Education, Health, Science, Top Stories

Declining Med School Standards in a Time of Pandemic

In the beginning were the Medical College Admission Tests, or MCATs, a time-honored means of ascertaining worthiness for medical school. Formulated by the Association of American Medical Colleges, the MCATs assessed an applicant’s cognitive heft and baseline acumen in such no-nonsense disciplines as anatomy, biology, kinesiology, chemistry, and other precincts of hard biophysical science.

Then, around the turn of the millennium, early social-equity advocates began insisting, in essence, that the MCATs unfairly limited med school to people who showed significant potential as doctors. Specifically, the pool of physicians being churned out each year was judged insufficiently diverse. A chief concern was that African Americans, 13 percent of the US population, represented barely six percent of medical school enrollees. Efforts were made; the numbers ticked up incrementally.

Then in 2009 the body that accredits medical schools, the Liaison Committee on Medical Education (LCME), touched off a parity panic across the med school landscape by issuing stern new guidance on diversity. In order to remain accredited, declared LCME, medical schools “must” have policies and practices in place that achieve appropriate diversity.” Enough airy talk of opportunity; let’s talk outcomes.

Words like “quota” were judiciously avoided but were legible in the reams of bureaucratic gobbledygook produced by newly socially aware medical administrators. Example:

Addressing the structural inequities laden in our system of selection of medical students… begins with ensuring we are using accurate metrics to set goals and track our progress. The representation quotient, one such metric, can be applied at the state and institutional level to ensure efforts align with the intended goal of creating a future workforce reflective of their respective patient populations.

Translation: If your enrollment of underrepresented minorities skews too far from population demographics, watch out. Thus began a willy-nilly search for correctives that today seems poised to eliminate all barriers—that is, uniform standards—that prevent med schools from simply anointing desired candidates qualified to practice medicine.

In the wake of the LCME’s watershed edict, working groups were convened, budget line items were created, and high-profile hires were made to facilitate diversity boosting and community recruitment. A main stumbling block seemed to be minority candidates’ poor performance on gatekeeper exams like the MCATs. Unintentionally ironic assertions began appearing in the literature. From anesthesiologist and author Dr. Maxime Madhere: “A huge obstacle to diversity is that most medical schools have the same criteria for all applicants.”

Equity advocates championed tests that emphasized “non-cognitive” factors in admissions decisions, such as the SJTs, with the SJ standing for situational judgment, not social justice (though a felicitous coincidence). SJTs, which appraise soft-sided skills like emotional intelligence, became at least a supplementary criterion at several dozen American med schools. Now, it’s beyond dispute that some of the skills tested for in the likes of the SJTs are desirable in a medical professional—emotional intelligence, empathy, compassion. They’re likely desirable in any professional, which is why such testing has been used in workplaces and other settings for years. And that is indeed the way the new testing was framed upon its entry into academic medicine.

But given the tenor of the times and the mandate from on high, it seems clear that the new testing was implemented at least in part as a workaround and as a sop to progressive dogmatists, who argued that admissions officers needed a benchmark to use apart from the knowledge testing in which minorities seemed relatively non-competitive (that disadvantage lingers, by the way). The primary selling point of SJTs was thus that they allowed schools to consider factors other than such blind metrics as a straightforward ranking of applicants’ college grades and MCAT performance. The MCATs themselves were revised in 2015 to give meaningful weight to areas of the social sciences.

Alas, under-represented minorites, once admitted, didn’t necessarily thrive. In fact, they were 97 percent more likely than were their counterparts to struggle academically as well as substantially more likely to wash out before graduation. This begat more scrutiny of the output end of the process. One white paper asserted uncritically, “In the competition to recruit minority students, most medical schools relaxed their admissions standards… On the other hand, no school relaxed its graduation requirements.”

There ensued calls for more hands-on mentoring and an increasing switch to pass/fail grading, thus creating less clear-cut performance gradients among students. Some advocated that the MCAT itself be pass/fail, in order to open up a larger pool of “qualitatively similar” applicants and allow more leeway in acceptance decisions.

The language of the social justice Left began appearing in diversity statements at even the most elite schools. From Harvard: “We acknowledge the strengths and weaknesses of our history and actively promote social justice, challenge discrimination, and address disparities and inequities.” Does that sound like med school rhetoric or a mission statement coming from an activist working group at Evergreen State? Yale’s statement stressed the importance of “speaking truth to power,” and that the school’s “ultimate goal is to better support student advocacy for social justice within and beyond the campus community.”

Seemingly left unasked was whether or not a medical school’s ultimate goal should have more to do with graduating quality doctors. Nonetheless, schools that failed to take heed risked having their hands slapped. The University of Missouri School of Medicine was twice threatened with loss of accreditation. By the decade’s end, this blitzkrieg approach to deepening the pool of diverse physicians began to pay noticeable dividends, according to a December 2018 study in the Journal of the American Medical Association that tracked minority enrollment since the 2009 LCME accreditation standard. Between 2017 and 2018 alone, the number of black students enrolled in US medical schools rose by 4.6 percent.

Unimpressed, critics complained that med school students were still 58.9 percent white. This, even though that stat remains well below census demographics, which indicate that 72 percent of Americans are “white alone.” Observers indicted even the newer generation tests for an endemic bias towards “privilege”: “Applicants with disadvantaged backgrounds still score lower on SJTs than their privileged peers, even if the difference is less than with the MCAT.” Always, that circular foundational assumption: that under-performance is, must be, a byproduct of some diabolical social antecedent: If the numbers don’t support an equity agenda, the playing field cannot, by definition, be level.

One sees the same line of argument in rhetoric from a group calling itself White Coats for Black Lives, or WC4BL. Founded in 2014, and modeled after the Black Panthers’ work in achieving equal healthcare access, WC4BL immediately demanded that med-school curricula include coursework in Black Studies and even intersectionality. Last year the group issued its second “Racial Justice Report Card,” which evaluated 17 medical schools through a social-justice lens. No medical school was graded higher than a B-. Harvard and Johns Hopkins received a C+. WC4BL told the Guardian that this signals a need for even more “robust” anti-racism training.

Other activists then called for a warmer embrace of so-called holistic admissions processes that further emphasize non-cognitive factors, with bonus points awarded for socioeconomic status, community service and “life experiences”; some suggested dropping the pretenses and unapologetically ranking candidates by race.

Let us close with a bit of inescapable context, the infectious elephant in the room, as it were: The world’s current struggles against COVID—19 underscore the vital importance of quality medicine. If you are the best and the brightest, you should be in medical school. You should not be in medical school for reasons other than that.

 

Steve Salerno is an essayist and professor of journalism. His 2005 book, SHAM: How the Self-Help Movement Made America Helpless, explored the self-improvement industry’s wider footprint in society. You can follow him on Twitter @iwrotesham.

Photo by National Cancer Institute on Unsplash.

Comments

  1. Wow, kudos to the author for taking on one of the more taboo topics in medicine right now. I was involved in medical school admissions in the early 1990s, and even then, there was an unspoken double standard applied to applicants in an attempt to promote diversity. One of my current colleagues recently left an academic appointment where he sat on the admissions committee for over a decade, and if his accounts are only half true, it is unsettling. He was forced to sign legal documents that he would never divulge the details of the process, or reveal the admissions standards. He shared one account where they reviewed a white male applicant with 3.7 GPA in physics from a well respected school with MCAT scores in the 85th-90%ile, and who had demonstrated unusual leadership qualities in his extracurricular activities. The committee decided to place him in the “wait list” category, acknowledging that he had “real potential”. The next applicant, and he swears it was the very next applicant, had a GPA of 2.9 from an average school in a relatively soft major, an MCAT score in the ~40th %ile, and little to nothing to distinguish himself outside the classroom; however, he did have a blended hispanic/african-american background, and the committee responded as though they had hit pay dirt. They pontificated about how such an applicant would be invaluable by bringing their life experience to the institution. My colleague listened, and then stated “To be clear, we are accepting a student with poor academic credentials because of his race, and we are wait listing a strong candidate because of his?”. The following day, he received an e-mail from one of his superiors warning him to avoid such divisive comments in the future. He resigned from the committee shortly thereafter.

    Look, in an ideal world, all of our professions would include the most talented individuals for that profession, and the phenotype of those individuals would more or less proportionately reflect those of society; however, it needs to be merit based and cannot be the result of well intentioned social engineering. I am certain that in the past there was discrimination against qualified candidates based on gender or race; however, lowering the standards of a profession does not somehow offset iniquities of the past.

    One of my lab partners in medical school was a member of a minority group, and he was quite vocal is his opposition to double standards for admission. He agreed that minority groups as a whole faced far more adversity in attaining high academic achievement; however, he would say “it is too late to level the playing field in medical school. It needs to start with better education at the elementary through high school level”. He was correct, and he watched in dismay as a few of the minority members of our class had difficulties passing the board examinations and getting to graduation. These students were not stupid, they were woefully unprepared for the academic rigor of medical school. It was no favor to place them in that environment without the requisite skill set, all in the name of achieving diversity.

    The hardest exam you take in medical school is the USMLE Step I. It occurs at the end of your second year of medical school, and any topic from the basic sciences of your first two years is fair game for testing. No exaggeration: I studied at least 10 hours a day for 6 weeks for that exam, and still felt woefully unprepared. Why is that test so important? Well, for starters, you couldn’t begin your clinical clerkships in third year without passing it first (or at least that used to be the rule). Additionally, it is the only nationwide standardized test that residency programs can use in trying to differentiate candidates (think of it as an ACT or SAT for medical students), and while imperfect like the ACT and SAT, it is one of the major criteria competitive programs have used to sort through candidates. A decision was made by the USMLE earlier this year to abolish grading for Step I and simply assign a “pass/fail” grade…I wonder why?

  2. I know nothing about this superior or your friend, but I am convinced that we are proceeding toward a day when all candidate selection committees of this type will be comprised solely of women of color.

    People who are the least likely to complain about racial and gender quotas.

  3. Yes, I think it would be difficult to be fair minded and sit on one of those committees. The sad thing is that the good intentions end up hurting the individuals they propose to help, but that is another story.

    While the author is on a roll, I would like to see him take on another controversial topic tangentially related to this one: as the enrollment of women in medical school has skyrocketed, what has been the impact on the medical workforce? Medical school admissions have been static since the mid-1990s with no increase in graduating physicians. Enrollment of women has skyrocketed to the point that women now constitute more than 50% of all medical students nationwide. That is commendable on many levels (assuming merit based), but does pose a challenge to our medical workforce. It is indisputable that women physicians choose part-time positions far more than male physicians, and are more likely to temporarily or permanently leave medicine in order to raise their families. The feminists will counter that this is the result of a misogynistic system that expects women to be the caregivers of their children, but in my experience, my female colleagues willingly chose to reduce their workload because they didn’t want to miss the opportunity to raise their children. I commend their commitment to family, but the reality is that it does put a strain on the physician workforce. Perhaps medical schools need to increase enrollment, and residency slots need to expand, to accommodate this demographic shift in the physician workforce.

  4. We are now on to life and death matters. Would you like to go under the knife of a “diversity” surgeon?

    Not long ago, “diversity” invaded air traffic control in the US.

    Have you had enough? How far do you want to take this? All the way to suicide? “Better dead than racist” – is that it?

  5. In an earlier life, I spent a great deal of time in the company of physicians of all races and specialties. I had the opportunity to speak to many of them on all manner of topics, not just medicine.

    Out of all that personal experience - and please note that I am not going to include links here to articles and studies that I’ve cherry picked off the internet - as I say, out of all that personal experience, I have formed these preferences:

    For a family physician, give me a woman every time. Race is not important.

    For any other specialty: give me a white or 2nd generation Chinese/Japanese/Korean man. The sexual preference isn’t important, but no transexuals.

    (These preferences are my own. Your personal experience may vary.)

  6. Unfortunate and unbelievable. I agree that a person allowed into medical school should be able to finish the course requirements.

    Yet, as an black female that has had to battle since high school, nepotism, stereotypes, and basically a world where white men struggle with power issues this article is disturbing.

    If our primary and secondary schools offered the same level of educational opportunities and rigor perhaps I can agree that there are not disparities and “every man for himself.”

    Here in Atlanta,GA the best public schools are located in areas that the average middle class family cannot afford. This means you are stuck with sending your child to a school that lacks resources, which means you probably will struggle to achieve a great GPA in college due to a subpar academic foundation.

    The private schools in Atlanta are predominantly white and once again certain groups are priced out, unless you can get a scholarship.

    The current church I attend is Southern Baptist, of course in a high end part of (the county). We had a class on racial reconciliation and the biggest point made was as Christians have we shared the burden of our brothers that are of color.

    I am conservative secondary due to my biblical beliefs, so please hear me out. How many people of color does anyone in this forum have in their inner circle? I mean you talk with, hang out with, your kids play together, and you work through cultural differences with as true friends.

    Most on this forum may have a token black friend that (trust me) has to assimilate in order for you to feel comfortable, because all of us hate discomfort.

    So when you develop this friendship and ask your fellow black physician, “what is it like being black and a physician in the US,” first expect surprise and second get ready to hear the pain and the hazards that still exist in the USA.

    Ask about their road to MD and perhaps then you may say to yourself, “what can I do to improve the road to medical school for a black child trying to make it to dream that is very elusive and at times unachievable.”

    However most of us live in the world of “status quo,” if it does not directly affect-you then do as others do just push out the words, “c’est la vie!”

    I end this by saying that I do agree that admission should be based on academic acumen, but maybe there is something to looking at the deeper issue of “why are minorities struggling to make the grade!”

  7. I like this question, and I think it’s a deeply important one. Not only for the racial aspect but for the completely separate issue of friendship. Or as you put it, “inner circle”.

    What is friendship, really? How do you find a friend, or do they just walk up to you and present you with friendship? How will you know that someone is truly a friend and not something less than that.

    What is the difference between a friend, a work acquaintance and a neighbor with children the same age as mine?

    It is one thing to say “people I socialize with”, but something else again to say “inner circle”. There, I think we’re talking about friendship.

    In my case, the category of “people I socialize with” was considerably larger in my teens and 20s that it is now. This is because of my age and current lifestyle. When I was young, I lived in cities the size of Atlanta where racial mixing was not only common but easy and convenient.

    Today, my home city and my circle of acquaintances are much smaller than in previous years. My “inner circle” is me and my wife. The true friends that I’ve retained live in other parts of the country, not here. Here, there are neighbors, but neither I, nor they, have small children in residence to provide social lubrication.

    So, in earlier years, I had black coworkers with whom I occasionally hung out with. One black girlfriend, who was most definitely not a token. And black neighbors.

    But today, the black girlfriend is wherever ex-girlfriends disappear to. I no longer have co-workers of any race. There are a handful of black neighbors down the street and around the corner, but we only nod to each other. I think they would be suspicious if I walked over there, past their white neighbors, and invited them over to the house for coffee. (You know, like I was trying too hard to be woke.)

    As I say, interesting question, but tangential to the issue of declining med school standards of admission.

    Oh, and welcome to the community.

  8. Actually, untrue. One of the things that a neurosurgeon needs to be able to do is absorb new knowledge in the field and decide what’s trustworthy. That’s done by basic neuroscientist, and it really helps to have a basic grounding in a bunch of these fields to be able to understand what’s going on. Besides which, a lot of these fields interconnect. It helps to understand something about pharmacology when you’re going into neurosurgery, which does depend of organic chemistry, as well as a certain amount of functional knowledge of the other body systems, because some of what is going on there can impact the brain in a major way. For example, some ataxias are actually caused by lung cancer. Understanding a bit of opthamology helps you figure out where certain tumors are in the brain. Things like that.

  9. My cardiologist is a fairly one-dimensional sort of person. He’s white, a man, with very little apparent personality and no particular interest in me as a person.

    But I happen to know where he did his fellowship, and I also happen to know, very well, the senior cardiologist who supervised him during that fellowship.

    I’m very glad this one-dimensional, rather cool and aloof white man is my cardiologist, although I suppose he may have taken the place of a less-qualified person of color in medical school.

  10. Never mentioned anything about the wealth of the applicant’s family or if he went to ivy league school, simply that he was a physics major at a well respected university (there are plenty of well respected universities aside from the ivys, and many are public universities). Your response exposes your bias, and I have no desire to engage with those who have accepted the intersectional world view. It is a waste of effort.

  11. Would you have found it “fine in the grand scheme of things” had you been passed over admission because those positions had been given to lesser qualified candidates? Would it really sit well with you to be seeking out work as a medical scribe, research assistant, or hospital transporter in an effort to boost a resumé that was already superior to many of the students sitting in the medical school lecture hall? Perhaps you would, but I’m doubtful.

    We can debate what factors are predictive for producing the best future physician, but once we agree on what those factors are and establish objective criteria, it should apply to all applicants, irrespective of race, gender, SES, sexuality, etc.

  12. It’s late, so I will keep this brief, but it strikes me as rather sad that you somehow feel that it is morally acceptable that you atone for the sins of an earlier generation. This is a slippery slope upon which you don’t want to start. Your generation is admirable in desiring equity, but I’m not sure it recognizes the long-term destructive nature of identity politics.

  13. Yes, I get it, but I still have problems with it. There seems to be an overriding assumption that all white/asian male applicants somehow have experienced privileged lives and, therefore, it is less of a sacrifice for them put their lives on hold for a year or two, or to be fully rejected and have to choose another career path. As I’ve stated previously, the identity politics game makes far to many assumptions (many faulty), ultimately values individuals based on phenotypic characteristics (or cultural assumptions) over which they have no control, and in the end gets quite ugly.

    Not to belabor the point with personal anecdotes, but I mentioned my African American classmate (I’ll call him Dave) who was somewhat vocal in his opposition to race-based standards. Perhaps this was because he had come from an affluent household, had attended outstanding schools, and had a strong academic record. His family had more personal wealth than most of our classmates, yet he was offered (and expected to accept) scholarships for reduced tuition, free books, etc…not based on need or the travails of his family of origin…solely based on the distribution of melanin in his skin.

    I make this point because one of our mutual friends was Asian-American and had a much different upbringing. He was first generation, his father owned a Chinese restaurant in a strip mall (I think it had a cheeky name like “Wok-N-Roll”), and he had spent his entire youth busting his ass at that restaurant (as had all of his siblings). The family scraped by because the labor was free. There was no time for him to build a resume with sports, scouts, drama club, etc. Steve went school, and then went straight to that restaurant where he would alternate working and studying until late in the evening…every day, every weekend…all the way through college. He had great grades from a local public college and he crushed his MCAT.

    To suggest that Steve should have somehow felt compelled to step aside (or delay his entry by a couple years) so that Dave could have a spot is ludicrous on the surface, yet that is exactly where race based admission policies lead us.

  14. I am convinced that we are proceeding toward a day when all candidate selection committees of this type will be comprised solely of women of color.

    Shame on you. Surely you meant trans women of color.

  15. I’m not sure what in the original article was “hateful.” Quite the contrary, it could be argued that it’s hateful to support policies which discriminate against individuals on the basis of their race. As such, affirmative action, as practiced in academic admissions and hiring, is unethical. I agree that it is appropriate to use performance-related criteria that extend beyond test scores, but these should be applied evenly. As another poster has commented, problems that lead to under-representation occur far upstream, and that’s where efforts need to be concentrated.

Continue the discussion in Quillette Circle

134 more replies

Participants