Admissions: To Do No Harm

Robert C. Bowman, M.D.

Numerous prospective medical students and their advisors are frustrated with the current change to computerized testing. More than just MCAT Registration concerns fuel the debates. The growing frustrations of those most aware of the pipeline to medical school and the changes that are occurring will continue.

How will students deal with the current computerized problems when they
don't have top colleges or top advisors
have an advisor not on this list serve and far less experienced in finding the answers
don't have professional or privileged parents who know how to handle such situations, and not always in agreeable ways
don't have any advisor
don't have the money for a "Kaplan" professor or an advisor at all?

How many going through these complications and how many hearing about the complications will think about trying again next year after a rejection?

What about top students by any measure who could choose any profession? Would they maintain interest in medicine over business or engineering or other careers when the very beginning appears poorly organized, unfair, or biased? Would we actually drive off those with the social conscience that we need so much of in a medical career?

Will those relatively new to the electronic age have even less confidence in computers and computerized testing and have even more anxiety that will impact computerized test performance?

Who will trace those who attempted to apply, and never overcame the new obstacles? Who will track the contacts of these students (fellow students, earlier class years, family, friends) who will get the impression that it is even more difficult to gain entry to medical school?

How many will be frustrated with dealing with the process of trying to become physicians that they will be even more likely to resent physicians in the future in their other health careers, as leaders in other professions, etc.? In web sites and in conversations with faculty I hear of potential California medical students that are quick to claim discrimination. Some are Asian students from just 4% of the population that already claim 23% of medical school admissions. What about Asians or whites with only tenths of MCAT points difference who did not get admitted, mainly because their parents were different than those who were admitted?

How valuable is a few hours performance in a lifetime that includes infinitely more numerous, longer duration, and more important areas relevant to physician performance? One that is currently abused by organized campaigns with a narrow agenda? One that limits medical school curricular improvement and development? One that limits admissions of those most different who have different career, location, and patient population preferences? One that limits the perspectives of the admitted medical students who become the leaders of the nation?

Why don't we change admissions numbers and focus and costs to admit far more and a much broader range of applicants with a plan to narrow this group down over time? Why not turn evaluation over to a medical school experience that is 4 years long instead of 4 hours long? One with far more contact time with evaluators, one that can measure performance over time, one that can evaluate interactions with patients, staff, supervisors, and others? Why not have more with medical training but not necessarily medical degrees, often by their own choice as much as by the school?

Why do we expend all of our evaluation resources on a standardized test rather than exploring factors likely to be more related to long term physician performance? Why does our nation fail to explore these areas most related to future performance as a nation as related to the qualities and quality of professionals? What does our nation say about these areas? Of those who stood with President Bush last night to be recognized for their outstanding contributions to the nation in a wide range of activities, only one might pass the MCAT given background. She has made far more money by working the standardized test performance improvement angle. She will continue to do well because she has the first shot a children before age 2, before new parents realize that their children are as limited by their environments as they are by access to Baby Einstein materials.

We are 80 years beyond the developers of standardized testing that noted that physician performance would not be linked to such testing. see Thorndike below or references at History of the MCAT from the McGaghie JAMA article

Again more than just standardized testing is involved. What happened to the wisdom of the ages and the critical and ongoing debates that helped shape top notch American medicine, health care, and education? Where are the constant debates that used to dominate any thought of changes in admissions or testing that might shift the balance toward narrow science focus and away from a focus on people orientation? The debate about the art and science aspects of medicine have ended and medical education reforms helped put them to rest 100 years ago. The science of the art of medicine is now real science involving quality, costs, access, and relationships involving people. The basic science, academic rigor, and intellectual focus of what used to be the sole "science of medicine" remains, but how valuable is this in isolation. How important is this without the direction and guidance from leadership that is aware and understanding of a wide range of perspectives. How critical is this when medical leaders can facilitate or retard the future development of the entire nation in their recommendations that impact health care costs and all other businesses, education, and activities in the nation?

From the Indiana University site: "Thorndike and his students used objective measurements of intelligence on human subjects as early as 1903. By the time the United States entered WWI, Thorndike had developed methods for measuring a wide variety of abilities and achievements. During the 1920's he developed a test of intelligence that consisted of completion, arithmetic, vocabulary, and directions test, known as the CAVD. This instrument was intended to measure intellectual level on an absolute scale. The logic underlying the test predicted elements of test design that eventually became the foundation of modern intelligence tests."

"Thorndike drew an important distinction among three broad classes of intellectual functioning. Standard intelligence tests measured only "abstract intelligence". Also important were "mechanical intelligence - the ability to visualize relationships among objects and understand how the physical world worked", and social intelligence - the ability to function successfully in interpersonal situations". Thorndike called for instruments to develop measures for these other types of intellect. "

"Thorndike developed psychological connectionism. He believed that through experience neural bonds or connections were formed between perceived stimuli and emitted responses; therefore, intellect facilitated the formation of the neural bonds. People of higher intellect could form more bonds and form them more easily than people of lower ability. The ability to form bonds was rooted in genetic potential through the genes' influence on the structure of the brain, but the content of intellect was a function of experience. Thorndike rejected the idea that a measure of intelligence independent of cultural background was possible."

Educational Psychology (1903) , Introduction to the Theory of Mental and Social Measurements (1904) , The Elements of Psychology (1905) , Animal Intelligence (1911) , The Measurement of Intelligence (1927) , The Fundamentals of Learning (1932) , The Psychology of Wants, Interests, and Attitudes (1935)

"Thorndike proposed that there were four general dimensions of abstract intelligence:
Altitude: the complexity or difficulty of tasks one can perform (most important)
Width: the variety of tasks of a give difficulty
Area: a function of width and altitude
Speed: the number of tasks one can complete in a given time .
His intellectual development of this multi-factored approach to intelligence contributed to a great debate with Charles Spearman (Spearman proposed a single, general intelligence factor 'g') that encompassed twenty five years."
The above from

For decades we have known at least enough to figure out that wide latitude was needed regarding testing and that interpretations of such testing should also be broad. More than a few areas of exploration have been noted. Those intimately involved in standardized testing have also revealed that some of these promising lines of investigation have been squelched (Anthony Carnevale, former ETS VP) There is now no doubt that those who are different in age, parent income, parent occupation, socioeconomics, culture, language, or proximity to medical school face greater barriers to admission   and are more likely to serve patients in need of care. There is even some reason to support that these physicians will deliver better quality of care at least for populations most like them and perhaps others. There is clearly evidence that higher income Americans are separating from lower and middle income Americans and this is also true in those admitted to medical school, a reliable pathway to higher income levels. Although few can or should doubt the validity of the MCAT or other standardized testing, it is the use and interpretation of such testing that is a concern.

It is not the fault of AAMC or any association that Americans have developed a distorted view of the validity of such testing, but it is the responsibility of AAMC and any others developing such testing to constantly inform the public of limitations in testing. They must also remove obstacles not related to future performance as physicians or as leaders of a nation. Declines of 30,000 taking the SAT test should be the subject of national investigations and efforts to restore access. Any declines in the numbers or types of students taking the MCAT should also be explored thoroughly. Medical education leaders seem to be aware of some of these problems, but it seems that more than a few Jordan Cohen addresses are required.  More accountability is needed such that deans and other leaders promote these values, explore new approaches, and strive for consistent progress in evaluation and assessment. They may even have to specifically fund individuals to do this work even when grants do not exist.

It is also our duty as Americans to inform AAMC and any others that fail to address areas that threaten our health care, education, security, medical education, or any other systems in the United States. At a time when editors of Academic Medicine are asking for new perspectives to guide the next 100 years, AAMC should be asking as well. We are registering our concerns and asking for improvements.

We are not blaming those who are attempting to implement the policies involved who are caught in the middle of the process and the debates. We are asking for an examination of the process and how important this process is to becoming a top quality physician. We are holding the process of premedical preparation and admission accountable to the same standards as the standards for physicians. We gather information, we learn, we make the best predictions as to who will make the best physicians, and we make the changes to accomplish this. Hippocrates noted the same concepts in Epidemics, Bk. I, Sect. XI. One translation reads: "Declare the past, diagnose the present, foretell the future; practice these acts. As to diseases, make a habit of two things to help, or at least to do no harm."

Robert C. Bowman, M.D.

Physician Workforce Studies

Admissions Ratios, Changing Admissions, and Physician Distribution

Ethnicity, Gender, Admissions, and Distribution of Physicians

Admissions Income Quartiles

Facilitating Physician Distribution

Admissions Package

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