As is the case with so many things in medicine, our selection process—for medical school, residency, and nearly every stage until a person has the requisite skills to practice—is riddled with suboptimal, if not entirely meaningless or counterproductive, proxy measures.
When we select college students for medical school, or medical students for certain residencies, the presumed goal is to select people who will become good doctors. On the first pass, we want to find those who will make good doctors generally, and on the second, those who will excel in specific fields. But if we’re honest, we’re terrible at this. We are absolutely abysmal at identifying the right people for the job.
Magical Metrics
The metrics required for field competitiveness are a reflection of supply/demand (i.e. the relative scarcity of training spots) more than the cognitive firepower, personality/disposition, or physical skills required for competency.
Our testing systems are, at best, inefficient measures of general intelligence and hard work. While those traits are important, the process we use to assess them requires students to spend countless hours learning material of dubious utility, often at the expense of other potentially valuable endeavors.
Economics teaches us that when resources are limited, the question isn’t whether something has value—most things do— but whether it’s the best use of those resources. There is no empirical evidence that our current testing paradigm or medical school curriculum broadly is the best use of applicants’ time, or that it effectively selects for the traits we actually care about.
On top of flawed testing—and accelerated by pass/fail Step 1—we have an obsession with CV-padding. Whether due to laziness, limited resources, or a lack of better alternatives, we’ve created a system that rewards applicants for amassing measurable activities that give the illusion of merit, even when those activities are empty gestures.
This leads to students wasting their free time on meaningless research, instead of pursuing hobbies, passions, or other fulfilling endeavors. To this, we’ve added a layer of well-intentioned but often questionable community service and outreach activities—nice in theory, but of dubious impact for both the person doing them and the community receiving them. None of these activities are inherently bad. Research isn’t bad. Helping people certainly isn’t bad. But when these tasks are reduced to tokenized, measurable units, we have to ask ourselves: are they being done in service of actual good, and is this the best way to accomplish that good? Is it possible for the outsider observer to distinguish the real deal from the slop?
Time & Money
Another valid criticism is that these demands favor students of means. Those with time, money, and connections are better positioned to engage in these resume-building activities, take gap years, or pursue additional schooling to improve their applications. This creates barriers for students without these resources. As if four years of undergraduate education weren’t enough preparation for a medical career, we’ve created a system where applicants need even more time, money, and effort just to qualify for medical school.
The irony is that other countries, and even parts of our own, have occasionally managed to streamline this process. Medicine faces a “good problem”: more people want to enter the field than there are spots. But we also face a deeper issue: many who do get those spots end up unhappy in practice or with no intention to practice in the first place. Some of this is due to the inherent difficulties of working in our broken healthcare system, but part of it likely reflects poor selection among applicants. Our laziness comes at a cost: we rob students of the full breadth of life when we force them into a narrow mold and make them compete in proxy contests trying to accumulate “experience.”
What makes a good doctor?
What actually makes a good doctor? Hard work, kindness, and resilience are likely more important than test scores or resume padding. Yet, as Peter Drucker famously said, “What’s measured gets managed.” When we measure test scores and activities, we optimize students to achieve those outputs. But those outputs come at a cost. And too often, that cost includes losing good, happy, and fulfilled students, trainees, and practicing physicians.