Ok. We are somewhere between 50,000 and 300,000 doctors short. Probably more, given our current approach to immigration, because 25 percent of all doctors in the US come from other countries – because we don’t send enough of our own students to medical school. Instead, we import our doctors from elsewhere, from places who need them more than we do.
So you might think we’d roll up our sleeves, develop new medical schools and residency programs and do everything we can to make it easy for our students to get in and go. But this is the US. And we have a market for medical services, not a health care system, which means no one is in charge of matching resources to need. And so there is no one in charge of fixing the problem of not enough doctors.
Instead of making it easy to apply and go to medical school, we make it incredibly difficult. Only saints and heroes survive the process.
How difficult do we make it? Buckle your seatbelts, Annie. We are going for a wild ride.
Almost everyone knows that to get into medical school, you need to graduate from a four-year college and both take and excel in all the prerequisite courses: a year of chemistry, biology, physics, and organic chemistry both courses and laboratories, as well as calculus. Accepted students need a 3.81 GPA or better. (In addition, many students take biochemistry and cell biology, which are useful in med school and even sometimes in practice.)
Then, you have to take and do well on a standardized test called (unsurprisingly) the Medical College Admission Test (MCAT), which takes most people three to six months to prepare for after taking the prerequisites, and costs $350. Many students also take a preparation course for the test itself, which usually costs $2000-5000.
Then there are two new tests, which many medical schools are starting to require called PREview and CASPer, which cost $85-100 and purport to test your situational judgement. The PREview is a test designed by the medical schools, who, it should be mentioned, are made of people who make a living from medical education, not from patient care, people who have built themselves a very nice and completely unregulated monopoly that supplies them with $250,000 a year jobs. (Remember, you have to jump through all these hoops to practice medicine. There is no competitive pathway. Where is the Federal Trade Commission when we need them?) These tests appear to predict who will do well in medical school, not who will be better doctors, because, of course, we have no good measure of what counts as a better doctor.
But that’s just the beginning. Then you are supposed to volunteer in a clinical setting, to prove how good you are at interacting with people. And you are supposed to volunteer in a laboratory, to prove what a good scientist you will grow up to be. Note that what we need today are primary care clinicians who know how to listen to patients and have empathy and kindness, not more scientists. Just sayin.
Then you have to fill out the application forms themselves. There is a common application form, which helps you get started and costs $175 for the first school and $46-57 for each additional school – and most people apply for between 17 and 25 schools. Then there is a secondary application, which you get to fill out if your primary application was good enough. The secondary application costs $75-150 per school. And each school has its own essay questions, which make the work of filling out all these applications a bear.
You also have to get letters of recommendation, which every applicant has to beg of teachers and physician mentors or friends, understanding that teachers of organic chemistry, biochemistry, physics, and biology may be very nice people, but few know much about actually practicing medicine. Even so, medical schools make decisions based on those letters.
Most students now take one to three years AFTER college to volunteer in a clinical setting, volunteer in a lab, prep for and study for the MCAT, PREview or CASPer, get their letters of recommendation and fill out all the application forms. One to three years, on top of eleven years of education itself.
Not surprisingly, there are consultants who help you fill out these applications and schedule and take the tests. They cost between $6000 and $10,000. So, guess who goes to medical school? People whose families have money already.
In addition, there is a process called a Committee Letter. Your college or university’s premed advisor or committee is supposed to write a letter that sums up all your recommendations and course work, and either does or does not recommend you for admission. I’m told that medical schools put lots of weight on these letters, even though they are usually written by people who don’t practice medicine themselves, and may have never even met the applicant. These advisors and committees have significant self-interest when they write these letters, because their college or university is often judged by its track record getting people into medical school. Do they recommend the people who will make the best doctors, which they have no way to predict? Or do they recommend people who have the best chance of getting into med school already, to keep their admission percentage high by discouraging those who don’t have the best shot at the outset? You tell me.
And oh, I forgot, students also have to go to interviews, if their applications are good enough to win them interviews. Which means nice clothes, new shoes, flights and hotels for each one. So maybe $1000 per interview. If you are lucky enough to get one. And perhaps $10,000 in interview costs. If you are lucky enough to get invited to ten interviews. Which most people need to have a good shot at one acceptance.
And all this is just to apply to medical school. Remember that, to be a doctor, you need four years of undergraduate school, four years of medical school, and three to five years of residency. Taking tests all along the way. That’s at least eleven years of schooling after high school. Why would any reasonable person want to do this?
There is no evidence, unfortunately, that any part of this process, any of these courses or the MCAT itself or the interviews actually selects for and prepares better doctors. This is just what we’ve been doing for the last hundred or so years to decide who gets into medical school. The mess that is US health care, however, is a pretty good argument that our process for selecting the students who will make the best doctors has been a miserable failure.
We have a cost and health outcome crisis in the US because we don’t have enough of the right kind of doctors, by which I mean doctors who love and care about their communities. Our medical school admissions process is flawed, self-serving, biased toward the rich, and completely crazy. And we are all crazy together to let it continue as it is.
You can find Michael Fine’s commentaries and short stories on
https://michaelfinemd.substack.com/and on http://www.michaelfinemd.com