Science as superstition: selecting medical students.

678 www.thelancet.com Vol 376 August 28, 2010 I entered medical school in 1968, hard on the heels of antiwar demonstrations and civil rights activism. There weren’t many student-activists entering the University of California San Francisco (UCSF) that year. Those few of us quickly sought each other out to set our agenda. High on the list was the need to demand of the Dean of the medical school that students be placed as full members on the school’s Committee on Admissions. They chose me to confront the Dean with our demand. Never one for direct confrontation, I uttered our “demand” to the Dean in what must have seemed a diminutive voice. White-haired and distinctive in his blue suit, white shirt, and tasteful tie, the Dean looked at me, paused, and replied, ”OK—You’re on.” For the next 5 years I sat as a full member of the admissions committee, spending several hours each week reviewing fi les, interviewing applicants, and meeting with the committee. I quickly learned the norms by which the committee selected its matriculants from among the pool of applicants. “His grades in science are strong—he’ll do fi ne. Admit.” “Sure he was the leader of his volunteer organisation, but he got a C+ in organic chemistry. Reject.” As I look back on this process, one applicant in particular comes to mind. I held his admission interview in the medical school cafeteria. I sensed his passion to become a physician. He communicated easily. He described the strong sense of connection he had felt with the patients at the free clinic at which he had volunteered. While I wasn’t yet sure what a great physician was, I had an intuitive sense he would become one. Yet the decision was “His science grades aren’t strong enough. Reject.” I felt personally bruised. But then, I was only the student—what did I know? 25 years later I began advising undergraduates at Stanford University, many of whom had come to Stanford with the hope of eventually becoming a physician. From many of these students I heard what would become a mantra. “I used to be pre-med, but...” It seemed common knowledge among these students that a C+ in organic chemistry was simply incompatible with hopes of becoming a physician. If you can’t do science, you can’t succeed as a physician. If all you can pull is a C+ in chemistry, it’s unlikely you’ll get into medical school. By then I had more than two decades of clinical practice experience to teach me what a great physician was. A great physician creates a bond of communication and trust with his or her patient; a great physician can sense the feelings the patient is struggling to express or afraid to try; a great physician is also technically competent and conversant in medical science. For so many of these students, as for the applicant in the cafeteria, I had a clear, intuitive sense that, given the chance, they would become great as physicians. A quarter of a century after the interview in the cafeteria I had the confi dence I was correct. To use a mediocre score in an undergraduate science class to disqualify these students from a medical career seemed indefensible. By then, however, my confi dence was tempered by the scepticism of a social scientist. As part of my doctoral training in sociology I had learned the importance of scientifi c evidence. I knew I must somehow test both my intuitive hypotheses regarding the students’ qualities and the assumptions on which admissions committees based their decisions. Is greatness in sciences such as chemistry and physics a prerequisite for greatness in medicine? What was the scientifi c evidence in support of this assumption? My research took me to the close of the 19th century. The profession of medicine in the USA was struggling to establish an identity. That identity, and the assumptions underlying it, became clear between 1893, with the founding of the Johns Hopkins School of Medicine, and 1914, with the tenth annual convening of the Council on Medical Education (CME) established jointly by the American Medical Association and the Association of American Medical Colleges. Addressing the CME in 1914, Dr Victor Vaughan, a founding member of the Council, spoke the core belief on which the American medical profession by then was built.