Kanter, Steven L. MD
Getting accepted to medical school must be about what the applicant knows, not who the applicant knows. And it must be about the applicant’s potential to master a set of complex skills, to cultivate a professional habit of mind, and to develop into a creative and independent thinker—not the applicant’s dependence on the influence of prominent individuals. Admission deans, along with many medical school faculty members and students, work very hard each year to achieve these ends. And that’s why it is so distressing to read newspaper accounts, from time to time, that suggest that the integrity of an admission decision may have been compromised.
Fortunately, this does not occur often, and my goal in this editorial is not to discuss any particular event or individual but rather to explore the broader issue of assuring the integrity of admission decisions. Specifically, I examine two Liaison Committee on Medical Education (LCME) standards that address how admission committees must make decisions, and I propose three ways to improve the integrity of the process.
To begin, it is important to acknowledge that making good admission decisions is hard. The task of figuring out who is to be admitted to a particular medical school is a complex problem encumbered by inherent uncertainty. There are no reliable measures that can determine which applicants will become good doctors and which will not. An admission decision requires the synthesis of many different kinds of information (often measured in different ways, and sometimes not measurable). Also, a good decision requires aligning an applicant’s credentials and aspirations with the vision and direction of the school. It is clear that admission decisions embody the four basic qualities that formally define a decision as difficult: the problem is complex, uncertainty is inherent, reaching a conclusion requires satisfying multiple, often competing, objectives, and different perspectives may lead to different conclusions.1
To optimize the ability to make good decisions in the face of these difficulties, many medical schools (essentially all in North America) assemble an admission committee comprising faculty and students who are charged to function as a deliberative body. A common practice is for the group to receive its charge from the dean based on his or her vision and the school’s strategic plan. Ideally, service on this committee will rotate to combine experience and continuity with the fresh perspectives of new members. The committee functions best if it has a clear understanding of its charge (often based on an annual or semiannual discussion with the dean), an explicit set of procedures, and the ability to exclude personal, financial, and political motives from the decision-making process.
The LCME, the body that accredits MD-degree granting programs in the United States and Canada, offers key guidance for admission committees (see http://www.lcme.org/functions2007jun.pdf, Section III, A). Two standards are of particular importance to making admission decisions: LCME standard MS-4 and LCME standard MS-7. MS-4 states: “The final responsibility for selecting students to be admitted for medical study must reside with a duly constituted faculty committee.” (Note that the LCME uses the word “must” to indicate “that the LCME considers meeting the standard to be absolutely necessary for the achievement and maintenance of accreditation.”) This standard implies that an admission committee is an executive decision-making body and not a group that simply is advisory to the dean. This interpretation is consistent with my experience as an LCME site visitor and is important to the integrity of the admission process for several reasons.
First, if a dean is to administer the medical school effectively, he or she must balance a complex set of competing interests (e.g., academic, financial, political, personal) that have the potential to adversely influence the quality of admission decisions. Thus, LCME Standard MS-4, by resting final responsibility with a faculty committee, isolates the admission process from those influences and protects the dean from possibly compromising the integrity of the process. The standard also facilitates a dean’s ability to communicate effectively with individuals who seek to influence the admission process. He or she can simply explain that medical school accreditation standards prevent deans from intervening in individual decisions of the admission committee.
Second, over time, a well-structured and well-functioning committee develops an institutional memory, a shared experience, and seasoned judgment. This enables the committee, as a whole, to overcome the limitations of a single decision-maker with less knowledge and experience.
Third, admission committee members work very hard reading thousands of applications, interviewing hundreds of applicants, and deliberating for hours at committee meetings. If the time they invested became useless because outside interests trumped their experience and judgment, they would quit. It would be impossible to recruit committed, devoted faculty members to serve on the committee and to do the time-consuming work involved in making admission decisions that are essential both for the good of the school and for the good of each applicant.
It is important to note that MS-4 does not preclude the dean from charging the admission committee to admit a kind of student based on a new strategic direction for the school. For example, a dean, after assessing the strengths and weaknesses of the institution, may see opportunities for students who have a passion to work in underserved areas or for those who wish to become physician– scientists. Yet even though the dean has the prerogative, and perhaps an obligation, to set the direction for the admission committee, the dean must not make individual admission decisions.
As for LCME Standard MS-7, it explicitly addresses the issue of external influence in admission decisions. It states: “The selection of individual students must not be influenced by any political or financial factors.”
LCME standards MS-4 and MS-7 are manifestations of an underlying philosophy that admission decisions must be based primarily on the quality of an applicant’s academic achievement, personal characteristics, potential for future growth and development, and potential to benefit from the school’s offerings and contribute to the school’s programs.
Admitting a student in violation of LCME standards MS-4 and/or MS-7 would be a disservice to the admission committee members who have worked so hard and so long to develop a philosophically sound and consistent approach to decision making. It would be a disservice to the faculty as a whole, whose interests are represented by the admission committee. It would be a disservice to all other students in the school, who were admitted without the benefit of outside influence, and to all other applicants who were denied admission due, in part, to the lack of outside influence. However, the most egregious disservice of all might be to the improperly admitted student, who may not be a good fit for the medical school, who may have been pressured by parents to attend, who may not complete his or her degree, or worse still, may complete it but be miserable for four long years. The dean has a crucial role in preventing such violations, by supporting admission decisions that comply with accreditation standards.
The LCME standards form the core of a sound approach to admission decisions. However, I believe that both medical schools and applicants could benefit from more comprehensive guidance to ensure the integrity of admission decisions.
First, I propose that the LCME consider strengthening and expanding the language of standards and their annotations to address more specifically issues such as the dean’s responsibility to provide leadership, direction, and a general charge to an admission committee; the dean’s responsibility not to interfere in admission committee decisions about individual applicants; and whether or not a dean should be allowed to ask the admission committee to reconsider a decision. Or should that be permitted only if the dean has access to new information that the committee did not consider?
Second, I propose that the GSA Committee on Admissions (of the AAMC’s Group on Student Affairs) should align its recommendations and guidance, in its well-regarded Handbook for Admissions Officers (http://www.aamc.org/members/gsa/coa/handbook/admissions_handbook.pdf), with relevant LCME standards. Specifically, statements such as “the medical school dean has ultimate responsibility for admissions …. ” should be clarified, since that statement could be interpreted to conflict with LCME standard MS-4.
And third, I propose a preventive strategy to educate deans (especially newly appointed ones), university presidents, and others about the integrity of the medical school admission process and the important accreditation standards that support it. An appropriate body, such as the LCME or the GSA committee, could send an annual letter to deans, sponsor brief presentations at orientation and development seminars for new deans, and seek other effective means of communicating this important information.
In sum, while well-crafted accreditation standards and time-tested guidance from the GSA Committee on Admissions are key strategies for making sound admission decisions and minimizing inappropriate influence, they are not enough. Assuring the integrity of the process also requires leadership from the dean, who is the role-model-in-chief for all faculty, students, and staff of a medical school.
Steven L. Kanter, MD