Some time ago, I had an interesting Substack Exchange with Michael Magoon, who runs this excellent Substack:
Michael and I had an interesting exchange, which is excerpted below. I wanted to answer his points, and he graciously allowed me to do so as part of a Substack post. The excerpt of his words is below.
But there are also organizational and societal effects. I have read numerous media reports about rapid growth of DEI in medical profession, including:
1) Forced hiring and admissions to medical schools of sub-par individuals because of their race.
2) Prohibitions of genetic research that might in any way show genetic differences between racial and gender groups.
3) Rejection of the concept of biological gender and pushing “gender-affirming” care on youths.
I want to address first the issue of admissions of sub-par individuals based on race. I want to leave hiring out of the picture, because I can’t find a lot of data to assess this carefully.
I think the notion that DEI admissions have grossly degraded the medical school admissions process is probably not true. Let’s start by conducting a thought experiment about medical school admissions.
Let’s assume that all of the medical school application process was scrapped, and we simply admitted students based on MCAT scores. Any given medical school has a very low acceptance rate; thousands of applicants vie for 100-150 spots. However, overall, some 55K applicants are competing for 22K first year spots, so the acceptance rate is 40%. According to an MCAT only regime, you would simply need to score in the upper 40% of applicants to get a spot somewhere.
The median score on the MCAT is 506.3 with a standard deviation of 10. To score anywhere in the top 40%, an applicant has to score 508.8.
The median White applicant has a score on the MCAT of 507.8, with a standard deviation of 8.7. 54% of all White applicants would cross that threshold of 508.8.
The median African American applicant has a score of 497.5, with a standard deviation of 10. 13% of African American applicants would be able to clear this benchmark.
The actual racial breakdown of Medical School first year students in 2022 was 52% white, and 10.2% African Americans.
In short, if we shifted entirely and solely to MCAT scores, the composition of a first year class of Medical students would look quite similar to what we actually have now.
I doubt that Medical School admissions committees are looking to stuff the class with inferior candidates just to meet quotas. Most likely, they are looking for qualified individuals, who also have the temperament to be good physicians. They are looking at “distance traveled”, to identify students who have had to overcome substantial barriers and obstacles. They are looking for students who they suspect will be leaders in the field and in their communities in years to come. This is very difficult to predict in advance. This means that Admissions committees are inherently given a great deal of discretion in making offers to candidates. But even if they were to entirely shift to an objective and quantitative process, it is unlikely that the composition of the class would change. Another way of thinking about this is that if an African American student with a relatively low MCAT score but a compelling narrative was offered a position at a medical school, she would be taking the place of an African American student with a higher MCAT score but perhaps a less compelling narrative.
I want to be clear: no two people are the same, separated only by a score. I think that schools are admitting candidates who they have faith in. But their selectivity is probably in line with what a test would have done.
So the core question here, is whether you trust the judgement of a medical school admissions committee over that of a test. This is a difficult question to answer. There are a number of countries that base all admissions decisions on a single test outcome. It is not clear that their doctors are vastly superior to ours. Furthermore, when we tend to think of leadership in medical matters, we tend reflexively to think of the United States. Maybe our process is better than an exclusively exam based selection process.
Here is my opinion. I think that the medical school process tends to take people as they are, and mold most of them into good doctors. How you find those people is mostly immaterial; by the time they get through, the process will make talented physicians of almost all of them. In my own personal experience, my formation as a physicians was mostly from the mentoring, habits and disciplines that I acquired through the medical school, residency and fellowship process, with at most only a tiny component from my training before medical school. In short, I trust the American medical education process, with numerous years of training, more than I trust any selection metric, either objective (MCAT scores) or subjective (Admissions committees).
Here is where I want to offer my prescriptions for how I would change medical school admissions.
I would start by letting a lot more people in. I think that we need to be training a lot more people to become physicians, to care for an aging population. I think the clinical volume is available, and I think that trainees can hold down the costs of operating a teaching hospital. In the longer run, an era of abundance in medical care will drive costs down, something that is sorely needed.
I would encourage training a lot more of a whole gamut of specialists. We are going to need more cardiologists and more urologists, in addition to many other specialties. As patients age, their organ systems need increasingly specialized care. I have very little patience for the notion that these complex workloads should fall heavily on primary care physicians.
I would endorse a separate track for people committed to primary care. The primary care pipeline has withered away, and I am deeply skeptical that this core specialty can be replaced at scale by mid-level providers (nurse practitioners, etc). Realistically, many students on this track would have lower scores than students admitted into more open-ended tracks.
I think most of medical education ought to be free. NYU went completely tuition free for its medical students, for at least the next 50 years. How? A one time grant of $400 million dollars from Ken Langone ($100 million) and other board members. This does not sound like a stunning amount of money to me. So far, there are 3 free tuition free medical schools in the United States: NYU, Cleveland Clinic and Kaiser Permanente. There ought to be a lot more.
Pre-medical education could use an overhaul. I am skeptical of the value of physics, organic chemistry and calculus to pre-medical education. I loved all those subjects, but I scarcely use any of those subjects as a practicing physician. I would retain molecular biology at the core of pre-medical education. I would add much more extensive course work on statistics. Lastly, I would make Spanish a requirement. We are going to be caring for predominantly Spanish speaking patients for a long time to come.
I will tackle the next two points in future posts.
The MCAT data for 2023 is here. The medical school composition data for 2022 is here. I am of course assuming that scores did not change much between 2022 and 2023. The statistical calculator that I used is here. If I have made any gross measurement errors, I would of course welcome the feedback.
Srihar,
Thanks for the compliment for my Substack column. I did enjoy our debates as you generally state your case in a respectful manner.
I must confess that I know very little about medical school admissions. As a former professor, I know far more about undergraduate admissions and have written books on the subject.
I am impressed by your data, but I don't know enough to analyze it carefully.
I know that in undergraduate admissions, there are wide gaps between the average GPA and standardized scores of Asian, White, Blacks, and Hispanics and that educational institutions have long set different acceptance criteria for each race to expand the number of Blacks and undercut the number of Asians. It is possible that there are fundamental differences for medical students and med school, but I am skeptical.
I believe that this practice is:
Unethical
A violation of the Civil Rights Act of 1964, both in letter of the law and in its intent
Undermines society overall by not making choices based on Merit, which I see is critical to all institutions in society functioning correctly
In many cases hurts the very people whom it is supposed to be helping by putting them in an environment where they cannot compete rather than an environment where they could thrive
Makes it harder for professors to teach as it creates much wider variance in how fast students understand complex material. The typical result is a "dumbing down"
Increases racial animosity both within the institution and outside it.
Undermines the popular trust within the public for that institution.
I am also very skeptical of your claim:
"How you find those people is mostly immaterial; by the time they get through, the process will make talented physicians of almost all of them."
In my experience and research the intellectual abilities of the students coming in are far more important to the outcome than the education itself (i.e. the reason Harvard grads are smarter is because their prestige enables them to get the smartest students, not because Harvard professors are better teachers in class).
My guess is that in the future there will be data to prove it.
And, no, I do not trust medical schools to make good judgments about admissions. I am confident they will discriminate based on their self-interest and ideological assumptions.
The admission system needs to be:
Transparent
Based on demonstrated academic achievement and tests that are proven to predict educational outcomes.
Ideally, the process should also be simple.
Here are more on my thoughts:
https://frompovertytoprogress.substack.com/p/lets-make-college-admissions-merit