February is, easily, the most difficult month of the year for many involved in undergraduate medical education, including Deans, admissions committees and administrative staff. This is not simply because of the long and dreary Canadian winter. It’s during this month that letters go out to applicants for admission indicating whether they’ve advanced to the next stage of the process: the on-site interview. All those involved in the selection process struggle with the knowledge that, for every letter that brings welcome relief and encouragement, several will result in bewildered disappointment. Two brief applicant profiles may serve to illustrate the issue.
Jessica is a bright, articulate and engaging young woman who, for as long as she or anyone can remember, has wanted to be a Doctor. She graduated from high school at the top of her class, with numerous awards recognizing not only her academic accomplishments, but also student leadership and community involvement. She received multiple university entrance scholarships and undertook an undergraduate program with courses that would provide a basis in biologic and physical science, which she feels is relevant to the study of medicine, but also selected to optimize her marks. She is very successful, maintaining a 3.8 GPA over her first three years. She also undertook a variety of volunteer activities, locally and abroad, involving health care in various settings. She took the Medical College Admission Test (MCAT) after both studying from a manual and taking a preparation course at significant expense. She did generally well, but was concerned about her mark in one of the four exam categories. Jessica applied to our medical school, but failed to even get an interview. This was related entirely to the MCAT score, as she feared.
Matt is not only an excellent student finishing in the top 5% of his high school graduating class, but also an elite athlete who accepts a full scholarship to an Ivy League university. He chooses this school because it will allow him to pursue his interests in philosophy and political studies at an institution with an international reputation for excellence in both disciplines. While there, he continues to excel academically, while becoming an accomplished varsity athlete. He also develops an interest in Medicine and, specifically, Public Health. He decides to apply to medical school and takes the MCAT, in which he excels in all categories. He would like to return to Canada for medical school, but also fails to even get an offer for an interview, largely because the grades for his philosophy and political science courses, although near the top of the class for every course, fall below our GPA cutoffs.
Jessica, Matt, their families, and everyone who knows them and their career aspirations, are understandably devastated and rather perplexed. “How can this be?”
Although these are both fictional accounts, a recent review of our applications at Queen’s shows that no fewer than 247 submissions matched the “Jessica” scenario almost exactly. The number of “Matts” is more difficult to determine, but likely similar and probably underestimated because many people in such circumstances will decline to even apply, recognizing the GPA issue.
For every jubilant success, we know there are about 7 “Jessicas” and “Matts” who will be very disappointed and may have to set aside or delay their life’s dream, despite being very capable, motivated and deserving. That reality is also personally distressing to the faculty and staff involved in the admissions process who, recognizing they cannot admit every applicant, endeavor diligently to develop fair and equitable processes.
A few realities about the medical admission process in Canada:
Among Canadians, there is a very high demand for medical education. At Queen’s we received 3818 applications for our 100 positions this past year. All Canadian schools receive many times more applications than they can accommodate. Statistics collected and published annually by the Association of Faculties of Medicine of Canada indicate that the Canadian schools collectively received 34,048 applications for their 2,877 total available positions in 2011. Assuming an application per candidate ratio of 3.3 (as Ontario statistics would suggest), it would appear that at least 10,318 individuals submitted applications that year. The hunger for a career in medicine is such that increasing numbers of Canadians are enrolling in medical schools in Australia, the Caribbean, Ireland and other countries, at considerable personal expense and with no assurance of postgraduate training or eventual qualification in Canada. Although no accurate data is available, it’s estimated that there are now more Canadians studying Medicine outside Canada than within.
Applicants to Canadian medical schools are knowledgeable regarding the process, and highly accomplished academically. Although, again, no data is collected on this subject our observation at Queen’s, which seems to be shared by other schools, is that the average GPA, MCAT scores and personal experiences reported by our applicants are increasing each year. Applicants understand the “system” and are highly strategic as they undertake their education and personal activities.
The number of medical school positions in Canada is fixed by public authority. Medical education is expensive and largely subsidized by provincial governments. Those governments therefore define the number of available positions, based loosely on anticipated demands for physicians. These estimations have fluctuated in the past such that we have seen periods of both contraction and expansion. At present, there are no plans in Ontario for expansion.
Medical schools place a priority on fairness and equity in their application processes. In the face of the virtual impossibility of selecting the “most worthy” from so many worthy applicants, schools opt to ensure objectivity and fairness in their processes. They are therefore drawn to metrics that provide some basis for objectivity. Unfortunately, all available metrics are inherently blunt and imperfectly aligned with the qualities all would agree are important.
Winston Churchill could have been talking about medical admissions when he famously described golf as “a game whose aim is to hit a small ball into a small hole, with weapons singularly ill-designed for the purpose”. Academic records, the MCAT, and quantified assessment of reported personal experiences all have significant shortcomings, as our examples above illustrate, but have the significant advantage of providing a numerical assessment by which candidates can be ranked without prejudice. Panel interviews and mini-medical interviews (MMIs) are being used increasingly by medical schools to better assess applicants personal qualities, and are certainly an improvement, but are very resource-intensive and difficult to conduct and evaluate in a reliable manner. It’s therefore not possible to apply such methods to the large number of applicants. Hence the staged application process and reliance on other academic and test metrics.
So, one must ask, do we have a problem? Despite all these shortcomings, the students who are finally admitted to our medical schools are an exceptional group of very talented, intelligent and capable young people who, with rare exceptions, have all the necessary qualities to become outstanding physicians. Our processes, although inherently blunt and likely misaligned, are objective and scrupulously fair to all applicants. Importantly, the Jessicas and Matts of the world, and their families, can perhaps take some small comfort in the knowledge that they are far from alone and have been treated fairly. Furthermore, medical schools recognize that even if they could personally interview or meticulously assess every applicant, most would still be disappointed. So, should we change and, if so, how? I welcome viewpoints, and will make that issue the subject of the next blog.
Anthony J. Sanfilippo, MD, FRCP(C)
Undergraduate Medical Education