Physicians

Is Medical School Admission Squashing Creativity?

What does it take to get into medical school today?

High MCAT scores. Pre-requisites galore, coupled with a stellar GPA. Research experience. Clinical experience. Volunteering.

It has become a series of check-boxes, many going through the process gripe. Worse, it’s an exercise in conformity.

Last week at TEDMED, Dr. Jacob Scott shone the spotlight on this system as a root cause of the lack of creativity among people going into medicine.

“You can’t take any risks, or you won’t get in [to medical school] – you won’t get into the club,” he told the audience. But, he continued, that means weeding out creativity. Future doctors are being trained to “memorize certainty,” rather than think imaginatively.

Having gone through the admissions process recently, I could relate to many of Dr. Scott’s sentiments. It’s true: preparing to get into medical school does little to encourage risk-taking. Admission criteria are rigid. And you know if you don’t do what they ask, there is no shortage of others who will.

Want to become a doctor? You can’t slip up, or you’ll fall behind. You can’t rock the boat, or you won’t get admitted.

This critique is not unique to medical education. Scott’s talk reminded me of a speech by former Yale English professor William Deresiewicz to the 2009 plebe class of the United States Military Academy at West Point. Skeptical of modern benchmarks of success, Deresiewicz told the young cadets:

“It’s an endless series of hoops that you have to jump through [to get into college], starting from way back… What I saw around me were great kids who had been trained to be world-class hoop jumpers. Any goal you set them, they could achieve. Any test you gave them, they could pass with flying colors…. I had no doubt that they would continue to jump through hoops and ace tests and go on to Harvard Business School, or Michigan Law School, or Johns Hopkins Medical School, or Goldman Sachs, or McKinsey consulting, or whatever. And this approach would indeed take them far in life.”

Apply that to medical school, and you get a system that selects for people who have known they wanted to be doctors since the first day of college, or even earlier. Often, that translates into students who come from families of physicians. Those who come to discover the beauty of medicine through another path, later in their academic trajectories, find themselves significantly behind – with the gap so large that many are discouraged to try. It’s too late to become a doctor, they think.

And the mandates keep escalating. In 2015, for example, aspiring medical students will have to endure a new MCAT (Medical College Admission Test): about two hours longer, with new sections on psychology, sociology, and ethics in addition to the previous sections testing physics, chemistry, biology, verbal reasoning, and writing.

I do not contest the goal of cultivating well-rounded students. But I would disagree that multiple choice questions are the best way to assess these forms of thinking. I could imagine a situation where actually grappling with ethical situations in real life could keep someone from adequately preparing for the ethical section of the exam.

Not every desirable trait is exposed through filling in bubbles.

To me, the new test means more mandates. More hoops to jump through. More rigidity. More contrived benchmarks of success. More ways to fall behind.

Pointing out flaws in a system is a good first step. But it’s not enough.

The real question is: can we propose a better alternative?

There is no such thing as a perfect admissions system. Every method you can conceive will have benefits and drawbacks.

You select a system by identifying different options, evaluating them, comparing them, and determining not the one stands out as ideal, but the one that is least bad. The one that maximizes what you consider the most important pros, and minimizes your conception of the worst cons.

It’s like what Winston Churchill said about selecting the best form of government: “No one pretends that democracy is perfect or all-wise. Democracy is the worst form of Government except for all those other forms that have been tried from time
to time.”

No doubt, the medical school admissions system has flaws. But can we do any
better?

If not by grades, MCAT scores, and extracurricular activities, how do you identify good future doctors?

The status quo certainly has its advantages.

After his TEDMED talk, I had the pleasure of sitting down with Dr. Scott. “I’m just
blowing the whistle,” he admitted. “I don’t have the solution.”

Still, he had some suggestions. One was setting quotas on undergraduate majors. We could create a class of twenty biology majors, twenty physics majors, twenty English majors, and so on. “Your ways of thinking are strongly defined by your major,” he explained. Thus, to assemble a diverse array of thinkers, recruit a diverse array of majors.

And yet – isn’t a person more than his or her undergraduate major? Isn’t that ignoring all a person’s other traits that would predict a good doctor? Creating a new check-box? Not rewarding holistic learning? I agreed that medical schools need diverse ways of thinking. But, I thought about the distinction between creating a well-rounded class – and a class comprised of well-rounded individuals. I wouldn’t want to neglect the latter.

I said this to Dr. Scott. He nodded and said: “right on.”

Maybe it’s that attitude, right there, that we need.

Discourse, not dogma. Not just criticizing the status quo, but proposing new ideas. Dialogue. An honest evaluation of pros and cons.

A person who says “right on” to opposing ideas. A person who can adjust his or her own ideas in response to new ones.

That’s a creative person. That’s a creative doctor.

Ilana Yurkiewicz is a first year medical student at Harvard Medical School with a developed interest in mass media and science journalism. This piece was originally featured on her Scientific American blog, Unofficial Prognosis.

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25 replies »

  1. My D is a HS Senior. Looking to go into medicine. Has a perfect ACT, almost perfect SAT. Has got a number of AP (12)

    She has been told that if she wants to maintain a high GPA in college she should not take college credits for the AP courses she has already got a 5 on. In other words, if she repeats the same courses, her GPA is likely to be very high (on the other hand, if she takes a credit and takes a course of higher level of difficulty, her GPA might end up becoming low). And a high GPA is what medical schools look at – not the level of difficulty of the course taken.

    If this is indeed true, then it looks like Med Schools don’t care about the level of learning – but only for check boxes. It is sad that bright kids interested in medicine don’t take higher courses but focus just of GPA.

    This, sounds absurd to me.

  2. This blog post is a bit old; however, I do hope to still stimulate some conversation!
    Yes, indeed, I do think the medical school (or, rather, pre-medical school) curriculum is in need of a reform. While the extensive pre-requisites are diverse in that there are many and produce individuals that manage to volunteer, do research, and nail A’s on a transcript, these numerous checkboxes leave room for not much else. Yet, what most interests me is the rigorous science-based pre-med curriculum that, rather than preparing undergraduate students for the years of medical training ahead (i.e. more science), seems to encourage an almost science-burnout. I experience this with many of my undergraduate peers now; they begin with a steadfast determination to make it to the M.D., and yet soon grow weary of their rigid schedule of science courses upon science courses. Students are longing to branch out and use their mind in different ways…so why won’t the society of medicine let them?
    There is value in the arts, the humanities, and history. In order to learn the human body and how best to treat it, one must first procure the “innate capacity for the understanding of human beings and affection of the human condition” that Lewis Thomas suggests. For the sake of fostering creativity and a diverse set of minds within our medical schools, we must first encourage diverse education throughout the period of undergraduate studies.

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  4. As a current aspiring physician as well as a senior in a BSN program, I believe that this diversity is needed. Many of the pre med biology students I have met at my large private university are closed minded. They are in college to keep a high GPA and hit all those check boxes along the way, and that is it. When it comes to getting into medical school, and understanding the content, I know everyone of them will be fine. Where I see the biggest issue is in patient interaction. As a nursing student, my education is focused on communication and patient interaction just as much as it is focused on the sciences. When I enter a unit, I am amazed at how poor the communication skills are of some of the physicians. Sure, a physician is there to confront the disease, but I think it is time that medical students and physicians alike take a page out of nursings book and really learn how to communicate. The best way for us to build physicians with this ability is to go beyond the strict sciences and recruit students from majors like nursing, social work, and other people focused majors into spending that extra year post bac and gathering the extra check boxes. If this can be done, MDs will not only be fantastic clinicians, but will also have the communication and interaction skills to make people feel like they are being cared for both medically and emotionally.

  5. Very interesting post, thanks for sharing. I happen to believe that the admissions process actually encourages creativity. Sure, you need to have high MCAT scores and great grades in pre-req classes. That can’t really be changed. However, there’s no written rule that you must major in science. Plenty of medical students majored in economics, business, engineering, and humanities, just to name a few. There’s also no rule that you must have a clinical volunteering experience. I personally believe it’s much more important to find something you’re passionate about and commit yourself to that cause for an extended period of time. Additionally, who says you have to do lab-based research? I’ve known plenty of students to do research in the humanities or business. I believe that you can be rewarded by medical schools for thinking outside the box. Admissions committees don’t necessarily want every student to be the same (and have checked off all of the same boxes). They’re looking for diversity and being creative is the perfect way for a student to set themselves apart.

  6. Welcome to the antiphysician lobby that lives by the adage “hear the lie enough and it will become truth”. And no thanks to colleagues who stupidly fuel it by trying to validate non physician trained paraprofessionals can step in. I still wait for malpractice carriers to catch up with the NP field, especially in some specialties that are allowing NPs to prescribe as liberally as I have witnessed first hand. We’ll see how many continue to practice once the costs finally hit home!

  7. I find it interesting that everybody is so adamant that doctors education needs to be tweaked because it is lacking in X, yet nobody seems to care about PA and NP education.

    Its hilarious how most of the people on this board think that PAs and NPs can and should take over primary care from MDs, yet all we hear on this board is how MD education is subpar, despite the fact that it is over twice as long compared to the midlevels.

  8. My opinion is that technology should only aid the learning process. When we are able to focus on the bigger picture because some of the “process” is streamlined we should be producing better physicians.

  9. I disagree with the assertion that the top notch med schools are less likely to have creative people because they have more “boxes” to check.

    I graduated from Johns Hopkins with 4 olympic athletes, several world class musicians, and many division I athletes. Other elite med schools have similar classes. You dont find these people studying medicine at Rocky Vista. If there is a lack of “creativity” in the med school applicant pool, it’s at the lesser programs, not the top notch ones.

  10. Per Will’s above last rebuttal to me re calculators cause atrophy, yes, in fact I do try to limit my use of calculators to very complicated math. How do you react standing in line waiting for someone to ring up a customer who can’t figure out how much change to give if the register is not working right? Or trying to add a couple of numbers that might be as quick as hunting down the gadget and turning it on and punching in the numbers? Rationalize and intellectualize your validating technology is ” about mechanizing simple things so we have time to focus on more conceptual problems”. I don’t think physicians as a whole really utilize their time so more efficiently just because of technology. How many people are playing with their phones or ipads when they should be doing patient care things?

    Careful, as I said before, the more things change, the more they stay the same. Technology is not freeing up time to allow us to relax, to rejuvenate. It is just upping the ante of giving the false sense of better answers and less room for negotiation. If electricity was silenced tomorrow, panic would be an understatement. I would be inconvenienced, but for some, the world would be over if power was indefinitely off.

    Again, I would hope not.

  11. “Technology is dumbing us as physicians down in the end.”

    Technology is about mechanizing simple things so we have time to focus on more conceptual problems. Hearing a murmur is a technological issue, it deserves a technological solution.

    For the last million years that technological solution has been a bunch of hair cells in the air sending action potentials through the thalamus to the auditory cortex. I don’t feel at all dumber bypassing such an error prone instrument if the option is available.

    P.S. Don’t worry about on the spot echocardiograms – they will be reasonably priced and common within 5 years. That’s the other nice thing about technologies.

    P.P.S. Do you use calculators? Or do you fear that your ability to do math will atrophy.

  12. The US health care system has set up a path to becoming a physician remarkably unlike that for advancement in most other industries.

    I think that our system would be much improved if we adopted the latter type of model. Wouldn’t it be great if one could enter the health care delivery field after earning a bachelor of science degree, work and take classes to develop skils to achieve progression milestones, and eventually become a physician if they reach the necessary level of experience and education? This would open up the door to so many more potentialy qualified candidates, enhance the supply of health care workers, and rely on a demonstrated track record including both work experience and education as the basis for advancement?

    Perhaps it’s time to consider a better approach!

  13. thank you for the validation to my comment. Not every office is going to have on the spot echo cardiograms nor digital stethoscopes. Hey, PET scans can be wonderful, yet not everyone can get one, much less insurers will pay for it without authorization hassles up the wazoo. I’m not talking about tertiary care needs, but what is in the average front line office.

    and it starts with attitude and philosophy. Technology is dumbing us as physicians down in the end. Do you like talking to someone who is just watching a screen in your visit? I hope not!

  14. In regards to your stethoscope comment – I hope not.

    On the spot echo-cardiograms and digital stethoscopes that can actually record sound (for reanalysis & a second opinion) are clinically superior.

    You try distinguishing between a grade 2 and a grade 3 murmur. Or try and tell if something is doing a crescendo or a crescendo-decrescendo. Or trying to tell whether the splitting time has increased or decreased on inhalation.

    Humans are fallible – listening through a stethoscope is subjective.

  15. Granted this only applies to US medicine and admission to medical school. I would be interested to learn more about other countries and their approaches including curriculum in the first 2 years instead of dumping a sea of abstract knowledge on med students.

  16. Thank you for your response, Ilyana.

    If students feel “stifled” or limited by checkboxes, they should take some time off before or after college to explore other interests. From my vantage point, such exploration is only encourage and rewarded by medical school admissions committees. In fact, the past decade might be the first time in American history that medical schools are rewarding such interests. I’d bet that the current crop of accepted students has a much wider array of backgrounds than any generation before it. Furthermore, medical students themselves are exploring more research projects, masters in public health, community service, etc. than ever before. If that doesn’t show freedom and creativity I don’t know what does.

    I appreciate that you took the time to raise an important point, and that you responded to the comments, but I can’t help but feel that all of the concerns you and Dr. Scott raised are less relevant today than ever before.

  17. Great Post.

    I do find it interesting that you are a student at Harvard, one of the more prestiguous (read lots of checkboxes) medical institutions.

    We often forget to look up and see what the rest of the world is doing. Because we are in a “system” and think that everything we do is unique to our “system,” we fail to realize that the need to check the box is everywhere in our society. It has nothing to do with medical school admissions.

    1st Grade, check – move onto 2nd Grade.
    6 months Learners Permit, check – move onto regular license.

    Obviously, those are very basic examples, but they show my point. We can’t think of them as a burden, but as barriers to entry – a very common business term. Do you want admission to medical school to be easy, so that everybody can get into it? Should we hand out medical degrees like we hand out trophies to little league players (everybody gets a trophy, win or lose)?

    The medical profession takes dedication. It is a grueling process. Are there things that need to change? Absolutely! But we need to make sure that the students that are accepted KNOW what they are getting into. That’s why the standards are so high.

    The MCAT is the great equalizer – a way to compare the masses on a level playing field, no matter what undergraduate education.

    Creativity comes through with extracurriculars, life experiences, personal statements. GPA and MCAT are just the door openers, it is up to the admissions committee to do the work and read the rest of the application.

    A great article that starts the discussion on how to make things better for all involved.

  18. Thanks for your comments, everyone.

    @bulldog: I think you are right that successfuly completing some of the checkboxes does involve creativity. One example that comes to mind is research — being in the lab itself is the checkbox, but some applicants have contributed to scientific discoveries at an impressively young age. It takes a greal deal of creative thought to do something novel in research.

    I would really like to emphasize that it’s the system itself, not any individual person or classmate, that seems questionable. For example, I have known people who were committed to being doctors later in life, but who felt very stifled in terms of what they could explore in college because of the rigorous requirements and checkboxes. Some people feel like college is their last chance to explore other interests, but are unable to because of the huge burdens that come with being “pre-med.” I’ve known a few people — incredibly talented people, mind you — who were scrutinized during the application process for not having had enough clinical experience prior to medical school. Do I think they are any less capable of becoming doctors? Absolutely not. It struck me as unfortunate, as they were being punished for “falling behind” according to some rigid benchmarks of what needs to be done as a pre-med.

    Of course, this is not to say that those who spend a lot of time on clinical activities are less creative. It just seems like the rigidity of the system limits our options. And it selects for people who know what boxes to check early on.

  19. This post assumes that students who are successful at “checking boxes” are not creative. Seems to me that the diverse boxes they check are proof of their creativity and general intelligence. Being able to conduct scientific research, volunteer at homeless shelters, accomplish some interesting extracurricular that makes an application pop, AND ace the MCAT? Pretty impressive and well-rounded.

    Also, I think the data are pretty clear that more and more students are being selected from non-biology majors, ethnicities underrepresented in medicine, after having spent several years out of school, etc. I haven’t watched the TED talk cause I find most of them entertaining but not very informative, but did you or Dr. Scott find any information to suggest that students are being selected based on narrower criteria, or criteria that stifle creativity? Seems like it’s quite the opposite. I mean, you go to HMS for goodness sake. Talk to your classmates, they’re probably very interesting people.

  20. Sorry, I don’t care how archaic I sound, I have not been overly impressed with the newer physicians in practice coming out since the early 2000s. If anything else to their narrow mindedness to be utterly dependent on technology, their zeal to limit call demands has only dumbed down the field to give the illusion medicine is a 9 to 5 job.

    The more things change, the more they stay the same. That is true in the end even in medicine.

    I bet there is even little reliance on a stethoscope anymore.

  21. I think that the entire system of health care squashes creativity. Medical school and residency training is far more stimulating than clinical practice where physicians are managed like production workers. In our current systems of care the only people with the time and power to be creative are administrators who don’t know anything about medicine and frequently find creative ways to consolidate their power rather than deliver health care. Their goal is to maintain leverage to manipulate physicians not to optimize a creative environment.

    Far from memorization, medical school and residency training is the only place where you are training in critical pattern recognition and pattern matching required to be an expert diagnostician. It is critical that students and residents are matched up with senior clinicians who have years and decades of those experiences and that this process is taught. It is the main point that differentiates MDs from nonphysicians who are frequently getting their degrees online.

    The knowledge base of medicine could be more dynamic and exciting for practitioners, but ongoing medical education and recertification does not really have the goal of a dynamic approach to physician education in a collaborative way. Medical specialty boards if anything have created an onerous recertification process that is far removed form what physicians need to stay current.

    In this environment of physician mismanagement there is really no room for creativity on the part of physicians at any level.

  22. See Lawrence and Lincoln Weeds’ “Medicine in Denial”

    VIII. Medical Education and Credentialing as Barriers to Progress
    A. Extending the health care reform agenda to medical educa- tion and credentialing

    1. A century of stagnation

    Productive use of advanced medical knowledge requires an integrated system of care with a rational division of labor in which all participants see clearly how their roles contribute to solving medical problems. All participants should be able to avail themselves of knowledge that individually they do not possess, practitioners should not be permitted to perform at a level beyond their demonstrated competence, and no group of practitioners should be able to pursue its own interests to the detriment of the larger system of care.

    Progress towards a rational division of labor within an external network of knowledge tools is largely absent. Isolated advances are not evolving and coalescing into an integrated system of care. We all are trapped in a non-system, where an elite class of practitioners is permitted to rely on limited personal knowledge and intellect. Graduate medical education and credentialing protect this physician elite from competition that could otherwise reshape medical practice. The health care system has thus been remarkably slow to adapt to the new environment created by modern information technologies. And that environment is still developing. Our culture is still working out the right division of labor between human cognition and external information tools. The subculture of education, however, lags far behind the domains of science and commerce in that development.

    Given this state of affairs, and given the need for an integrated system of care, how should medical education and credentialing be reformed? To better understand that question, it is useful to look back a century ago to Abraham Flexner’s famous 1910 report on medical education. At that time, many physicians were educated outside of universities. They attended trade schools with low admissions standards, and much of their learning occurred through apprenticeship. Their training did not keep up with scientific advances. Rejecting this model, Flexner advocated the Johns Hopkins, post-graduate model of education, founded in basic science, conducted at universities, and oriented towards research, not practice. As described by Paul Starr, Flexner saw that “a great discrepancy had opened up between medical science and medical education. While science had progressed, education had lagged behind. ‘Society reaps at this moment but a small fraction of the advantage which current knowledge has the power to confer.’

    Were Flexner to return today, he would find that current knowledge has the power to confer vastly greater advantage than it did a century ago. But he would not find that society reaps a greater fraction of that advantage. “Between the health care that we have and the care we could have lies not just a gap but a chasm,” the Institute of Medicine has found.234 Failings in medical education and credentialing are a central reason the chasm exists…

    2. The medical school experience

    According to the Institute of Medicine, “many believe that, in general, the current curriculum is overcrowded and relies too much on memorizing facts” and that “the fundamental approach to clinical education has not changed since 1910.” Even though the issue is largely absent from the health care reform agenda, many involved in medical education recognize that this stagnation is unacceptable.236 Consider the following 2003 commentary on Harvard’s New Pathway curriculum. After reciting that this reform “reinvigorated the educational experience” and “served as a national model for similar reforms,” Dr. Joseph Martin described the sense of futility felt by many:

    But despite all the New Pathway has accomplished, one of its central aims— the true integration of clinical and basic science learning throughout four years of medical school—remains a largely unfulfilled promise.

    … There is a pervasive and growing sense—not only at Harvard but around the country—that current approaches are no longer working.

    Let me report on some of the observations that have defined this sense of unease with the clinical phase of the student experience.

     Hospital inpatient services are becoming less representative of the full spectrum of illness and patient experience. Rapid patient turnover limits opportunities for students to develop relationships with patients and follow their progress over time.

     The increased pace and intensity of the hospital environment makes it less hospitable to the educational needs of students, who are often marginalized as members of inpatient teams. For example, students rarely take a history or perform a physical exam on patients.

     Clinical faculty – particularly senior faculty – are less involved in students’ education, and a student’s contact with a faculty member may be transient.
     Ambulatory care operates with severe time constraints, compromising the ability of students to learn well in those settings.

     Evaluation of student performance is highly variable. The lack of direct observation of students by faculty is a major problem in both inpatient and outpatient settings. The tools used to assess students are not very useful in discerning whether they have achieved core competency.

     Students receive too little opportunity to appreciate the importance of science as the underpinning of clinical medicine, and to address social, ethical, cultural and professional issues. And finally,

     The variability in the content and educational rigor of the clinical experience is unacceptable. Students are often not provided with explicit clinical goals. …

    [A] major overarching concern is that basic science and clinical medicine are not well integrated across the four year curriculum. Students lack clinical experience in the early years, and basic science is largely ignored in the latter years…

    …Failure to integrate the two is predictable, given what happens in the medical school curriculum.

    At the beginning, faculties overload students with abstract knowledge—textbook answers to questions they never asked about observations they never made. Learning of this kind is the antithesis of scientific inquiry. Students who undergo this process can easily become doctors who “quote what is in the book and deny what is in the bed.” A number of studies, for example, have documented the phenomenon of students who unconsciously “fabricate” findings in patient examinations, perhaps because the findings “are consistent with their understanding of the disease believed to exist or because they are consistent with the ‘classic presentation’ of the disease felt to be most likely.”

    After the beginning curriculum, medical students are thrust into clinical settings with the hope that they will somehow learn to apply their abstract knowledge to real patients effectively while mastering a broad range of manual skills. Yet, absent are the optimal conditions for learning—manageable scope, an individualized program, the opportunity for single-minded attention, careful progression from simple to complex tasks, close feedback. Learning tends to happen on a “sink or swim” basis, with students often left to their own devices, receiving less structure and less organized feedback than in their formal education. The environments in which students are placed do not assure mastery of essential skills. Nor do these environments foster the disciplined behaviors that medical decision making demands. Indeed, the medical school environment violates a basic educational principle stated by John Dewey: “We never educate directly, but indirectly by means of the environment. Whether we permit chance environments to do the work, or whether we design environments for the purpose makes a great difference.”

    Teaching skills and behaviors is not emphasized in medical education. Rather, its “traditional emphasis is on teaching a core of knowledge, much of it focused on the basic mechanisms of disease and pathophysiological principles.” But no definable core of knowledge is actually transmitted to or used by practitioners in patient care with any kind of uniformity. Whatever core of knowledge medical schools attempt to teach varies from one institution to another, students do not learn all they are taught, they retain only part of what they do learn, that residue varies with each individual, and some of that residue quickly becomes obsolete. Continuing education courses merely continue this futility. It should thus come as no surprise that continuing education has been found ineffective… [pp 195-200]

  23. I think there is a bit of truth here. I know that I have been concerned about some of my recent hires. They came from top notch institutions (places like Hopkins, Cleveland Clinic, Mayo, Duke) and had excellent scores. Once out in practice they have had trouble adapting to working on their own, as they are incredibly rigid in their thinking. This is something new I had not seen in the last 25 years. Hope it is just an anomaly.

    Steve

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