WHAT makes a doctor? How does a high school graduate turn into a compassionate, caring professional with skill and wisdom to whom you would entrust your life, or the lives of your family? How do medical schools decide what are the right characteristics, choose the raw recruits, and undertake the conversion from raw material to finished product?
A maxim for doctors is “To cure sometimes, to relieve often, to comfort always”. Sounds a bit old fashioned, but wouldn’t it be wonderful if all doctors were trained to adhere to this? This rule underscores what patients instinctively know; that the attitude of the doctor is central. While cure is the ideal, it is not always possible.
However, even when cure is not an option, good doctors are skilled to provide relief with their care, supportive medication, rehabilitation, and a properly understood explanation. Thus they ensure the patient enjoys the optimum health possible.
But medicine demands more than that. “To comfort always”. Now there is the challenge. This is where the empathy and compassion of the doctor go hand in hand with their clinical skills, and show the essence of humanity.
Another maxim we go by is similar, “Treat your patient as you would wish yourself be treated”. In short, treat your patient with scrupulous care, with consummate skill and with dignity.
Quality assurance
Yet in the modern world, the making of a doctor has become a commonplace event, a process undertaken by many universities which also turn out graduates in many other disciplines. All certified as having a certain quantum of knowledge and skills. But is that sufficient? Defining quality assurance for compassion and humanity – now that presents a real challenge!
Quite a lot of “market” study has been done with consumers – just ordinary people. Invariably they want the sort of doctor described above. They certainly want skill in diagnosis and treatment, but over and over again, they respond that they want someone who will listen. Not just someone who will fire questions at them. Rather someone who will really know their concerns, who always treats them as a complete human being and the focus of their attention. Only when you have this patient-centred medicine can you achieve optimal care.
So what do leading medical schools do about this? How should you make a doctor?
Quite a lot has been written in the medical literature, and one thing is clear. There is no magic, no alchemy. You can’t make gold from base metal. You may find a nugget, you can clean it, shape it, polish it, but you can’t make gold in the first place. It is the same in medicine. You can find the potential for good doctors in undergraduates, you can clean, shape and polish them into good doctors, but you can’t make them into people they are not.
The quality of the medical course will certainly affect the quality of the finished product, but if you want a wonderful doctor, you have to have the right material. The psychological make-up, the underlying values and personalities of people are remarkably constant once they reach young adulthood. So selecting students for these underlying values
at the beginning of the course is essential, as they can’t be taught.
Much can be taught by a well-balanced and well-constructed course. Ethics, communication skills, counselling skills can all be taught alongside the technology of genetics, surgery and critical care
Desired attributes
My own research with medical students has shown their psychological make-up at the time they entered medical school not only predicted their later attitudes, but to some extent, also predicted their probable peak skills, especially their excellence in communication skills.
Much work has been done to try to define in detail the desired attributes of a doctor, and then devise selection methods to predict these.
The classical test has always been the score in a pre-university course such as matriculation, A levels, or similar. The rationale has been that a doctor must be intelligent to master and apply the masses of knowledge required, and a good score in these tests measures intellectual capacity and the ability to work hard. Intellectual capacity is clearly important. But medicine is as much the art of life as it is a science, as any clinician worth his salt will attest.
Last year in Malaysia, many students with straight A’s were not offered places in local medical schools, which caused much concern. However, exam performance should not be the sole determinant of selection for training to be a doctor.
A measure of intellectual capacity can tell us nothing about people skills, personality, ethics, capacity to accommodate complexities and shades of grey, and about integrity. As more students demonstrate their excellent intellectual capability, we need to be more discriminating and find proper criteria to rate and rank them.
Other measures are being used to supplement selection for medicine. Many university medical schools use their own researched measures of aptitude for medicine. Each is refined over years, to try to develop a valid test that really tests what it is meant to.
Testing techniques
The right tests can be good predictors of the attributes we want in our graduating doctors. Monash University, for example, uses a three-tiered system for assessing the suitability of every medical student, the process having been researched and refined over the last 12 years.
Firstly, we use the results of pre-university courses eg A levels, Australian matriculation, International Baccalaureate or other. These measure the capacity to undertake intellectual studies, work hard and succeed.
Then there is a three-hour questionnaire. This may be the UMAT (Undergraduate Medicine and Health Sciences Admission Test) or the ISAT (International Student Admissions Test). These look at underlying aptitudes, separate from knowledge which has been formally taught.
The UMAT has three sections, looking at critical thinking and problem solving, interactions with others, and abstract non-verbal reasoning. It has been developed for use within the Australian context and is not used for selection of international medical students outside of Australia.
The ISAT is a test of a candidate's general academic abilities, but it is not a test of curriculum knowledge. It is designed specifically for use in a setting where English may not be the student’s first language, and where students may have come from a range of very different pre-University programmes.
There are two components of the test, which measure the students’ critical reasoning (recognition of meanings, interpretation, extension of concepts, drawing of conclusions), and their quantitative reasoning (analysis, decision-making, deliberation).
Finally, Monash uses a carefully developed semi-structured interview, with multiple interviewers for each student. The interview is quite lengthy and addresses motivations, a range of different communication skills, interpersonal skills, the ability to
think through issues and many others in a highly-structured process.
Interviewers are both doctors and non-doctors, and are selected from alumni and staff of the university, or may be respected volunteers from the general community.
Balanced assessment
They are each carefully trained to undertake the interview without bias. Each interviewer individually rates the student during the interview, and then the interviewers discuss their separate ratings and come to a consensus.
Any disparity between their views is recorded so that the interviewers themselves are subject to peer review. By this means, fairness and lack of discrimination is assured. The interview process has itself been the subject of detailed study, and numerous scientific publications have resulted, demonstrating its validity as a selection method.
The results of these three different selection tools are then combined, to give a final profile and ranking. The process is complex and demands significant commitment and investment of time and effort on the part of the medical school but has been shown to identify students, who in general, have not only the intellectual capacity but also the work capacity and the spirit to fulfill their destiny as healers.
A person who gets straight A’s is not necessarily cut out to be a doctor. Medicine is a calling as much as a career; it needs to be seen as a vocation, and not just a well-paid job. Doctors will receive good rewards and social status for what they contribute to society, although this is not what drives them. Good doctors are driven by their wish to contribute a service to those in need.
An essential if difficult responsibility for medical schools is to assist the community by selecting carefully those who shall best be able to acquire the skills of a doctor, and apply those skills with insight and integrity ‘to cure sometimes, to relieve often, and to comfort always’.
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