Using interviews to select medical students

This is the fourth in a series of posts about entry of students into medical school. In the last post, I blogged about personality traits that may be better suited to being a medical student. Unfortunately, most schools in the US do not use personality profiles as a screen for incoming medical students.

At most schools, the closest that we come to this is the admissions interview. Many believe that a 30 minute interview is a good way to weed out bad apples. I am not sure that this is true. Just on the surface, it seems like an experienced interviewer may be able to identify highly dysfunctional people. By dysfunctional, I mean traits that would be obviously detrimental to their function as a physician. These obvious dysfunctional traits are things like: students who have difficulty talking to others, students who have flaws in their ethical approach to life, and students who have problems with their reasons for entering medical school. But what does the literature say?

Powis, et al (1) used a case-control design to study students who were admitted to medical school but did not graduate. They retrospectively analyzed 56 paired cases and controls. The cases were students who had left medical school due to failure or withdrawal, while the controls were students who had completed medical school. The controls were all students who had excelled in the their academic performance. The students who left medical school had all been rated lower at their admission interview. Effect sizes were statistically significant in the Overall rating (ES=2.17), self-confidence (ES=2.59), perseverance (ES=2.98), and tolerance of ambiguity (ES=1.04).

The Powis study used a objective and structured interview and they compared the students who left or were dismissed from medical school to those who received Honors in medical school. It is not clear that the admission interview would distinguish between failing students and anyone who would not fail. Admission interviewers have widely variable reliability. Powis found the inter-rater reliability varied from .23 to .63 for seven different qualities assessed by two faculty members. Other studies have found that reliability data is better for interview programs that use a structured interview process (.82 to .84) while with unstructured interviews the reliability is .61 to .75. (2)

So, reliability is not great, but seems to be better with more structure. Part of what provides structure is giving interviewers training and giving them types of questions to ask. But (and this is a big but)...I think that the interviewer has to be experienced as an interviewer. They have to be able to sort through the information presented by the student. They have to be willing to ask probing questions and be willing to make the student uncomfortable. Questions about ethical grounding or hypotheticals about decision-making are difficult. Interviewers can be blinded by other characteristics. Like MCAT scores．

For instance, I have heard interviewers say, well they didn't interview very well but they have great MCATs, so they will do fine. I am not kidding, I really heard a faculty member say that. And they were being serious! I know that is not supported by the data, but you still hear it a lot. The interviewer has to be experienced enough to ask tough questions. Not just, "tell me about your fraternity activities in college" but hard questions about ethics, hypotheticals, and dilemmas. They have to ask about motivation, why do they want to come to medical school. They have to get beyond the pat and prepared responses that students practice during their mock interviews and really push the student to get at internal motivations and thought processes.

And what about medical students? In my experience the medical students that we ask to interview are pretty good at sniffing out the bull. But their problem is that they feel so happy to actually be in medical school and almost finished (our interviewers are fourth year students) that they tend to be a little easy on the score sheets. Gutowski and colleagues,(3) looked at current medical student interviewers. They found that when compared to faculty interviewers, students wrote more about applicants' motivation, personality, communication skills, and interests. Student wrote more in the overall evaluation sections (p<0.001) and gave more examples on the motivation section (p<0.0011) and communication skills section (p<0.0035).

So, I guess the bottom line is that there is no easy way to figure out who are the right students to admit to medical school. We should push for multi-dimensional models that minimize the MCAT and utilize personality characteristics. We should ask the admissions committee (and the dean) to define what they think are the qualities and characteristics of the students that should matriculate to our medical school. And maybe most importantly the admissions committee should be held responsible for the results of their work.

References
(1) Powis DA, Neame FLB, Bristow T, Murphy LB. The Objective Structured Interview for Medical Student Selection. BMJ. 1988;296:765-768.
(2) Albanese M, et al. Assessing Personal Qualities in Medical School Admissions. Acad Med 2003;78:313–321.
(3) Gutowski CJ, et al. Current medical student interviewers add data to the evaluation of medical school applicants. Medical Education Online 2010;15:5245.

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