The student lottery
How do we decide who will make the best doctors?
A few years ago, at a friend’s barbecue, a worldly and usually quite articulate man I knew in the way you know a friend of a friend stopped telling me where to buy and how to cook the best sausages in Melbourne and started bemoaning the injustice of graduate-entry degrees. “I’ve paid hundreds of thousands of dollars in private school fees so my children can get into medicine or law if they choose to, and then the unis go and change the rules!” At many universities in Australia, you now need a basic undergraduate degree before you can apply to study any of the lucrative professions. I smiled sweetly. “P’raps,” I said, “there’s a way you can pay for your kids to be spoonfed through their undergraduate degrees too?”
Lots of people want to be doctors. Why is that, really? I mean, I’d highly recommend it as a job: it’s mostly interesting, requires no small talk, and you don’t get bossed around very much. And essentially – at least as a physician – you get paid to listen and to think, two things I’d happily do for free. But when you’re conducting medical school admissions interviews, the answer you hear to the why-do-you-want-to-be-a-doctor question is most often some variation on “To help people.” Which is usually bullshit. (Or if it’s not, it soon will be.) Even if the student’s conscious aim is to embark upon a career that will “help people”, there’s generally some other quest behind or beside that altruistic urge: the quest for knowledge, power, money, discovery, respect, glory, stable employment, a genderless title. If all you wanted was to help, there are plenty of understaffed homeless shelters desperate for a fresh set of hands. Teachers, social workers and nurses all help people, but there aren’t ten applicants for every place in those disciplines.
All over the world, doctors are respected and respectfully remunerated. How medical schools choose among the big pool of hopefuls is a subject constantly debated in institutions and journals. When I was at high school in the ’80s you needed to study science and get around 100% in your final exams to get in to medicine. I didn’t know any doctors besides the awkward local GP, being a doctor had never crossed my mind, and, if it had, I wouldn’t have had a chance in hell of getting in. But in the past few decades medical schools have been trying to choose those who they think will make the best doctors rather than the best students. Yes, you can imagine the debates.
Entry criteria vary from campus to campus. Most universities in Australia use some combination of academic achievement, “personality test” and interview. For a long time now Dutch universities have chosen most of their students by lottery (and most studies show that these randoms perform just as well as the students they’ve hand-picked). You don’t need to be exceptionally smart to be a good doctor. Medical school’s not hard, it’s just lots. The marks competition – like the lottery – is simply a cost-efficient, completely transparent cull.
The University of Newcastle’s medical school was the first in Australia to propose entry criteria based on more than pure marks. The school was founded in 1975 by a group of medical education radicals who suffered fierce opposition from the establishment. Not only because they changed the focus from rote to discovery, and threw the students into the hospitals from day one (rather than year four), but also because they suggested that the best future doctors aren’t necessarily high school students with exam marks in the top 0.5%. (Full disclosure: in 1998, to my great astonishment, they let me in.)
It’s hard to argue that the ideal medical workforce should be mono in culture, class and gender, which was what traditional entrance requirements mostly got you. Come from the same place, hang out together every day for another five or six years, maybe get a few lectures on cultural diversity, and then flood the entire country.
Look at the statistics: your life is mostly determined by where you’re born and what you can afford to buy there. A lottery, if you will. And if all you can afford is cheap bread and entry to a local school that is overcrowded, under-resourced and has no playground because it was hocked in the ’90s, well, the odds that you’ll get diabetes and not get into medicine are pretty good.
The groups who are least represented in higher education – especially in medicine – are also those with the poorest health: people from low socio-economic backgrounds, and indigenous Australians. Two-tiered private/public everything doesn’t help. But when it comes to tertiary education, studies consistently show that one of the major barriers to these groups even applying is the perception that they do not belong there.
The Newcastle founders wanted not only more Aboriginal health content – dire-looking graphs, hands-on cultural exposure – but also to graduate Aboriginal doctors. They took their idea to the indigenous communities and proposed modified entrance criteria that took account of social disadvantage. There were complaints, from parents who claimed it was “unfair” and a way of “stealing” places from those who’d “earned” them. The government agreed to fund an additional four places to silence the “unfair advantage” arguments. (It’s funny, there are never headlines suggesting that maybe it’s unfair to pay many tens of thousands for kids to be pimped up to scratch.)
The University of Newcastle currently has 60 indigenous students studying medicine across two campuses. A dedicated unit offers cultural, pastoral and academic support. There are around 200 indigenous doctors now practising in Australia – we need ten times that number to reach population parity. Whether these doctors end up directing health policy or working in Darwin or in Macquarie Street, they stand as the most powerful symbol of what is possible for those who’ve never won any kind of lottery.