admissions assessment, medical school admissions, intrinsic motivation based selection, bias, burnout, medical education, intrinsic motivation

The stakes in the medical school admissions process are high and research in areas of medical education and medical school admissions process have been intense for decades. Universities spend a lot of time and resources hoping to select applicants most likely to become fantastic doctors in the future, possessing the essential core competencies & frameworks valued in the profession.

Professional misconduct and burnout could be prevented during the selection process by selecting the best-suited candidates for admission. Our physicians accumulate a vast amount of training and expertise, which they use in service of their communities. I personally have tremendous respect for medical doctors both because of my own personal history with medical doctors who have literally saved my life and allowed me to enjoy a quality of life that would not have been possible otherwise, but also because I have been fortunate enough to work with, learn from, and teach with over 50 medical doctors over the past several years. However, professional misconduct and burnout remain of great concern for the profession, its reputation, and the healthcare recipients. Is it possible to prevent these problematic issues at the earliest stage of the training process, at candidate selection? Selecting the right candidates during admissions could reduce these problems, AND produce higher performers who are happy at their job. However, this difficult task has eluded admissions thus far.

But why is it so hard to select future doctors that possess the essential core competencies given decades of research?

To answer this question we recently conducted a study of the medical school admissions process in the United States & Canada with several additional questions in mind:

1) Is the admissions process able to select applicants who are intrinsically motivated to pursue medicine?

2) Does the admissions process favor wealthy applicants as suggested by previous reports?

3) If there is bias, what is the source?

4) Why are the current admissions tools not as effective as originally intended?

5) Are certain admissions tools more effective than others in selecting future physicians?

6) Are future doctors satisfied with the status quo or do they prefer improvements to current admissions practices?

7) Lastly, is there a better way to select applicants?

Let’s explore the answer to each of these questions based on the findings of our recent research studies.

1) Is the admissions process able to select applicants who are intrinsically motivated to pursue medicine?

First, why is motivation important? Motivation is important because it is the primary cause of behavior. We are likely to engage in an activity and display certain behaviors because we are motivated by social pressure, rewards, fear, status or perhaps we are motivated because we find the activity itself rewarding.

Motivation can be subdivided to intrinsic motivation and extrinsic motivation.

Intrinsic motivation is defined as the desire to engage in an activity that is rewarding on its own regardless of external rewards, such as money, status, and social pressure. For example, if you think back to your childhood, the copious amounts of time you spent playing video games or playing with your toys are examples of intrinsic motivation. You probably did not require any external pressure to engage in such activities. In fact, if you were like me, you probably persisted despite external pressures, such as your parents’ advice to stop so you can finish your homework instead.

On the other hand, extrinsic motivation is defined as the desire to engage in an activity due to external pressures such as rewards, status, social pressure, and fear. The behavior is normally discontinued as soon as the external pressures are removed or it is replaced by a different behavior given new and greater external and/or internal pressures. For example, someone primarily motivated by financial gains will readily quit their current job for a new job with a larger salary.

The theory of motivation, or Self-Determination Theory (SDT) was initially developed by Edward L. Deci and Richard M. Ryan and has been elaborated and defined by academics from around the world. In the intervening decades motivation has been studied in education, entertainment and media, healthcare, organizations and work, video games, physical activity and exercise and a multitude of other applied domains. The reason motivation is so important in all these fields can be summarized easily:

People whose motivation is genuine or self-authored when compared to those externally controlled to act have more interest, excitement, and confidence, which results in enhanced performance, persistence, creativity, self-esteem, and general well-being. This is true even when the people have the same competence or efficacy for the activity.

For more background research on motivation, click here, here, here & here.

Selecting candidates based on their intrinsic motivation not only benefits the community by producing higher performing professionals, but also benefits the practitioner as intrinsically motivated individuals report higher self-esteem and well-being. In addition, intrinsically motivated individuals would be less prone to professional misconduct and burnout.

So back to our first question: Is the admissions process able to select applicants based on intrinsic motivation?

Based on our study, it appears that the majority (68–75%) of future doctors are primarily motivated by wealth, status or because one or more family members were doctors or other healthcare professionals. Only 25–33% appear to be intrinsically motivated to pursue medicine without the need for external rewards.

Our results are similar to an AAMC survey of graduating medical students. In the survey the students were asked, “How influential were the following in helping you choose your specialty?” The choices included extrinsic motives such as “income expectations”. The results show that year after year only ~22% of respondents chose income as bearing “no influence” on their decision to choosing a speciality, meaning only 22% were intrinsically motivated regardless of monetary reward. This provides a layer of validation for our studies. Furthermore, our gender and income breakdowns were also comparable to official reports as highlighted below.

If this is the case, the implications include utilization of resources for training of applicants that don’t really want to pursue medicine for its own sake. Additionally, extrapolating the worst case scenario one could imagine that patients might be at risk if our selected applicants are not intrinsically motivated because when things get tough (as they often do in medicine or any other profession for that matter), those who are not genuinely interested won’t be able to cope with stress and instead might show signs of professional misconduct, burnout and even attrition.

2) Does the admissions process favor wealthy applicants as suggested by previous reports?

Comparable to previous reports, our findings show that admissions practices appear to favor those from wealthy families in the United States & Canada. One striking result was the observation that 57% of the accepted applicants in the United States come from families earning over $80,000/year, while 60% of U.S. households make less than $75,000/year. Even more remarkable was that 30% of those accepted come from households making over $120,000/year, while only 9% of the general population in the U.S. makes over $100,000/year (We noticed similar trends in our Canadian study).

That’s not all. It turns out that 54% of respondents in our study identify as Caucasian with 39% of those coming from families earning over $120,000/year. This was the highest proportion of all groups. In fact, 69% of respondents coming from families earning over $120,000/year identified as Caucasians..

On the other hand, 61% of those identifying as visible minorities were from families earning less than $80,000/year.

Perhaps most troubling was the fact that the wealthy appeared to receive more than one acceptance more often compared to low income applicants, giving them more choice and freedom to choose their future medical school.

3) If there is bias, what is the source?

It’s hard to provide a simple answer to this question because there are multiple factors in play but I’ll share our finding and my personal opinions below.

While most previous reports have suggested that it is the admissions process that creates the bias in the first place (for example, click here, here, here, here, here, and here), some have argued in previous commentaries that the bias is partly due to the presence of admissions coaching programs that add “a further socioeconomic barrier to medical education”.

While it is not possible to rule out other external factors, our research does not support the latter conjecture.

Notably, our findings in the U.S. and Canada clearly showed that there are no significant correlations between income level and the probability of use of admissions coaching services.

So if access to coaching is not causing the observed bias, what is?

I tend to agree with the reports that suggest it is the admissions process that inadvertently creates the bias in the first place and here are some of the possible sources of that bias:

A) The heavy emphasis on grade point average (GPA) and medical college admissions test (MCAT).

Some have argued that such tests create a bias and that’s because those of lower income levels are too busy working multiple jobs in order to pay their bills and simply do not have the time to improve their scores, regardless of whether preparatory courses are available to them. Therefore, every time admission involves selecting those with the best GPA and MCAT scores, there’s going to be bias.

The use of GPA and standardized testing is an out-dated practice introduced during the industrial revolution and their roots can be traced back to the 1800s starting with the work of Adolphe Quetelet, which was then continued by Sir Francis Galton, Frederick Winslow Taylor, and solidified by Edward Thorndike. Schools at the time were primarily concerned with training factory workers and introduced school bells to mimic factory bells and condition children for their future jobs. Thorndike’s work gave rise to the introduction of GPA and standardized testing for sorting students, which he believed could predict future success, but that we now know is not necessarily the case. Their use is quickly falling out of favor leading Harvard Professor Todd Rose to coin the term “averagarians”, which he defines as anyone “who uses averages to understand individuals”. For a more detailed explanation, I highly recommend his book, “The End of Average

B) The heavy emphasis on extracurricular activities and reference letters.

Again those that come from higher income levels are at an advantage because not only do they have the luxury of time to pursue such activities, they also benefit from connections, knowing the system, and having a network that can support and advise them when required. Furthermore, students know exactly what type of activity to choose to get into medical school, so having participated in the activity in such instances is not indicative of future behavior since the behavior had been extrinsically motivated by the pressure from the medical school admissions process.

C) High cost of the application process.

Not only should applicants be prepared to pay thousands of dollars for the application process, those who make it to the interview stage also have to pay for travel and accommodation at different geographical locations with costs easily reaching tens of thousands of dollars. This can significantly limit the number of applications and interviews, and thus opportunities for acceptances, for applicants with limited financial resources.

D) High cost of tuition.

Tuition costs range from mid $20K to $50K per year for most schools and loans, for those who qualify, only ensure that applicants will have to pay it back later with interest. This again will limit the number of programs applicants from lower socio-economic levels can realistically consider.

E) Lastly, I believe the entire process would benefit if additional checks and balances are introduced including democratic election of admissions officials, satisfaction guarantees in case of errors similar to what we take granted from other organizations, greater transparency about admissions scores, and the abandonment of the practice of privatization of university-initiated admissions related spin-offs. One could argue that it is problematic to think that academic institutions are developing their own admissions tools, profiting from them, and testing their validity themselves. In other words, “who watches the watchmen?”.

4) Why are the current admissions tools not as effective as originally intended?

In my opinion, there are multiple reasons for this:

A) Most admissions tools operate under the assumption that the key to predicting future behavior is to measure current behavior using tests of academic acumen and tests of professionalism. Therefore, the question has been “how can we develop a test that tests professionalism and academic acumen?” While these tests might be able to predict future test scores, there is little evidence that they can predict future on-the-job behavior when the applicants have matured into independent professionals and are no longer under the supervision of such tests. This is not surprising because how an individual performs on a test is very different to how they behave in practice. In essence, these tests are merely predictors of performance on similar future tests. However, the reality is that motivation is a predictor of future on-the-job behavior, including professionalism and academic performance, as highlighted above. Instead the question we should be asking is “how can we develop a test that measures the intrinsic motivation of our applicants?”

B) They create further bias by eliminating applicants based on grades, standardized tests, and other metrics before the interview. This process ensures that the process is unscientific and unfair, and reduces the talent pool, eliminating potentially excellent future professionals early in the process. The best selection process would allow the entire pool of applicants to have a fair chance to participate in the entire process before a selection decision is made.

C) They add direct and indirect costs. For example, MCAT and situational judgement tests add a direct cost to the application process, while interviews add the indirect cost of traveling, as underscored earlier.

D) They are unable to detect intrinsic motivation, which as discussed earlier is the primary predictor of future on-the-job behavior.

5) Are certain admissions tools more effective than others in selecting future physicians?

We did not observe any significant differences across current admissions tools in the observed trends reported in our studies and discussed in this article. Situational judgement tests, interviews, and other admissions tools all appear to be equally unable to detect intrinsic motivation and are equally likely to favor the wealthy as highlighted by our study.

Additionally, similar to previous findings, the Multiple Mini Interview (MMI) appears to significantly favor female applicants and that it also appears to favor Caucasian applicants, although the latter trend was not statistically significant in our study (P=0.11). The MMI has also been reported to favor higher income applicants, in agreement with our findings.

6) Are future doctors satisfied with the status quo or do they prefer improvements to current admissions practices?

The majority (90–95%) of the respondents in our studies, while possibly receiving favourable treatment by the existing process, nevertheless believe the current admissions processes need an overhaul. The overwhelming majority (94–97%) indicated that they would support a new, improved and transparent admissions screening tool.

7) Is there a better way to select applicants?

Yes, intrinsic motivation appears to be a better way to select applicants.

Our results show that intrinsic motivation does not change over time and is not correlated with wealth or racial background. Including intrinsic motivation in the admissions process, in addition to eliminating sources of implicit bias discussed above, could be a new way to select applicants that are genuinely interested to pursue medicine while promoting diversity, making the admissions process more equitable, and saving time and money all at the same time. The end result could ultimately be high performing practitioners, who genuinely look forward to each workday.

Of course, the ability to measure intrinsic motivation although necessary is not sufficient on its own. The admissions process must also measure other factors that have been proven to be predictors of future success and must be designed in a certain way to make it scientifically sound and fair. I will discuss how exactly to do this in a this article.

If you like to get early access to SortSmart® Admissions selection tool, click here to learn more. 

Behrouz Moemeni, PhD

CEO @ SortSmart