AMA Journal of Ethics^®

From a program director:
“…she would be a minority woman who graduated from Harvard Medical School at the top of her class, got honors in all her required third-year clinical rotations, had been elected to AOA, had a PhD with a record of significant research and funding, scored in the 99th percentile on USMLE Steps 1 and 2, acquired superior reference letters from top colleagues in our specialty with whom she had worked closely and who said they wanted her in their program, had a dynamite personality, and had the energy of a thirteen-year-old.” 
Iserson’s Guide to Getting Into a Residency, 5th edition [1]

For many years in American medical education admissions, medical schools and residency programs nationwide found their candidates by looking for certain concrete, measurable qualities: academic achievement on a standardized level, volunteer and other clinical experience, and professional and educational leadership. More recently, admissions committees and governing bodies such as the Association of American Medical Colleges have made attempts at both the medical school and residency level to assess candidates more holistically, looking for qualitative aspects of character, such as empathy, emotional intelligence, and values. In this issue of Virtual Mentor, we seek to address the many ways in which medical school and residency program admissions policies are moving toward a more holistic process. In doing so, we explore some pitfalls of these new systems as well as old problems that have not yet been corrected.

Schools have also been actively making shifts to seek out not only racial diversity but more recently, students from more economically diverse backgrounds. Indeed, the collective body of physicians in training has drastically changed in a short period of time, as elucidated in this month’s medical narrative by Samuel Shem, MD, PhD.

The motivations for the recent paradigm shift in admissions are wide-ranging and can be interrogated from both “student-centered” and “society-centered” perspectives. Medical schools and residency programs have control over admissions, and, while it could be argued that the annual residency match results continue to show a decrease in the number of primary care physicians in training, it also may be thought unwise to stifle student autonomy, passion, and commitment to a chosen field. We know that, for decades, medical schools sought out an archetypal student, one who excelled academically. Not much emphasis was put on seeking those with difficult-to-measure but equally important aspects of character that are imperative for good patient relationships and communication. Perpetuation of medical school culture that existed for so long now appears to be incompatible with community health imperatives and the need for cultural understanding in medicine.

Moreover, ethics and professionalism are well-accepted standards, and instruction in these values has been included in the formal curriculum of medical schools for quite some time. Yet the prevalence of professional violations, including cheating and substance abuse, in medical student populations is still overwhelming and may not be affected by formal ethics teaching, suggesting that a well-defined, clear standard of conduct and level of conviction may need to be directly sought in candidates during the admissions process.

From a populations standpoint, the percentage of students coming from medical families is rising in medical schools nationally and globally, despite most schools’ increasing search for students from diverse backgrounds. Likewise, students from medical families have, in the limited literature, been shown to be more likely to enter competitive specialties, and their choices of specialty are easier to predict, which may indicate informed interest. Having parents from a medical background may confer distinct advantages to students by molding or directing their interests and informing them about securing admission to medical school, successfully completing it, and becoming a better doctor. But overselection from this group may lead to homogeneity in the physician population and may increase barriers to entry for first-generation medical students. This phenomenon is addressed in a case discussion in this month’s Virtual Mentor by Norma E. Wagoner, PhD, and Carol L. Elam, EdD.

Several challenges have been posed to the changes in the goals of medical school admissions and means of achieving them. Since efforts to diversify the ethnic and racial backgrounds of medical students began more than 40 years ago, the U.S. Supreme Court has heard two cases brought by students who thought that a school’s preference for diversity in the class cohort caused their rejection. Valarie Blake, JD, MA, reviews those cases in her health law article.

As more in-depth testing on personality and ethics knowledge have been introduced on a regional and national level, questions have been raised about the standardization, replicability, and statistical validation of such tests, as well as the concern that they might suppress, rather than promote, diversity. This question is taken up in two commentaries—one by Asher Tulsky, MD, and another by Matthew J. Zirwas, MD, and Julie M. Aultman, PhD—on the ethical use of personality testing and behavioral-based interviewing (BBI) during residency admissions.

While progress has been made in creating an ethical admissions process, some flaws remain. Again, many of them concern the degree of variability among medical schools’ methods of evaluating students, a process that has huge implications for a student’s professional development and career path. Two evaluation tools, the letter of recommendation and the medical school performance evaluation (MSPE), and the potential biases and hazards associated with these tools, are discussed by Rick D. Axelson, MD, and Kristi J. Ferguson, MSW, PhD, in their state of the art and science article and by Marianne M. Green, MD, John X. Thomas, MD, and Sandra M. Sanguino, MD, in their op-ed. In their journal discussion, third-year medical students Kevin McMullen, Matthew Janko, and Kelley Wittbold question the findings of a study published in 2011 that concluded that the genders of MSPE authors and the students they were writing about did not affect ranking decisions.

The current system of residency admissions is also open to the charge that it creates incentives for students to compromise their ethics for the sake of succeeding in the match, for instance revealing their rank list ahead of time or accepting positions “under the table.” This sort of deception undermines the fairness and anonymity of the match, which in theory should allow for improved student outcomes. Jennifer A. Sbicca, MD, Katherine Gordon, MD, and Stefani Takahashi, MD, engage this topic in a case commentary, as does Justin List, MD, whose medicine and society article investigates whether medical education admissions policies work against the very sorts of candidates they wish to find.

This issue of Virtual Mentor also looks ahead to expected changes in admissions and what effects these may have on future medical students and residents, be they traditional applicants or otherwise. For instance, the National Resident Matching Program (NRMP) will this year introduce its “all-in” policy, under which residency programs that participate in the match will not be permitted to take any candidates whatsoever from outside of it. The implications of this are discussed in the policy forum article by Jennifer Saultz, MD, and Nathan Wright, MD. And, in another state of the art and science article, Erik Porfeli, PhD, and I explain a new instrument designed to gain insight into a student’s ultimate career outcome by assessing both inventoried and expressed interests.

This changing emphasis in assessment of personality and interests is not universal. In the interest of an outside look at our system, Andreia Martins Martinho surveys European systems of admissions in her medical education article.

Finally, we affirm that academic excellence and strong qualitative personality traits are not dichotomous and should not be addressed as such. Admissions standards can be modified to identify students with a reasonable degree of both, which can serve to help medical education become aligned with society’s needs while also applying an appropriate degree of rigor to admit the best and brightest students. As Geoff Norman writes, “The solution does not come from de-emphasizing marks, but from developing better measures of other characteristics that are equally important, but poorly measured” [2].