It’s this simple: The medical school admissions system is bloated and reinforces implicit and systemic biases leading to further social inequity. Medical schools across the country are going through thousands of applications and making literal life-changing choices for these students. Introducing randomization into the admission process would simplify and address the built-in issues in this process. Admissions tests do not determine the quality of a doctor’s care. As the COVID pandemic has shifted many societal norms, perhaps this is an opportunity to improve an overly complicated application process. This approach is not completely novel; McMaster University’s program introduced a partial lottery this year. A friend from internal medicine residency struggled with test-taking; he failed Step 1. Yet apparent “failure” had little impact on his career trajectory. He became chief resident of a major internal medicine residency and is currently a clinical director for an academic internal medicine clinic in a major metropolitan city. He is also incredibly compassionate and provides the best evidence-based care I have seen. His apparent failure of tests was not predictive of the dedication and compassion he shows his patients daily. The Association of American Medical Colleges lists 15 core competencies for applicants to focus on admission into medical school. They note the list was determined after “extensive review of the medical education and employment literatures with input from several blue-ribbon and advisory panels, including Social Sciences Foundations for Future Physicians, Behavioral and Social Sciences Foundations for Future Physicians, Institute of Medicine, 5th Comprehensive Review of the MCAT Review Committee, Accreditation Council for Graduate Medical Education Outcome Project, the MR5 Innovation Lab, and others.” The AAMC includes a 27-page handbook for applicants to review and brainstorm how they can best demonstrate these competencies on an application. For example, the “Service Orientation” competency states the applicant must “Demonstrate a desire to help others and sensitivity to others’ needs and feelings; demonstrates a desire to alleviate others’ distress; recognizes and acts on his/her responsibilities to society; locally, nationally, and globally.” This usually translates into extensive volunteer work. This also implies time and resources to dedicate to such endeavors and automatically excludes those who work second jobs to support family or who do not have connections into other medical systems. Under the “Thinking and Reasoning Competencies,” the included sub-headings are “Critical thinking, Quantitative Reasoning, and Scientific Inquiry.” Many of these are evaluated in a standardized test fashion thru the Medical College Admission Test, or MCAT. Schools often use this score as a cutoff for admissions. One study found a difference in MCAT performance over different ethnic groups. The research shows differences were likely socioeconomic in nature and not biases inherent in the test. The gap between the number of medical school spots and medical school applicants has grown every year. At Rush Medical College, where I work, they reported 7,485 completed applications competing for 156 spots in the M1 class. For the 2019 year, administrators offered 509 interviews. The AAMC reports the attrition rate for graduation has been steady at about 3 percent for the past 20 years. The data shows 1.3 percent of this rate is attributed to academic reasons, while the remaining were cited as non-academic reasons. Given the inherent issues with these competencies and the enormous untapped pool of presumably qualified applications, perhaps instead of spending so much energy ranking all of them, it is possible to remove potential biases in the application system with a lottery system. Yes, there is uncertainty in introducing a random lottery and its potential effect on physician quality and in medical science. So studies are needed. One study could take half of a medical school’s spots and designate them as the control arm; this group would receive “usual care.” These applicants are ranked on traditional measures of application review, interviews, and meeting discussions. The intervention arm would be applicants who meet some baseline characteristics but were not deemed high enough to be allocated in the control arm. The 15 core competencies are used, but the goal is to use the competencies to determine a baseline. This baseline could be developed simply by looking at applicants who were on the lower tier of rank lists. That would create a pool of applicants which would then be randomly lotteried. The lottery would be run, and then those applicants would be combined with the traditionally ranked group. This would create the final list of medical students who were accepted. This research experiment needs outcomes. What is the marker of a successful doctor? In contrast to the uncertainty of how undergrad traits determine a good physician, using metrics that signal a successful physician- such as board certification, fellowship matching, resident evaluations, or chief resident placement could be the hard outcomes. The control arm would clearly have applicants that would be perceived as traditional “top tier.” This could lead to useful information if the intervention group has the same overall outcomes as the control. By design, this system would not interfere with any medical schools’ ongoing affirmative action policies. For example, saving spots for underrepresented minors is still the practice. The lottery system would be another tool to help reduce deep societal inequities. If the lottery ends up not affecting doctors’ quality, there are numerous potential benefits both in the short and long term. Immediately administrative resources of time and energy would not have to be spent ranking students so meticulously. Once they know they have met the lottery’s baseline requirements, these students can instead focus on actual personal growth tailored to their own needs. At Rush University, applicants average 1,496 hours of community service. My own application for medical school noted 50 hours of volunteer service. More importantly, this system would address application inequity and give everyone an even playing field. Yes, this system can be frightening. Physicians tend to want to take control, whether that is to help a patient feel better or do everything to advance the profession. However, if the lottery reveals that doctors remain as dedicated as they have always been, perhaps it is a tool to free up resources, combat biases, and move toward a more just world. Caspian Kuma Folmsbee is an internal medicine physician. Source
