“If you can’t measure it, it doesn’t exist.”

This was the mantra of a former mentor and research supervisor with whom I had the opportunity to work during my fellowship. In the early days of Echocardiography we, and many others, were working hard to bring some degree of quantitative rigour and credibility to a developing imaging modality which, at that time, consisted of rather blurry black and white recordings of the beating heart on a small screen. The images could be photographed and even videotaped. As such, they were remarkably informative to the person obtaining the image and treating the patient under observation, but the technology provided no inherent measurements and could not be transmitted to referring physicians. If Echocardiography was to have sustaining value as a service to the larger medical community, most contended, it must yield measurements that would differentiate normal structure and function from the pathologic. Hence countless postulates, projects, manuscripts, publications and fellowships, including mine.

In most cases these efforts to derive measurements and “normal ranges” from moving images have been of great clinical value and has advanced patient care. However there have been, and continue to be, numerous instances where over-zealous attempts to quantitate have caused misinterpretation, often due to over-simplification of a complex image or set of images that has much more value to the observer than any static measurement can convey. Trying to compress the meaning of an image into a set of simple measures will always have inherent limitations. What numeric value could one apply to da Vinci’s Mona Lisa that would convey even a fraction of what the human eye and mind can perceive in a few seconds of observation?

Recently, considerable controversy has arisen in the United States as a result of attempts to incorporate measurements of adversity into the college admission process. The Scholastic Aptitude Test (SAT) is undertaken by American high school graduates and is a key component of their application to colleges and universities. It is widely considered to be a primary driver of admission decisions in an environment where admission to “top tier” universities is highly competitive and, recently, the subject of criminal prosecution in the United States.  

This new score, dubbed the “Adversity Index” is a composite of 15 factors, including measures of crime rate and poverty in the neighbourhood in which the applicant has been raised and an assessment of the “quality” of the high school attended.

https://www.wsj.com/articles/sat-to-give-students-adversity-score-to-capture-social-and-economic-background-11557999000

It provides a score scaled between 1 and 100, with higher scores indicating greater degrees of “disadvantage”. The Adversity Index is not used to adjust SAT test scores in any way, but provided separately to admission committees, presumably to “contextualize” the scores as they see fit.

The intent appears to be to level the admissions playing field that most agree favours applicants from wealthier backgrounds who can attend more academically rigourous high schools and benefit from more time and support for academics. It is also felt to identify students who have overcome personal adversity and demonstrated commitment and resourcefulness in order to achieve their success. The New York Times article cited above quotes Mr. David Coleman, CEO of the College Board:

“Merit is all about resourcefulness. This is about finding young people who do a great deal with what they’ve been given. It helps colleges see students who may not have scored as high, but when you look at the environment that they have emerged from, it is amazing.”

As one might imagine, not all agree. American College Testing (ACT) provides an alternative admission test for college applicants. Its CEO, Mr. Marten Roorda states the counter-argument in a recent blog post:

 “The algorithm and research behind this adversity score have not been published. It is basically a black box. Any composite score and any measurement in general requires transparency; students, teachers and admissions officers have the right to know. Now we can’t review the validity and the fairness of the score. And even if that changes, there is also an issue with the reliability of the measure, since many of the 15 variables come from an unchecked source — for example, when they are self-reported by the student.”

http://leadershipblog.act.org/2019/05/adversity-score-college-boards.html

All this comes about at a time when college and university admission processes are under siege as a result of a number of highly publicized reports of inappropriate influence exerted by wealthy and influential parents.

https://www.cbsnews.com/news/college-admissions-scandal-bribery-cheating-today-felicity-huffman-arrested-fbi-2019-03-12/
https://www.nytimes.com/news-event/college-admissions-scandal

The repercussions and resulting enquiries have uncovered dubious practices, even in venerable institutions.




https://www.nytimes.com/2018/10/19/us/harvard-admissions-affirmative-action.html?module=inline

And so, what are we to make of all this? Does any of this translate to Canada, and specifically to medical school admission, certainly among the most competitive choices available to young people? A few key questions and postulated answers. (Please note: following are the opinions of the author, and the author alone).

Q. Does wealth and privilege facilitate admission?

A. Almost certainly yes. For further discussion see previous blogs:

Does every Canadian have equal opportunity to pursue a Medical Education?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1165&action=edit

Medical School Admissions: Unintended Consequences

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=407&action=edit

Medical Student Debt: A problem, or shrewd investment?

https://meds.queensu.ca/ugme-blog/wp-admin/post.php?post=1807&action=edit

Q. Do we wish to admit a more diverse student population, including students from traditionally socioeconomically disadvantaged groups?

A. Yes. All medical schools have engaged this challenge in various ways. At Queen’s both the medical school and university have made clear statements to this effect.

https://www.queensu.ca/universityrelations/equity
https://meds.queensu.ca/academics/undergraduate/policies-committees/diversity-equity-statement

Q. Do adversity experiences build qualities desirable in medical school applicants?

A. They may, but not necessarily. Simply experiencing adversity is not sufficient. That experience must have resulted in a valuable learning experience that has contributed to the applicants ability to choose and undertake a career in medicine. In fact we must recognize that adversity experiences, unfortunately, have the potential to be highly damaging.

Q. How does “disadvantage” equate to “adversity”.

A. They correlate, but not precisely. To use an example from the cardiology world, sedate hypercholesterolemic people are at higher risk of developing premature ischemic heart disease, but they may not, and many active folks with normal cholesterol levels will. This is the nature of a “risk factor”. Lower socioeconomic status certainly puts one at risk for greater life adversity, probably at a linear fashion where poverty levels virtually guarantees adversity. Conversely, socioeconomic stability certainly provides no immunity from adversity experiences.   

Q. Will an Adversity Index developed from compiled demographic and self-reported data provide a valid reflection of a student’s development and preparation for a career in medicine?

A. In and of itself, probably not. The information upon which it is based is inherently flawed, imprecise, and subject to manipulation.

Q. Will an examination of personal adversity and its impact on personal growth be helpful?

A. Yes. The study and practice of medicine requires commitment and resilience, both of which can be developed by adversity experiences successfully engaged.

And so, examining disadvantage is essential to addressing diversity goals, but Admissions Committees must develop robust methods to  determine if adversity has been experienced, and what impact has resulted from those experiences. A numerical index such as that developed by SAT may provide a useful starting point, but is no more revealing than is a linear dimension obtained from recordings of the beating human heart.