Character, Color, Admissions, and Physicians

Robert C. Bowman, M.D. Initially posted on HLTHPROF 2/2003  Version with links and updates at http://www.ruralmedicaleducation.org/admissions/character_color.htm In response to the knowledge that there were certain groups attempting to use the media and lawsuits to remove programs and admissions that they feel favor minority candidates:

Few people are capable of expressing with equanimity opinions which differ from the prejudices of their social environment. Most people are even incapable of forming such opinions. -- from a school dropout named Albert Einstein

My best rebuttal of those who would attempt to make us "color-blind" in admissions is to note the need for physicians to be the best people. We need physicians of character and compassion, dedicated to service. The failure to attract and admit these physicians, I believe, is responsible for many of the negative trends currently damaging medicine today, especially such as the rise of medical errors that should be a greater source of terror than any we have yet actually experienced (even service to the underserved and the declines in those interested in primary care).

Everyone is a prisoner of his own experiences. No one can eliminate prejudices - just recognize them. Edward R. Murrow

After reviewing a good portion of the literature regarding admissions that relate to graduating more rural and family medicine and primary care doctors and more doctors for underserved areas (growing list at  http://www.ruralmedicaleducation.org/admissions/admissions_for.htm ), and after applying this information over the years, as well as observing the graduates of programs involving these characteristics, I have consistently seen the following:

The physicians that we all want for ourselves or for our nation are most importantly a matter of who they are as persons, rather than their intellectual credentials or the type of training that they undergo.

My mother was a nurse in a clinic and she was amazed (and sometimes frustrated) at how long people would wait late into the evening to see certain doctors. The only thing that I can see that was different was that the doctors worth waiting for (and working with) were people of character.

The sad fact is that people who have had lives that have not really been tested and stressed in certain ways, are not as likely to people of character. They might yet become so later in life, but they are not there yet. When they are tested, they might overcome their obstacles and learn from the process, but they might not.

People of character can be trusted more to undergo the rigorous training of medical education and still remain people of character, doing what they set out to do or were called to do. I could go on and on about the dangers of putting medical training into the hands of a person without character, but this is another topic.

In the best of all possible worlds the majority of all entering medical students would end up as generalists, but all physicians - family practitioners, physiatrists, urologists, allergists - would be well-educated, highly intelligent, well-rounded, personable, honest, altruistic, highly motivated individuals who had tested themselves prior to medical school in some tangible way against their goal of a medical career and a service profession. Don Madison Acad Med 1994 Oct;69(10):825-31, Medical school admission and generalist physicians: a study of the class of 1985.

There are characteristics that should be preferred by admissions committees of all types of professional training. These indicators include service orientation, maturity and/or older candidates, and interest in serving the underserved. There are also markers such as a sincere interest in choosing family medicine. This may be a simple interest, or it may represent a more complex marker of several factors such as doing something different or serving or making a difference or interacting a certain way with patients, rather than just a surface appearance of a career in FP. There are other medical careers that may similarly represent a person who is not afraid of obstacles.

MCAT and GPA do not help in the assessments of special characteristics. Given the time it takes to evaluate candidates adequately and the tendency to delegate these tasks to others or to testing, measures such as MCAT and GPA may actually be harmful.

The use of such measurements by certain groups in lawsuits tends to attempt to simplify a very complex process of assessing a person for a career extending for decades and impacting many lives in ways far beyond intellectual categories. See footnote below.

A common denominator for those attempting to evaluate a person thoroughly, is the life events experienced. Often it is most useful to pay attention to the obstacles that students have encountered and how the students reacted. Many of these obstacles had a lot to do with the environment of the candidate at birth (or even at conception), instead of what they have done in their lives.

Tragedy can make you bitter or better. - author unknown

Admissions Challenges Alabama - admissions committees face great challenges balancing academics, failure rates and diversity in ethnicity and geography. The fact is that the predictors are poor and it is far to easy to decline admissions to rural and ethnic background students. Relying on measurements instead of more comprehensive evaluations is a major problem facing medical schools and national workforce goals (private link)

The following is a response I had to the following charge in the current Future of Family Medicine project that involves multiple organizations and millions of dollars. It is an attempt to help family medicine renew and take advantage of trends and be pro-active instead of reactive. I am not a formal part of this, other than to write in my contributions as a family physician. The bold print is from FFM at http://www.futurefamilymed.org/  , the italics are my responses (RCB).

Patient priorities noted on FFM scream out to us that patients care more who the doctor is, their characteristics and values, whether than how they are trained. This has more to do with selections.

Patient satisfaction involves areas such as making a difference, bonding, getting to know patients - all these have to do with personal characteristics such as service orientation, maturity, communication skills, past experiences with a variety of people from all walks of life, understanding the broad variety of human existence, etc.

1. Generating understanding of family practice - my thoughts: who we are speaks more than marketing
2. Organizing individuality (FPs are rugged individualists) - my comment: emphasizing our individual leadership at the community and grassroots levels are more important than control concerns by FP leaders
3. Winning respect in academic circles: - my comment: the past decades have told us in FP that resources invested here have been wasted, better to focus on community and local groups and organizations, who will then put the pressures on academics to do what is needed
4. Making family practice an attractive career option - It is already a great option, for the students who are being rejected or who are disillusioned with medical education and could overcome this with encouragement at the preprofessional level
5. Addressing America’s obsession with science and technology. Society, generally, is enamored with science and technology, which, in turn, influences perceptions of what is regarded as medically "critical." Family practice, however, is associated with neither. - Good luck, this is like trying to pry the car keys out of the hands of Americans. This obsession is not under our control, but it is something which was responsible for the rebirth of family medicine. Again a good portion of our power as family physicians derives from our position between patients and technology, to help them understand and use it appropriately. The American public may be obsessed with Science and Technology, but they are just as aware of how badly they are being treated by physicians. Increasingly patients come to us for explanations as they are deluged by information, some science and some not. This role will only get more important.

The wise family physician is one who knows how much he/she is but is more concerned with how much more he/she can become Hunter Woodall, Family physician

Robert C. Bowman, M.D., Co-Chairman

Rural Medical Educators Group of the National Rural Health Association

UNMC Department of Family Medicine Director of Rural Health Education and Research