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Replace the Med School Interview with fMRI: A Modest Proposal

The views expressed are those of the author and are not necessarily those of Scientific American.

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A fashion faux pas almost prevented me from getting into my dream medical school. Midway through the interview there, the interviewer pointed to my left earlobe and said, “Do you really think we accept men who wear … those things?”

I had no idea what he was talking about at first, but then remembered the gold post I’d forgotten to remove. In a disdainful southern drawl the interviewer let me know how dark a shadow this stylistic error cast on my otherwise favorable application.

I left his office fairly sure I would not be admitted. I also doubted whether I wanted to be admitted to a school that selected physicians on the basis of their jewelry. Really?

Twenty years later, medical schools around the country still struggle to find the right way to decide who should be the physicians of the future, and who should not. Most have evolved past caring about male earrings, but what are the right criteria for admission – what makes a good proto-doctor?

Over forty thousand students apply to medical school each year. Each applicant spends thousand of dollars in fees and plane tickets, and institutions spend still more to screen, host, interview and pick among the hordes of black-suited applicants. Increasingly, medical schools are considering innovative and creative ways to distinguish the most promising applicants from the rest.

New approaches include

1. Using a more holistic review rubric that de-emphasizes grades and MCAT scores, such as at Boston University;

2.  Suspending traditional pre-med requirements for humanities students, such as at the Icahn School of Medicine at Mt Sinai; and,

3. Creative admissions interviews that include problem solving, multiple mini-interviews and even observed standardized patient interactions.

Each of these innovative methods sounds great. Used in combination I suspect they will identify applicants with the necessary academic chops plus a great bedside manner.

Finding applicants with the potential to have great bedside manners is the real challenge of the admissions process. Many applicants are smart enough to know enough and think clearly enough to become full-fledged physicians. But those academic traits combined with the kind of compassion, resilience and moral reasoning patients need is still rare.

Why not just MRI applicants instead? Brain metabolism is different in normal experimental subjects watching videos of people suffering compared to those who lack empathy. Isn’t that really what we’re seeking in a physician – empathy, or compassion?

Imagine the cost savings. Students could foot the bill for the MRI, skip all those unnecessary interviews, and still save money. Medical schools on the other hand would be spared the yearly search for a needle in a haystack of applications. A computer could plug and chug grades, MCAT scores, recommendations, and, newly, fMRI results. And, boom: you’re in. Or you should be imprisoned as a psychopath. Simple.

But wait, you say, surely an MRI misses something – isn’t an fMRI too blunt of an instrument? What about bedside manner? Couldn’t an applicant be smart, and non-psychopath, but still the wrong person to bring bad news or consolation?

There’s an app for that.

Or at least there could be.

Malcolm Gladwell of Blink fame popularized the work of Stanford psychologist Nalini Ambady who showed how quickly we discriminate good teachers from bad ones. She showed that students who viewed ten-second videotapes of a professor teaching gave the same ratings as students who took the professor’s whole course, suggesting that accurate impressions are made in an instant.

I bet we could apply these findings to the search for future physicians. We could pose a tough ethical puzzle to them, or ask them to engage a fictitious patient, and record their “doctoring” for two minutes. If Gladwell’s observations hold, we could easily discern the applicants with good natural bedside manners.

Here’s my proposal: take four years of grades, MCAT scores, the recommendations of close mentors, and instead of the unscientific, laborious, and not to mention expensive interview process, we snap a quick fMRI and film a two-minute video.

What could go wrong? I can hear the critics who will decry the fMRI and video approach as incapable of detecting the real core of what it means to be a great physician. But here’s my real argument: I don’t think a 30 minute interview can either. Nor a 45 minute psychotherapy session while the applicant juggles. There is only so much the application process can determine, and I think it makes sense to keep our eyes on that ball.

Ultimately, I got into my dream medical school despite the earring gaffe, and I loved it. I even joined its admissions committee, taking every opportunity to admit qualified applicants who wore earrings.

Images: on Huberman interview, by Sandra Steinbrecher; FMRI scan during working memory tasks, by John Graner, Walter Reed National Military Medical Center; surgery scene, by U.S.Navy.

Tim Lahey About the Author: Tim Lahey, MD MMSc, is an HIV doctor, an associate professor at the Geisel School of Medicine at Dartmouth, and chair of the bioethics committee at the Dartmouth-Hitchcock Medical Center. Follow on Twitter @TimLaheyMD.

The views expressed are those of the author and are not necessarily those of Scientific American.

Comments 7 Comments

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  1. 1. Diogenes11 10:10 am 08/8/2013

    An enjoyable read! But what about the selection of monosyllabic pathologist savants who can recognize any tumour from a smattering of cells? Or sociopathic Neanderthal surgeons with the manual dexterity and bloody, bold resolve of Macbeth, who can extirpate the tumour for the pathologist’s perusal?

    Perhaps the brave new world of MRI determinism will have to stream applicants based on multiple areas like motor or visual cortex responses. While empathy and compassion are laudable, I’d rather have an uncaring surgeon who can cut straight (may not even need to be human, like the next generation of da Vinci robot…) than a caring, clumsy one.

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  2. 2. Diogenes11 10:19 am 08/8/2013

    Of course, while you might get away with a gold ear-stud despite the image degradation, an MRI-selected applicant would do poorly if he forgot to remove his ferrous piercings.

    It still comes down to a potentially jewellery-based selection, although your suggestion may be lethal to the rejected!

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  3. 3. wwwd91 11:19 am 08/8/2013

    I am guessing that with a title like “A Modest Proposal”, this article is a bit tongue-in-cheek?

    Otherwise, I don’t understand how a bioethicist is going to just brush aside and ignore all the ethical ramifications with this consideration and the limitations of fMRI in “mindreading”.

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  4. 4. wwwd91 11:19 am 08/8/2013

    I am guessing that with a title like “A Modest Proposal”, this article is a bit tongue-in-cheek?

    Otherwise, I don’t understand how a bioethicist is going to just brush aside and ignore all the ethical ramifications with this consideration and the limitations of fMRI in “mindreading”.

    Link to this
  5. 5. jtdwyer 12:30 pm 08/8/2013

    Unfortunately, even if Dr. Lahey is making a social commentary about jewelry rather than a serious proposal, there seems to be plenty of neurologists intent on promoting the idea, despite having no more comprehension of brain function that a probe of microprocessor electrical signal flows…

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  6. 6. tlahey 12:38 pm 08/8/2013

    @ Diogenes11 – I fear you may have identified a lethal flaw in the plan – fMRI would effectively (and rudely) bias against festooned applicants. Must re-evaluate.

    @wwd91 – investigators recently identified the brain locus responsible for ethical ramifications so soon I’ll be able to keep them more in mind.

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  7. 7. tlahey 12:40 pm 08/8/2013

    @jtdwyer but my magnet is bigger than theirs

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