Mon September 5, 2011

Number 160 and Up

In the medical community team-based care is starting to replace the old model of doctor knows best and makes all the decisions. And even though he was taught that way, KUNC commentator Dr. Marc Ringel is fully behind the new method.

I just joined the Admissions Committee of the CU School of Medicine. My duty, along with about a hundred colleagues, is to select 160 students for the class of 2016. 

The best way to convey the depth of our responsibility is to quote a saying recited by every medical student since time immemorial. “Do you know what they call the guy who graduates last in his class?”


Which means that we must strive to assure each one of the 160 women and men who matriculates is highly likely to be a quality doctor upon graduating.

Number 160 in the class isn’t dumb anyway.  The University of Colorado anticipates receiving 4 or 5 thousand queries to fill its 160 slots.  Less than one in ten of these applicants will be interviewed.

Which means that the School of Medicine gets to pick its entering class from among a pretty elite group.  One could almost argue for performing the last cut based on lottery, rather than on the labor- and time-intensive process of interview and deliberation.

Lots of studies have shown that once a student exceeds a certain (high) level of undergraduate grades and medical college admission test scores, further increments in these so-called objective measures hardly correlate with a physician’s career success.

So we look for other not-so-objective qualities among the applicants, qualities like integrity, compassion and flexibility, by putting applicants through two half-hour interviews. 

Recognizing how fickle and imperfect the one-on-one conversation is, subject to all the vagaries that make each of us the unique individual we are, the folks at the medical school admissions office will try out a new interview technique on a subset of this year’s wave of applicants.

The method, called “multiple mini interviews (MMI),” has already been employed at eight U.S. and thirteen Canadian medical schools.  It works sort of like speed dating.  Applicants line up outside a series of rooms, each one occupied by an interviewer.  On the door of the room is a sheet describing an ethical dilemma, a question like:  Is it okay to prescribe an unproven alternative therapy?  Are insurance co-pays appropriate?  How should a doctor’s personal feelings about newborn circumcision enter into the advice he gives patients?

After turning over the sheet to read the question, the candidate is given a couple of minutes before plunging in to discuss it.  Eight minutes later she finishes up and moves on to the next room, ethical dilemma, and interviewer…and so on, until she has completed six mini-interviews in one hour.

Interviewers are not expecting a right or a wrong answer.  Questions are chosen exactly because they pose dilemmas that lack clear solutions.  Evaluators are trained to listen for things like the candidate’s ability to think on her feet and her respect for the point of view of others.

The traditional mold that our training poured me and my cohorts into designates the physician as the decision maker.  It’s everybody else’s job to follow the doctor’s orders.  

Team-based care is taking the place of the old hierarchical model.  Each member of the team is expected to exercise her unique perspective and skills, in coordination with the others, to provide the best possible care to the patient. 

Studies have shown that the bulk of medical errors occur, not because the doctor-in-charge didn’t know enough, but because caregivers failed to communicate with the patient or with each other.  Team-based care is a potent remedy. 

Needless to say, this new way of providing care has huge implications for educating doctors.  Learning to balance original thinking with listening and collaboration becomes a priority for training.  Which is why I have great hope for MMI.  It is designed to tease out the sorts of attitudes and personality traits that would make a potential doctor-to-be a team player.

I’m tremendously impressed by the students we already have in our medical school classes.  They are smart, compassionate and amazingly well rounded.  Only time will tell if a new way of interviewing candidates will result in selecting even more of the sorts of people who will turn out to be the kind of doctor you and I would like to have taking care of us.

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