Social engineering in Australian medical schools

“In teaching there should be no distinction of classes.” – Confucius, Analects XV. 39

In the May 2006 edition of “The NSW Doctor” (journal of the Australian Medical Association (NSW) Limited), an opinion piece was written by Dr Julian Parmegiani, a well known forensic psychiatrist titled “Medical Schools and the Meritocracy Crisis”. Within the article expressed a view I had long held though perhaps not “politically convenient” within the current views of medical student selection.

In Australia, there has been a move towards “interview” based selection for potential medical students compared to the previous system of “academic achievement based” (“meritocratic”) system. When I entered the undergraduate medical program at the University of NSW (the last bastion of the “old school”), entry was entirely based on my performance in the HSC (“higher school certificate”). Offers into the program had a number of prerequisites (insofar as subject choices and performance in those subjects in the last two years of secondary education) and was then applied on a “demand” basis. For example, there were “x” number of positions and the top “x” candidates (in terms of the “TER” or tertiary entrance rank, a composite number determined statewide “ranking” on HSC performance) were given those positions.

Medicine is in relative high demand and attractive to those who perform well academically and as such resulted in a degree of “academic elitism”. This criticism is valid. In my year, prospective medical students had to be ranked in the top 0.4% of all students completing the HSC to be successful in securing a place in the undergraduate medical program at the UNSW.

I clearly remember the other criticisms at the time. It was purported that the meritocratic system produced (quoting Parmegiani’s article):

“… idiot-savants with no interpersonal skills, altruism, or empathy.”

The “unhappy mother” argument was common. “My ‘little Jonny’ would make a fantastic doctor but only got a TER score of 90”.

And of course, there was the veiled but palpably popular opinion that only the socially retarded dare utter that “there were too many Asian medical students”.

A few years into my medical degree, the UNSW succumbed to the tides of change and it too instituted an interview based system.

The ideology behind an interview based selection system is so that qualities that are not necessary represented in the sterile TER such as ethics, empathy, and altruism would be considered as criteria. The flip-side, of course, is to weed out the aforementioned “idiot-savants”. This ideology is admirable. Pragmatism and practical implementation is nevertheless necessary.

A quick review of the medical student intake population in programs based highly on interviews reveals several key biases compared to the old meritocratic system. The medical students are significantly whiter, from wealthier backgrounds and more likely to be from a family of doctors.

Is this “racism” as suggested by Parmegiani? Perhaps, though I believe it to be unintentional.

Is this “social engineering”? Absolutely.

The problem is that the interview is hardly unexpected and nor are the selection criteria. The interview process may well work for a cohort of “naïve” applicants but the reality, however, is somewhat different. Prospective students more often than not have been “coached” and “trained” for the interview. “Confidence” and good performance in a career changing interview is hardly a measure of being a virtuous doctor. Furthermore, interviewers are notoriously bad at detecting lies or exaggerations.

States Parmegiani:

“The interview will not identify altruistic, kind and empathic doctors. The most successful candidates won’t turn into the über-doctors expected by selectors. Who looks calm while playing Russian Roulette? Successful students might just be a tad more psychopathic, manipulative and intent on recouping their investments”.

The meritocratic system undoubtedly selects out the obsessively academic, schizoid and potentially immature individual as medical students. However, the rigor of the medical training program selects out those unsuited for clinical practice. Most have the capacity for the academic intensity, but those who lack the necessary social skills and are unable to develop them will usually leave the medical program. Although one of the aims of the interview based system is to promote “variety” in the people who train in medicine, I do not believe that this is borne out, except in the post-graduate medical programs. My experience is that those who are selected through the meritocratic system are in fact more diverse in their opinions and views when graduated and practicing medicine.

That is not to say that medical graduates or medical students selected on an interview based system are in any way inept or incompetent. Most are excellent doctors or are well on the way to becoming one. Nevertheless, there is a question of fairness and equity. In Australia, there are far more people with the aptitude of being a good doctor who want to become one, than there are available training positions (or fundamentally, the economic and service need).

Meritocracy is the great leveller. The arbiter is academic ability. Even if society deals a candidate a favourable hand, the judge is still talent, effort, dedication and ability. Like it or not, the social engineering in the interview system selects out the less academically able, the socially advantaged, the coached, and the psychopathic.

A historical analogy from Parmegiani:

“…in 1905, Harvard adopted admission criteria based on merit. By 1922, the number of Jews began to rise dramatically, making up more than 20 per cent of Harvard’s freshman class. Jews were thought to be insular, sickly, and unsuitable. In addition, they displaced the sons of wealthy Anglo-Saxon alumni, a development that threatened donations. The Ivy League (Harvard, Yale, and Princeton) responded to the meritocracy crisis by changing the definition of merit … “Candidates had to provide personal essays, demonstrating their aptitude for leadership, and list their extracurricular activities.” This sounds familiar. The proportion of Jewish students fell rapidly by 1933.”

I am uncertain as to when or if the selection process into medical schools in Australia will change. I am somewhat enthused by the publication of the opinion piece by Parmegiani so that at least this topic is being raised and hopefully debated. My personal opinion, and though this may be a broad brush, is that the interview based system was introduced as part of a social agenda to engineer a new brand of doctor who would fit a certain idealised mould. Though conceivably not without merit in its philosophy, its implementation and outcome should be cause for alarm.

Source article:
Parmegiani, J. Medical Schools and the Meritocracy Crisis. The NSW Doctor, May 2006, p.10-11