Robert C. Bowman, M.D. Initially posted on HLTHPROF 2/2003 Version with links and updates at http://www.ruralmedicaleducation.org/admissions/character_color.htm In response to the knowledge that there were certain groups attempting to use the media and lawsuits to remove programs and admissions that they feel favor minority candidates:
Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions. -- from a school dropout named Albert Einstein
My best rebuttal of those who would attempt to make us "color-blind" in admissions is to note the need for physicians to be the best people. We need physicians of character and compassion, dedicated to service. The failure to attract and admit these physicians, I believe, is responsible for many of the negative trends currently damaging medicine today, especially such as the rise of medical errors that should be a greater source of terror than any we have yet actually experienced (even service to the underserved and the declines in those interested in primary care).
Everyone is a prisoner of his own experiences. No one can eliminate prejudices - just recognize them. Edward R. Murrow
After reviewing a good portion of the literature regarding admissions that relate to graduating more rural and family medicine and primary care doctors and more doctors for underserved areas (growing list at http://www.ruralmedicaleducation.org/admissions/admissions_for.htm ), and after applying this information over the years, as well as observing the graduates of programs involving these characteristics, I have consistently seen the following:
The physicians that we all want for ourselves or for our nation are most importantly a matter of who they are as persons, rather than their intellectual credentials or the type of training that they undergo.
My mother was a nurse in a clinic and she was amazed (and sometimes frustrated) at how long people would wait late into the evening to see certain doctors. The only thing that I can see that was different was that the doctors worth waiting for (and working with) were people of character.
The sad fact is that people who have had lives that have not really been tested and stressed in certain ways, are not as likely to people of character. They might yet become so later in life, but they are not there yet. When they are tested, they might overcome their obstacles and learn from the process, but they might not.
People of character can be trusted more to undergo the rigorous training of medical education and still remain people of character, doing what they set out to do or were called to do. I could go on and on about the dangers of putting medical training into the hands of a person without character, but this is another topic.
In the best of all possible worlds the majority of all entering medical students would end up as generalists, but all physicians - family practitioners, physiatrists, urologists, allergists - would be well-educated, highly intelligent, well-rounded, personable, honest, altruistic, highly motivated individuals who had tested themselves prior to medical school in some tangible way against their goal of a medical career and a service profession. Don Madison Acad Med 1994 Oct;69(10):825-31, Medical school admission and generalist physicians: a study of the class of 1985.
There are characteristics that should be preferred by admissions committees of all types of professional training. These indicators include service orientation, maturity and/or older candidates, and interest in serving the underserved. There are also markers such as a sincere interest in choosing family medicine. This may be a simple interest, or it may represent a more complex marker of several factors such as doing something different or serving or making a difference or interacting a certain way with patients, rather than just a surface appearance of a career in FP. There are other medical careers that may similarly represent a person who is not afraid of obstacles.
There are other markers that predict likelihood to go to underserved areas. These includeRural Background which is the most important marker for those who are far more likely to choose rural practice (multiple studies), and minority background, which predicts underserved practice at a rate four times the usual graduate (40% vs 10%). Additional predictors of the most needed medical careers and locations are origin of the candidate from lower socioeconomic levels and leadership items in college. Studies of religious characteristics and whether candidates apply these to their lives might give us additional markers but we live in interesting times where values that shaped our nation are too controversial for such studies.
It's important that physicians practice in rural areas because of who they are and what they want to become. Robert C. Bowman, M.D. 2002
MCAT and GPA do not help in the assessments of special characteristics. Given the time it takes to evaluate candidates adequately and the tendency to delegate these tasks to others or to testing, measures such as MCAT and GPA may actually be harmful.
The use of such measurements by certain groups in lawsuits tends to attempt to simplify a very complex process of assessing a person for a career extending for decades and impacting many lives in ways far beyond intellectual categories. See footnote below.
A common denominator for those attempting to evaluate a person thoroughly, is the life events experienced. Often it is most useful to pay attention to the obstacles that students have encountered and how the students reacted. Many of these obstacles had a lot to do with the environment of the candidate at birth (or even at conception), instead of what they have done in their lives.
Tragedy can make you bitter or better. - author unknown
We all know and have discussed how the usual admissions process rewards those with high MCAT and GPA. We seem to be doomed to hear even more about them. MCAT and GPA may be markers for tremendous gifts, but gifts do not always transfer into accomplishments. That which is given can also make one less likely to apply the gifts or even more error prone (Florida study of FPs with high scores on boards that were more likely to be involved in malpractice actions Intellect and Malpractice ).
The "noncognitive," or psychosocial, measures increased the magnitude of the relationships between the predictive and criterion measures of the students' academic performances, beyond the magnitude attained when only the conventional admission measures were used (14% variance explained by "noncognitive" vs 4%). Therefore, psychosocial measures should be considered as significant and unique predictors of performance in medical school. Hojat, M., Robenson, M., Damjanov, I., Veloski, J.J., Glaser, K., & Gonnella, J.S. (1993). Students' Psychosocial Characteristics As Predictors of Academic Performance in Medical School. Academic Medicine, 68, 635-637. http://www.aamc.org/students/mcat/research/bibliography/hojat001.htm
Admissions Challenges Alabama - admissions committees face great challenges balancing academics, failure rates and diversity in ethnicity and geography. The fact is that the predictors are poor and it is far to easy to decline admissions to rural and ethnic background students. Relying on measurements instead of more comprehensive evaluations is a major problem facing medical schools and national workforce goals (private link)
The Dynamics Of Race in Higher Education An Examination of the Evidence http://www.aera.net/reports/
The authors concluded that both non-academic and academic factors are related to medical school performance. Additionally, the authors cautioned that while academic factors appeared to be better indicators of academic achievement, they might not be equally predictive across institutions. They emphasized that determining which non-academic and academic variables are the best predictors of academic achievement in various medical school environments is critical. http://www.aamc.org/students/mcat/research/bibliography/webb001.htm
While addressing a highly motivated group of young scientists Albert Einstein said, "Gentlemen, try not to become men of success. But rather, try to become men of value."
A valuable person is able to form relationships and understand them. Such a person can make adjustments and continue to stay on course with their life. Carmichael gives us a hint of the kind of person needed in family medicine at The Family in Family Medicine. I think this applies to the kind of physicians and professionals that we need, one who is able to work in multiple dimensions and a variety of relationships.
The following is a response I had to the following charge in the current Future of Family Medicine project that involves multiple organizations and millions of dollars. It is an attempt to help family medicine renew and take advantage of trends and be pro-active instead of reactive. I am not a formal part of this, other than to write in my contributions as a family physician. The bold print is from FFM at http://www.futurefamilymed.org/ , the italics are my responses (RCB).
Charge: Develop a strategy to transform and renew the specialty of family practice to meet the needs of people and society in a changing environment
My current hypothesis/bias: Little in the FFM materials or actions will be able to accomplish this change, save changing those admitted to medical school. Although preprofessional and admissions efforts are mentioned in some discussions (but not FFM materials seen so far), there is little plan, organization, or emphasis to this key element. Medical education has made major reforms not by changing environments, or faculty, or curricula, but by changing those who were admitted to medical school (Flexner’s Impact on American Medicine). Family medicine has made great strides because generalist physicians became leaders in admissions ( Basco, admissions leadership). This is also the effort most likely to accomplish the intended result of transformation and renewal of family practice to meet the needs of people and society. It might also transform American medicine and medical education. It also has a chance to transform America herself, because students hold so much underutilized potential. see http://www.ruralmedicaleducation.org/hope.htm
None of 5 major task forces of FFM are involved in admissions/preadmissions directly (practice redesign, training redesign, delivery assurance, role communications, system leadership) Training redesign might address it as a sidebar. Half or more of the effort should involve admissions, with at least 2 of 5 task forces.
Patient priorities noted on FFM scream out to us that patients care more who the doctor is, their characteristics and values, whether than how they are trained. This has more to do with selections.
Patient satisfaction involves areas such as making a difference, bonding, getting to know patients - all these have to do with personal characteristics such as service orientation, maturity, communication skills, past experiences with a variety of people from all walks of life, understanding the broad variety of human existence, etc.
1. Generating understanding of family practice - my thoughts: who we
are speaks more than marketing
2. Organizing individuality (FPs are rugged individualists) - my comment: emphasizing our individual leadership at the community and grassroots levels are more important than control concerns by FP leaders
3. Winning respect in academic circles: - my comment: the past decades have told us in FP that resources invested here have been wasted, better to focus on community and local groups and organizations, who will then put the pressures on academics to do what is needed
4. Making family practice an attractive career option - It is already a great option, for the students who are being rejected or who are disillusioned with medical education and could overcome this with encouragement at the preprofessional level
5. Addressing America’s obsession with science and technology. Society, generally, is enamored with science and technology, which, in turn, influences perceptions of what is regarded as medically "critical." Family practice, however, is associated with neither. - Good luck, this is like trying to pry the car keys out of the hands of Americans. This obsession is not under our control, but it is something which was responsible for the rebirth of family medicine. Again a good portion of our power as family physicians derives from our position between patients and technology, to help them understand and use it appropriately. The American public may be obsessed with Science and Technology, but they are just as aware of how badly they are being treated by physicians. Increasingly patients come to us for explanations as they are deluged by information, some science and some not. This role will only get more important.
More about making family practice an attractive career option. Several barriers make it difficult to attract new physicians and keep current family physicians motivated to practice: a. Lack of monetary reward b. Little recognition in the medical field c. Managed care realities d. Quality yielding to quantity
Comment: All of these matter less to physicians committed to service, patients, relationships that they matter to those attracted to medicine by income. Also studies show these matter least to those most interested in rural practiceCharacteristics of Rural Interested Students (also I might add that this "lack of monetary reward" is one of the most ridiculous items in the whole report so far. I believe that many if not most family physicians are not upset with their salaries. The ones that are upset are the ones who cannot keep from comparing themselves to other doctors. It is likely that this latter group will never be satisfied. Both groups would not be upset if other doctors in the nation that were not FP got paid $180 - 200 k instead of $300+k).
If we family physicians truly embrace policies and programs to find, encourage, equip, and admit the students who care and serve into medical school, then the public will see us as Doctors Who Care and Serve. Leaders will have no choice but to bring pressure on admissions. Ongoing revelations of medical errors, exploding technology, problems with access, efficient and affordable care, and increasing needs for safety net physicians will only move people and their leaders towards us.
Elitist programming, direct marketing, and academic respect will only identify family physicians with the rest of physicians out there creating more problems and more costs.
Final thought: Although it would be nice to make our jobs as family physicians easier, we must remember that some of the potential changes we are discussing might attract more of the type of physicians that make us less proud to be family physicians. Similarly some of our "obstacles" that we face in family medicine are the very ones that shape us into the people that we must be to be good family physicians.
The wise family physician is one who knows how much he/she is but is more concerned with how much more he/she can become Hunter Woodall, Family physician
Robert C. Bowman, M.D., Co-Chairman
Rural Medical Educators Group of the National Rural Health Association
UNMC Department of Family Medicine Director of Rural Health Education and Research
Footnote: American Civil Rights Institute and the Center for Equal Opportunity imply that special programs are in violation of federal civil-rights laws, "scholarships, internships, research fellowships, enrichment programs, and summer camps, mainly in the fields of science, medicine, and engineering." Given that they are preaching to parents who have money and influence, parents who sometimes have high expectations for kids even though the kids many not deserve these, parents who have gotten their way by intimidation before, parents who have rescued their children from consequences, parents who have manipulated awards or competition or other obstacles in their desires that their children have perfect lives, they will be a force to reckon with. God help us if some of these children become physicians and are not somehow humbled by the process or subsequent life events..
I operate from a perspective -- a belief, a feeling -- that the more I can understand where other people are coming from and what they value, the more I can trust them and they can feel comfortable with me. In essence, the more we mutually trust each other, the more we really understand each other -- that is the key to making things happen." Don Weston, Vice-Chancellor of Health Sciences in West Virginia
A few days have passed, and then I received a real treasure of encouragement. Better Than a Promotion
Character and Mentorship
Character vs Culture in the Media: Guess who wins
Technology Character and Family Medicine
Minority Vs Rural Early Admits
Character: the Narrow Road, Suffering, Perseverence, Hope, Heart
The Dynamics Of Race in Higher Education An Examination of the Evidence http://www.aera.net/reports/
Guidance on affirmative action admissions policies On June 23
Many of us thought the battle for Family Practice was over. We are finding that the battles have just begun. It is a hard road that we have to travel. Family practice has survived creation and vision, it must survive revision and complacency - Robert C. Bowman, M.D. 2000
Side Effects of Selecting for Family Medicine
Medicine, Education, and Social Status