer would have been sufficiently presumptive to assume that he knew better than a committee of  professional peers whether a candidate was fit to become a physician or not.
     Things are quite different today, when short of criminal activity, no  matter how inadequately a candidate performs he/she is almost certain come out of the program with an MD degree.  The martinets of Academe dare not face the legal teams that will appear on their door-step to challenge their decisions.   As you may have already read in a previous blog, a failed resident is currently trying to establish a suit against Western University, (until recently the University of Western Ontario) for failing to pass the specialty fellowship examination.  Should he succeed the nature of medical education in Canada, and perhaps elsewhere, will be radically changed.   Since it is almost impossible to fail a candidate, the admission process is critical, because once admitted, short of illegal or immoral behaviour, almost everyone who gets into med school will come out as a qualified physician.  The old joke, Q. "what do  they call the person who graduates at the bottom of his medical school class?" A." Doctor!" isn't so funny anymore.
     The Universities, the licensing bodies, the doctor's union (the Canadian Medical Association) and virtually all of the medical associations are intimidated by the prospects of litigation, or falling foul of government and its legion of administridiots. There remains a method in addition to marks, to attempt to ensure that the quality of prospective physicians and other health care workers meet an acceptable standard.  That is by the selection requirements to get into medical school and even that is a target of the bureaucrats.   So, let us at least make it as relevant as possible.
     Not  all schools require a personal interview and other requirements, such as letters of reference and letters from the candidates vary considerably from school to school.  Aside from marks, some of the qualities are extremely difficult to assess even in a carefully planned interview and almost impossible without one.
    The academic knowledge component is the most easily examined and tends to be the most  emphasized, perhaps because it is so well documented and available.    While undeniably important, it is often over-emphasized. In many areas of medical  practice there are very important skills that are unrelated to high marks.  For many years I have maintained that a B+ student with the right qualities can make an A+ practitioner.
     The value of the interview is that it gives skilled interviewers an opportunity to observe the general  presentation of the candidate and his/her attitudes, aptitudes and aspirations.   Admission interviews are very labour intensive.   They require training of the interviewers and tie up four people per interview, and I suspect for that reason in many institutions much of this sort of information is gathered by references, letters or essays written by the candidate and/or referees.  Unfortunately, these are often more indicative of the candidates ability to hit on the 'right' formula and sometimes templates are easily recognizable in the letters submitted.
     In the interview, the demeanor and general presentation of the candidate tells a lot.  Anxiety is normal and we spent some time in making the applicant as comfortable as possible.  Some candidates were obviously well rounded, had broad interests in what is going on in the world and showed comprehension appropriate to their age and experience.  Some were totally lacking in general knowledge.   Some had never read a book. Some had a realistic idea of what it might be like to be a physician and had talked to a doctor or nurse or someone at their local hospital.  Some had aspirations and ambitions to do something in health care, like be a family  doctor or a pediatrician or a 'research' doctor.   Some had no such aspirations and one fellow answered my question re an important achievement with, "I'd like to get around the golf course in par."        
    There were four interviewers and while that may have been a bit  overwhelming, it made the procedure very fair, as each interviewer graded the candidate separately and only after the interview did we compare scores.   If ALL of the interviewers were not very close in their assessment, the candidate got another interview.   That did not happen very often. 
    I continue to believe that the interview is an important part, perhaps the most important part of selecting prospective physicians, who will deliver the best possible care to the population.   I hope it will not be abandoned in favour of easier but less valuable methods of selecting the future generation of physicians. 
If you have any opinions on this, share them with me!!

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