Are we getting the right students into the medical school?
To answer this question, we have to decide what we want students to look like when they get out of medical school. There is some debate about this but not as much as you would think. Once we decide what characteristics we want our graduates to have then we can start looking for those characteristics in the students that get admitted to medical school. It is the most important question if we want to answer the first question. Why is it so important?
That is simple. The outcome is determined by the input. It is like the old computer adage—garbage in, garbage out.(1) Not that medical students are garbage by any means, in fact they are a pretty amazing group of young men and women. But, if we wanted all of our graduates to be black, but all of the students that were admitted were white, how much success would we have? Not much! In the same vein, if we wanted our graduates to all speak Spanish, what is the easiest way to accomplish this? Clearly, admitting students that speak Spanish is far easier than teaching them Spanish during medical school.
This discussion works for a lot of the characteristics that people think are important for their personal physician to have. Take communication skills. We can teach them techniques to improve their communication skills and their techniques in taking a medical history. If the students that we admit to medical school have poor listening skills or they are very shy and do not like to talk to other people it will be much harder to end up with a graduate that has good listening skills.
Another example is professional behavior. I like to call this “not being a jerk” but it is much bigger—self-sacrifice, commitment, respect, accountability, and trust.(2) Can we teach those things? I don’t think so. I think a student either has those characteristics or they don’t. They do not learn them in medical school. We have to admit students that have the characteristics and then we can teach them how to actualize them as a medical student and physician.
The funny part of this is that we take this for granted with one attribute: the ability to do well on standardized, multiple-choice question tests. No one argues that an incoming medical student should not be good at that skill (and for sure it is a skill that is learned). So the graduating output is a physician who is good at answering multiple-choice questions. No surprise, but is that what we want. It is clearly part of what we want, right? We believe that doctors should have a basic minimum knowledge base in medicine, but is that the only key to being a good doctor?
We need to start thinking about what we want in our graduates. The US spends a lot of money on educating doctors. State tax revenue supports many schools. Federal research dollars support the infrastructure at many schools. Students pay tuition with the help of federally backed student loan programs. Even graduate education is mostly funded through federal Medicare dollars. (see the great piece on GME accountability by Kenny Lin, MD, MPH, at the Common Sense Family Doctor) But for all of this, we the people, have very little say on the output. There has been remarkably little discussion of accountability of medical schools to the tax payers for their physician graduates.
Do they have the characteristics that we need from our physicians?
Do they care for the people that need to be cared for?
Are graduates practicing in the geographic regions that we need them to be practicing in?
I think the answer to all of these questions is—no, unfortunately. There is this idea that it is ok for medical student outcomes to be market driven. That is rubbish! The people are paying for medical education. We deserve to get the right outcome for our money.
This brings me back to my original question—are we getting the right students into medical school? If we want to change the answers to the three questions above, then we have to change the students that come into medical school.