The case for high medical school standards and for better use of a doctor’s day.
As a former University of Minnesota Medical School admissions committee member and a board-certified dermatologist a few years removed from my own residency, I read with interest the May 18 article on medical school selectivity (“Numbers foretell a doctor shortage”). Two interconnected narratives require additional, finely pointed discussion.
First is the popular view that there is a looming, severe physician shortage. The second is whether admissions standards, under pressure from the predicted shortage, will remain sufficiently stringent to ensure high-quality candidates.
Bleak physician head-count projections reflect extrapolations from per-doctor capacity based on seeing a fixed, maximum number of patients daily. If the patient population increases and becomes more ill, while the physician production rate remains constant and retirement remains steady or increases, there is an approaching physician shortage.
But what if there isn’t a looming shortage? What if the real danger is incoming physicians practicing under today’s dominant but flawed patient interaction model? Perhaps, by working smarter and committing to a team-based model, the health care system can deliver high-quality care to more, and sicker, patients using the same number of physicians. We may, in fact, have a physician surplus.
Physicians in traditional clinic settings can spend the majority of their time on tasks that underutilize expensive, specialized and lengthy training. Doctors complete paperwork, perform patient-education tasks ripe for delegation and generally micromanage team members. In addition, health care administrators routinely add paperwork and spurious quality measures to the workloads of already beleaguered physicians. The same administrators balk at hiring scribes and additional medical assistants for tasks that do not require a medical school and residency education.
Instead, doctors should spend patient-centric time concentrating on difficult diagnostic and therapeutic decisions — or performing difficult technical tasks — that befit the rigor of medical training. Everything else can be delegated to teams of skilled and essential physician assistants, nurses and medical assistants.
At the same time, it is said the most costly item within a hospital, measured in dollars and poor outcomes, is a doctor’s pen. A physician without the capacity or training to juggle myriad differential diagnoses not only is unnecessarily expensive — ordering unwarranted imaging, lab tests and consults — but also dangerous. Patients die from diagnosis delays and poor medical management decisions.
For that reason, allowing and expecting “average” science students to become physicians leading health care teams will only worsen a trend toward less competent medical care. Medical schools should fortify — not dilute — admission standards.
Medical school administrators must hold the line on candidate quality over quantity. If anything, schools should tighten admission criteria. Formidable competition for openings, along with the fortitude to counsel unqualified applicants with “courageous conversation,” is fundamental to high-quality, physician-led medical care in the future.
We must also re-evaluate long-standing admission metrics used to predict the adequacy of a future physician. What if the MCAT score is a poor surrogate for diagnostic acumen? The urgency around the future of medical care makes it mandatory to look more energetically at applying retrospective data to develop higher-value predictive tools. Who are the best physicians? What did their profiles look like in terms of activities, GPA and MCAT scores upon admission to medical school? How do we prospectively identify more of these men and women?
Improving the quality of patient care will not survive lowering the bar for medical school admissions. We must carefully consider whether the problem is a looming physician shortage or the current medical care model at the root of that assumption.
Dr. Neil A. Shah is a board-certified dermatologist in practice in St. Anthony.
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