Transforming Admissions: The Gateway to Medicine

Abstract

IN THIS ISSUE OF JAMA, A STUDY BY EVA AND COLleagues describes the multiple mini-interview (MMI) process pioneered at McMaster University and its association with students’ national licensing examination scores. The MMI is based on sequential structured interviews, with a series of tasks analogous to the objective structured clinical examination. The authors found that students who were accepted by McMaster based on their MMI results and other application data scored higher on Canadian licensing examinations than students who were not accepted by McMaster but attended other medical schools. The MMI appears to be an effective technique for probing dimensions ranging from applicants’ responses to novel situations to their reactions to an ethical conflict. The adoption of the MMI by more schools also may increase the diversity of medical student personal attributes, which may lead to increased opportunity for student professional growth, increased specialty distribution, and improved patient care. The MMI is one important, relatively new tool that medical schools have developed as part of an admissions process known as holistic review, a “flexible, highly individualized process by which balanced consideration is given to the multiple ways in which applicants may prepare for and succeed as medical students and doctors.” The goal of holistic review is 3-fold: to assess applicants’ academic readiness; to gauge their intrapersonal and interpersonal competencies, such as integrity and compassion; and to promote diversity in the student body. Ultimately, the hope is that medical schools’ use of holistic review and a competency-based admissions process will better enable identification of students who have the greatest potential to be the physicians of the future. Traditional admissions processes have placed considerable weight on measures of academic readiness, such as Medical College Admission Test (MCAT) examination scores and grade point averages, when deciding which applicants to interview. Although MCAT scores are a reliable predictor of academic success in the first 2 years of medical school, they are not strongly correlated with later outcomes in medical school or practice. Nevertheless, MCAT scores appeal to admissions committees because they allow for easy comparison of applicants from different undergraduate schools. Although academic credentials have an important place in medical school admissions, there is increasing recognition that overreliance on measures of academic readiness may eliminate some applicants who could become excellent future physicians. As a result, medical schools are moving toward a broader view of medical school readiness that emphasizes the competencies applicants have demonstrated in addition to their academic credentials. This change is essential to identify future physicians with the skills and knowledge to manage illness in the 21st century. For example, in the last 40 years, the largest contributors to increased life expectancy in the United States are reduced tobacco consumption and increased levels of exercise, both of which are behaviors linked to disease prevention. To prevent and treat disease in the future, physicians must have cognitive and behavioral competencies. The new MCAT examination, beginning in 2015, will shift toward a broader definition of academic readiness. The new MCAT will achieve this by including a new section on behavioral and social science content and by revising the current verbal section to test the way examinees reason through text excerpted from books, journals, and magazines across a variety of disciplines, including ethics and philosophy, cross-cultural studies, population health, and other subjects. Although robust measures of academic readiness will remain important, admissions interviews continue to offer a key opportunity for schools to gauge the second dimension of holistic review: interpersonal and intrapersonal competencies, ie, the personal characteristics required of physicians to practice patient-centered care. In assessing competencies, such as oral communication or resilience and adaptability, a variety of approaches are emerging, including assessment centers to evaluate medical school candidates’ personal and interpersonal attributes, situationbased judgment tests, and hybrids of these interview approaches. The movement toward competency-based ad-