Follow up

I wanted to follow up on some issues that I have blogged about recently.

On February 4, 2011, in my post Why do we put so much import on the MCAT , I wrote about the value of the admissions test for medical school. The Medical College Admissions Test is one of several screening mechanisms used by medical schools to determine who should be allowed to pursue medical training. A recent editorial (1) in the New England Journal of Medicine by Joshua Tompkins (Science Journalist and Medical Student at the USC Keck School of Medicine) discussed the expense of MCAT and Board prep courses. According to Mr. Tompkins, medical students are taken advantage of by a "multi-million-dollar industry in commercial exam-preparation assistance". These (for-profit) companies play on student's fears--fears of failing, of not getting a high enough score to get into their residency of choice, their fear of not matching in any residency.  The problem is that there is little to no evidence that these board prep courses actually do anything to affect a student's score on the MCAT  or USMLE step 1.  A systematic review of commercial test preparation (2) found that "current research lacks control and rigor" and the evidence to support these courses was weak or non-existent. According to Mr. Tompkins, pre-clinical medical students "focus on obscure minutiae and rare conditions" and "spend less time studying the common diseases they will face during clerkships, residency, and practice".

And while we are talking about medical school admissions. In another recent blog, Personality traits that predict success in medical school , I wrote about using personality profiles to chose which students should be in medical school. An article in the July 10, 2011 New York Times by Gardiner Harris, New for Aspiring Doctors, the People Skills Test reports on the use of a specific type of medical interview that is being implemented at Virginia Tech Carilion School of Medicine in Roanoke, VA. The Dean at Virginia Tech Carilion is a family doctor named Dr. Cynda Johnson. She happens to also be a former resident and faculty member from the University of Kansas. Virginia Tech Carilion (and several other schools) are using the multiple mini interview or MMI to screen potential medical students. The test is administered to students as part of their medical school interview and is designed to "assess how well candidates think on their feet and how willing they are to work in teams". According to Dean Johnson, "if people do poorly on the MMI, they will not be offered positions" in the medical school class.  The MMI is also a pretty good predictor of performance in the preclinical years of medical school. (3)

Way to go Virginia Tech. This is definitely a step in the right direction.

References:

(1) Tompkins J.  Money for Nothing? The Problem of the Board-Exam Coaching Industry. NEJM 2011; 365 (2): 104-105.

(2) McGaghie WC, Downing SM, Kubilius R. What is the impact of commercial test preparation courses on medical examination performance?  Teach Learn Med 2004; 16 (2): 202-11.

(3) Eva KW, et al.  The ability of the multiple mini-interview to predict preclerkship performance in medical school. Acad Med  2004; 79 (10 Suppl): S40-2.

A new blog: A Journey to Family Medicine

I would like to introduce you to one of my students. Brooke is a brand new fourth year medical student. I have known Brooke since the first month of medical school. She was assigned to my PBL (problem-based learning) group. This means that she and nine of her classmates were going to be meeting with me every month or so to work our way through a clinical case. Every basic science module has PBL cases. There are multiple purposes for these PBL groups: to learn about clinical medicine, applying basic science concepts to a patient case, to learn about the professional aspects of medicine, and to foster and promote interactions with medical school facutlty members. We get to do all of that and more.

The PBL groups are definitely one of my favorite parts about being a teaching faculty member. Our students come into school with such high expectations and aspirations. They are not cynical or jaded (yet). They have a lot of different motivations for medicine but generally have one thing in common--they want to help people. Usually, by the end of two years, I know these students pretty well. I learn about their families. It is great getting to know them individually as people, not just as students. I don't try to talk them into going into primary care, but they do get two years of listening to my opinions (for what that is worth).

So Brooke was in the last Family Medicine clerkship this year. By the time, I saw her, she had already taken Internal Medicine, Surgery, Geriatrics, Neurology, Psychiatry, Pediatrics, and OB/GYN. The students at the end of the year are an interesting group. Clinically, they are very accomplished. But often they are stressed. They are trying to decide what residency program they should try to get into. They are tired after a year of long clinical rotations. And, honestly, they are often a little cynical about the educational process and medicine. There is data that says that students' empathy and emotional intelligence falls throughout the third year.

But Brooke was excited. She could not wait to come to Family Medicine. She told me the first week that she had been thinking about it for a long time and had decided that Family Medicine was the specialty that she was going to choose. She is smart. She could do anything that she wanted to do. She is confident and poised. She is a class leader. Not formally, but informally. The other students on the rotation looked to her for leadership which she provided quietly without any fanfare. And she decided that she wanted to be a family doctor. I must tell you, that is one of the greatest thrills!

So, I asked her if she would write about her experience. She is going to blog from now until Match day and maybe beyond. She is going to write about her life and being a medical student. She is going to write about the process of applying to residency, interviewing, and the Match. I hope that if you work with medical students you will tell them about her blog. The name is: A Journey to Family Medicine.

How much should medical school cost?

It does not seem that many people care very much about the cost of medical education in the US. But we should be concerned. Did you know that the average debt for a medical student on graduation from a state funded medical school is about $150,000. To put that into perspective, the average cost of a four bedroom house in suburban Kansas City, where I live, is $225,517 not much difference.(1)

Many people will see that and say,"who cares, doctors are rich". I can't argue with that fact, doctors are rich. Physician salaries are in the top 5 percent of all jobs in the US. A recent blog from Dr Joshua Freeman described the top 10 paying jobs in America. Physicians held 9 of the spots. There are many ways to fund medical school, including loans, repayment plans, and my personal favorite-having a rich dad. I remember the first day of my medical school experience and one of the women in my class asked a question during the financial aid lecture. "Can you send the bill to my daddy?" Repayment programs can be very effective. Here in Kansas, we have one of the oldest and best. Students that commit to practice in an underserved county (that is most of Kansas), choose a primary care specialty such as family medicine, internal medicine or pediatrics, and maintain their academic standing are given a full tuition scholarship and a monthly stipend. Over its 50 year history the Kansas Medical Student Loan program has placed hundreds of students in communities across Kansas.

So back to why should we care about this? Well, as I discussed in a previous blog, Production of Primary Care Doctors, [ student debt is one of the primary deterrents to students choosing primary care specialties such as family medicine. The equation is fairly straight forward. More student debt leads less students choosing family medicine residency training (and other primary care specialties). Less students in family medicine residencies means less primary care physicians in practice. The data at this point is pretty clear. If there are less family doctors per capita in a county in the US, that county is less healthy. The citizens die more frequently, they are hospitalized more often, and over all they are less healthy.

Wow, all of that because medical school costs a lot? No, not all but enough that a recent Op-Ed in the NYTimes should be given some serious thought. Drs Bach and Kocher proposed that medical school tuition should be free. Then how would we pay for it? Their idea is a good one. Tax the students that want to choose specialty practices. Basically, the idea is that medical school is free if you choose to practice in a primary care field like family medicine or general pediatrics. If you decide that you want to be a dermatologist or a radiologist or another specialty then you have to pay for your training.

That may seem unfair to the students that want to go into dermatology, but remember the state and national government (and we the people) have a huge investment in medical education and the health care field. $1,400 for every car you buy from General Motors is for health costs, medicaid accounts for 1/3 of the budgets in most states, and even private medical school receive millions of dollars from the federal government to support biomedical research. And we don't need more dermatologists. We do need a strong and vibrant primary care infrastructure. The beauty of this idea is that it could be changed as the physician practice population changes. If we need more anesthesiologists then we make the payback less. If we need more general surgeons, then we make the pay back less to do general surgery. If we need less plastic surgeons then we just raise the payback more. How much? How ever much you need. Would a student choose to do orthopedic surgery if medical school was going to cost them a million dollars? How about 2 million? You get the idea?

Will this ever happen? Unlikely, but we can hope...

References
(1) http://money.cnn.com/pf/features/lists/hpci_data/index.html

The new (and improved?) MCAT

Some of you may have heard about the proposed revisions to the Medical College Admissions Test. What do you think about the changes?

The AAMC released the preliminary report from their MR5 advisory committee. This task force was appointed in 2008 with broad representation from medical school deans and administration, basic science and clinical faculty, premed advisors, and included a resident and a student. This group, chaired by Steven Gabbe, MD (Senior VP for Health Sciences THE Ohio State University) was given the task of making recommendations for changes and revisions to the MCAT "that are likely to increase the exam’s value to medical school admissions committees and examinees".(1) The last time that the MCAT was significantly revised was in 1991.

The MR5 Committee got feedback from faculty at medical schools, deans and administrators, resident physicians, and medical students.  In spite of this, some of the changes have gotten significant criticism. They have made fourteen recommendations, including an increased emphasis on Behavioral and Social Sciences Principles and Critical Analysis and Reasoning Skills. (2) 

As I wrote about in a previous blog, Why do we put so much import on the MCAT? , the MCAT has major problems when used as a decision point for medical school.  The MCAT may even be a negative predictor for some important characteristics of physician behavior, such as verbal fluency, breadth of interests, and the ability to communicate. (3) 

So, it seems that changes to the test would be welcomed. I don't know. Honestly, my major problem is not the composition of the test so much as the way that the test is used by medical schools across the country.  The MCAT is the primary determinant for students' admission to medical school, often overshadowing other important factors such as communication skills, altruistic intentions, and a service orientation.

I was surprised by some of the comments on the AAFP's website . These were comments that were posted by readers after an announcement about the MR5 recommendations. Some physicians seem to feel that the changes that are recommended by the MR5 committee will make students less qualified for entry into medical school. "I was always better at Chemistry and science than in fuzzy subjects that didn't require logical thinking" and "Medicine is a scientific profession which requires the high-caliber minds who can think scientifically and objectively". And then there was my favorite, "Is this another attempt at the academia trying to brainwash students?"

I think much of this concern comes from a misunderstanding of the value of the test. It also may have something to do with changes in medical education and the practice of medicine that many physicians are not ready to embrace.  Medical school needs to do a better job of preparing students for practice in environments that are team-based and collaborative, and use information at the point of care.  The days of a physician who acts and practices alone and in a vacuum are gone. We need students who can work with nurses, pharmacists, physical therapists, social workers, and lay patient educators. (4)  The days of a physician who knows everything about everything that they do are gone. There is too much information.  We need students who can access information at the point of care and interface with electronic resources at the same time as they interact with a patient.

So, what should be in the MCAT. I would like MCAT to test some of the important aspects that are beyond the science. Science is not that hard to teach. Make the science portion pass / fail. If you meet this level, we think you can pass USMLE Step 1.  But many other important topics are harder to teach. Why can't the MCAT have more emphasis on ethics?  It could have more questions about health policy and the politics of medicine.  I would love to see a personality profile measure built into the test. What about service and altruism. What about team work? Are there measures of how collaborative people are in team situations? Now some people will say a test can be scammed for those kind measures. I am sure that is true, but with the numbers of people taking the MCAT and the amount of resources that are available, I bet a valid and reliable test could be constructed that would measure more than just knowledge.

References:
(1)  https://www.aamc.org/initiatives/mr5/
(2)  https://www.aamc.org/download/182662/data/mr5_preliminary_recommendations.pdf
(3)  Gough HG. Some Predictive Implications of Premedical Scientific Competence and Preferences. J Med Educ  1978; 53: 291-300.
(4)  http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html

Production of primary care doctors

COGME has just released their 20th report, Advancing Primary Care. Unless you are a real geek like me, you probably don't know what COGME stands for. COGME is the Council on Graduate Medical Education. COGME was authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, training issues and financing policies, and to recommend appropriate federal and private sector efforts to address identified needs. The legislation calls for COGME to advise and make recommendations to the Secretary of the U.S. Department of Health and Human Services (HHS), the Senate Committee on Health, Education, Labor and Pensions, and the House of Representatives Committee on Commerce. The Health Professions Education Partnerships Act of 1998 reauthorized the Council through September 30, 2002. Since then, the Council has been extended through successive annual appropriations governing the Department of Health and Human Services.(1)

Now, there is some history here.  In January 1994, COGME released its Fourth report, Improving Access to Health Care Through Physician Workforce Reform. In that report the authors took the position that the physician workforce was not meeting the needs of the US healthcare system and the public need. The report concluded that we needed more generalist physicians.  Their recommendation was that 50% of all graduates should enter practice as a generalist physician (Family Medicine, General Internal Medicine, and General Pediatrics). Their goal was to attain this by 2000. As we know that did not happen. In fact, it went the other direction.

But interestingly in their Sixteenth report, Physician Workforce Policy Guidelines for the United States, 2000-2020 (2005), COGME reversed themselves and said that market forces should determine the proportion of students in an in specific specialty. The exact recommendation was: The distribution between generalists and non-generalists should reflect ongoing assessments of demand; therefore, COGME does not recommend a rigid national numerical target.  Wow, what an amazing mistake that was.  Since that time, the proportion of students choosing family medicine and primary care in general has continued a downward trend. In 2008, the total proportion was down to 32%.  Clearly market forces are not working.

Dr Jerry Kruse, Chair of Family & Community medicine at Southern Illinois University who I wrote about in a recent blog was Chair of one of the writing groups for the COGME report.  According to Dr. Kruse, market forces didn't work because there is not a traditional supply and demand market in the US healthcare system. What we have is really a supply and supply market.  We have a virtually unlimited amount of care that can be delivered (whether it should be is a different discussion) and a funding pot that rewards doctors, hospitals, DME companies, etc for doing more (See Dr. Lin's post at the Common Sense Family Doctor). The rewards are financial and huge. So, the market is designed to reward doctors financially in specialties that do more technical and procedural things. (A more detailed discussion of this can be found in a recent post by Matthews and McGinty on the Wall Street Journal Health blog.) These are specialties such as, Radiology, Orthopaedic Surgery, Anesthesiology, and Dermatology. The "ROAD", as some medical students have taken to calling it.

Medical students are not stupid. They figured out that the financial rewards of practicing in the higher paid specialties were extraordinary. The median lifetime income gap between a student choosing primary care versus a specialty is 3.5 million dollars.(2) Currently, US primary care doctors earn about 55 percent of what specialists earn on average. When primary care doctors' salaries dropped as a proportion of specialists' salaries, interest in family medicine and other primary care areas also drop. The key number seems to be around 70 percent. If the income of primary care doctors as a proportion of the income of specialty physicians goes up then student interest goes up as well. The Altarum Institute estimates that increasing primary care income to 80 percent of specialty income would double medical student interest in primary care. This would increase the percentage of students choosing primary care to about 40 percent.(3) 

Canada had the same problem. From 1998 to 2004, they had a 25% drop in students choosing family medicine and it worried the Canadian health ministry.(4)  In a country that has universal coverage, it is vital that the primary care base is adequate. In Canada, they understand and believe that they need a specific number of family doctors in order to be able to take care of the populace. To address this national crisis (their words not mine) they invested in student interest by building up and supporting medical school family medicine interest groups (FMIG).  And they raised the salary of family physicians. They did not make family medicine and specialist salaries the same, but they raised the proportion to 87%.  By 2006, the median income of Canadian family physicians was $212,000 per year compared to the median annual specialty income of $245,000.(4)  That was enough. Interest started going back up. Medical students choosing family medicine has increased by 27 percent each year since 2004.

Why can't we do that in the US? There are so many reasons that I don't think I could even begin to cover them all but let me hit some of the highlights. We don't have a national universal coverage system.  Doctors are mostly self-employed or work for large healthcare organizations (like hospitals). The government does not directly decide how much doctors are paid.  (For more on this, read Dr. Freeman's post Outing the RUC: Medicare reimbursement and Primary Care) 

The most important reason is probably that we don't see this as a national crisis.  Most people think that we have the best healthcare system in the world. Unfortunately, the data does not support that. We have a mediocre healthcare system compared to the rest of the world by any measure. The primary care base is the key to the system. We need to and should adopt the COGME recommendations. If we don't have enough primary care doctors (translate=enough students choosing family medicine), the US population will be less healthy. There is no question. Our population will be less healthy, people will die prematurely, and it will cost more.(5)

References
(1) http://www.cogme.gov/whois.htm
(2) Wilder V, Dodoo MS, Phillips RL Jr, Teevan B, Bazemore AW, Petterson SM, Xierali I. Income disparities shape medical student specialty choice. Am Fam Physician. 2010 Sep 15;82(6):601
(3) Altarum Institute. (2009). Updates to BHPR phy­sician supply and requirements models. Presenta­tion to COGME, p. 15. Rockville, MD, from COGME 20th report
(4) Canadian Institute for Health Information. (2007, December 13). Physicians in Canada: Average Gross Fee-For-Service Payments, 2005-2006. Re­trieved May 11, 2010, from http://secure.cihi.ca/ cihiweb/products/FTE_APP_2005_Eng_final.pdf
(5) Phillips RL Jr, Bazemore AW.  Primary care and why it matters for U.S. health system reform. Health Aff (Millwood). 2010 May;29(5):806-10

Using interviews to select medical students

This is the fourth in a series of posts about entry of students into medical school. In the last post, I blogged about personality traits that may be better suited to being a medical student. Unfortunately, most schools in the US do not use personality profiles as a screen for incoming medical students.

At most schools, the closest that we come to this is the admissions interview. Many believe that a 30 minute interview is a good way to weed out bad apples. I am not sure that this is true. Just on the surface, it seems like an experienced interviewer may be able to identify highly dysfunctional people. By dysfunctional, I mean traits that would be obviously detrimental to their function as a physician. These obvious dysfunctional traits are things like: students who have difficulty talking to others, students who have flaws in their ethical approach to life, and students who have problems with their reasons for entering medical school. But what does the literature say?

Powis, et al (1) used a case-control design to study students who were admitted to medical school but did not graduate. They retrospectively analyzed 56 paired cases and controls. The cases were students who had left medical school due to failure or withdrawal, while the controls were students who had completed medical school. The controls were all students who had excelled in the their academic performance. The students who left medical school had all been rated lower at their admission interview. Effect sizes were statistically significant in the Overall rating (ES=2.17), self-confidence (ES=2.59), perseverance (ES=2.98), and tolerance of ambiguity (ES=1.04).

The Powis study used a objective and structured interview and they compared the students who left or were dismissed from medical school to those who received Honors in medical school. It is not clear that the admission interview would distinguish between failing students and anyone who would not fail. Admission interviewers have widely variable reliability. Powis found the inter-rater reliability varied from .23 to .63 for seven different qualities assessed by two faculty members. Other studies have found that reliability data is better for interview programs that use a structured interview process (.82 to .84) while with unstructured interviews the reliability is .61 to .75. (2)

So, reliability is not great, but seems to be better with more structure. Part of what provides structure is giving interviewers training and giving them types of questions to ask. But (and this is a big but)...I think that the interviewer has to be experienced as an interviewer. They have to be able to sort through the information presented by the student. They have to be willing to ask probing questions and be willing to make the student uncomfortable. Questions about ethical grounding or hypotheticals about decision-making are difficult. Interviewers can be blinded by other characteristics. Like MCAT scores．

For instance, I have heard interviewers say, well they didn't interview very well but they have great MCATs, so they will do fine. I am not kidding, I really heard a faculty member say that. And they were being serious! I know that is not supported by the data, but you still hear it a lot. The interviewer has to be experienced enough to ask tough questions. Not just, "tell me about your fraternity activities in college" but hard questions about ethics, hypotheticals, and dilemmas. They have to ask about motivation, why do they want to come to medical school. They have to get beyond the pat and prepared responses that students practice during their mock interviews and really push the student to get at internal motivations and thought processes.

And what about medical students? In my experience the medical students that we ask to interview are pretty good at sniffing out the bull. But their problem is that they feel so happy to actually be in medical school and almost finished (our interviewers are fourth year students) that they tend to be a little easy on the score sheets. Gutowski and colleagues,(3) looked at current medical student interviewers. They found that when compared to faculty interviewers, students wrote more about applicants' motivation, personality, communication skills, and interests. Student wrote more in the overall evaluation sections (p<0.001) and gave more examples on the motivation section (p<0.0011) and communication skills section (p<0.0035).

So, I guess the bottom line is that there is no easy way to figure out who are the right students to admit to medical school. We should push for multi-dimensional models that minimize the MCAT and utilize personality characteristics. We should ask the admissions committee (and the dean) to define what they think are the qualities and characteristics of the students that should matriculate to our medical school. And maybe most importantly the admissions committee should be held responsible for the results of their work.

References
(1) Powis DA, Neame FLB, Bristow T, Murphy LB. The Objective Structured Interview for Medical Student Selection. BMJ. 1988;296:765-768.
(2) Albanese M, et al. Assessing Personal Qualities in Medical School Admissions. Acad Med 2003;78:313–321.
(3) Gutowski CJ, et al. Current medical student interviewers add data to the evaluation of medical school applicants. Medical Education Online 2010;15:5245.

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Personality traits that predict success in medical school

This is the third in a series of posts about my concern with the students that we are bringing into medical school. I am constantly reminded that not everyone believes that there is a problem. Some think that we are getting the right students into medical school. My question. The burning question for this series of posts is: if we are getting the right students in, why is the end product not meeting the needs of America? Or the needs of our individual states? There was a recent op-ed in the New England Journal of Medicine by Stephen R. Smith, MD, MPH from the Warren Alpert Medical School at Brown University.(1) Dr Smith said "medical schools must recognize the current factors that discourage medical students from pursuing primary care careers and then devise ways to overcome these barriers."

My first post in this series, Why do we put so much import on the MCAT? was about the MCAT and why (in my opinion) we need to de-emphasize the MCAT as a criterion for entry into medical school. I am not the only one saying this. Dr. Smith said, "The first test of this commitment will come in the way in which admissions are handled. The little evidence that is available on factors predicting career choice indicates that students who express a desire to serve underserved populations, who demonstrate altruism, and who are committed to social responsibility are more likely to go into primary care." Dr. Smith went on to say that "admissions criteria need to be broadened beyond scores on the Medical College Admission Test (MCAT) to include these personal attributes. The school should adopt an “MCAT-blind” admissions policy, dictating that students whose MCAT scores are at or above a predefined minimum that predicts a likelihood of success in medical school should then be considered further for admission without the reporting of their MCAT scores to the admissions committee."

In my last post, Characteristics of Future Physicians, I blogged about characteristics that I believe that we should want in graduates of our medical schools. There are several factors that medical school faculty have rated as extremely important but very hard to teach. My argument is that we should select students who already have those traits prior to matriculation. Some of the traits listed are obvious: (1) is emotionally stable; (2) is a person of unquestionable integrity; (5) is unusually intelligent; and (6) has sustained genuine concern for patients during their illness.  Some are less obvious but seem really important: (9) is motivated primarily by idealism, compassion, and service; (14) is able and willing to learn from others; (17) is observant; and (18) is adaptable.

So the question for today is: are there personalities that do better in a medical curriculum and those that do worse? If you read the article by Dr Sade (2) I am sure that it is no surprise that there are some personalities that do better in medical school and some that seem to struggle more. Medical school is an extremely stressful environment. Many of the students that come to medical school, have never struggled academically in their lives. I have heard folks say, medical school is a pressure cooker.

The pressure cooker brings out all of the problems. It stresses them. It pushes them in ways that many of these students have never been pushed. 28 percent of physicians report that they have stress that affects their ability to provide clinical care.(3) A recent systematic review found that medical students perceive similar levels of stress to physicians.(4)

I see students struggle because they have never been in this kind of situation. Students are young, they are often coming straight from undergraduate school. Students that come to medical school have often not had any real life experiences. They have not had a job, or had extensive life experiences. Then we put them into an academically stressful environment that is extremely competitive and at some schools even cutthroat. The good news is that some personalities may be better at handling the stress of medical school, and then potentially life as a physician. McManus (5) studied stress in UK students over a period of 12 years. The authors found that stress could exacerbated or even caused by personality factors, specifically by high levels of neuroticism, low levels of extraversion and low levels of conscientiousness. These traits are dimensions that are part of the Five Factor model of personality. This model is well accepted and validated. The model is used by many of the studies of personality contributing to success in academic settings.

Another study from the UK (6) looked at Goldberg's "Big Five dimensions of personality" to study 176 medical students at the Nottingham Medical School. The authors compared the students' personality scores and academic assessments in Years 1 through 5. The conscientiousness dimension was a significant predictor of academic performance in the pre-clinical years but interestingly in the clinical years (Years 4 and 5) it correlated with poorer performance.

So, there are personalities that may be more suited for medical school. And even more importantly, these personality traits can affect success as physicians. The Aussies looked at this a few years ago. In this study, Knight, et al (8) studied whether personality characteristics, measured by the Hogan Developmental Survey (HDS), were associated with academic performance in 139 medical students. They found that borderline/schizoid and narcissistic/antisocial characteristics were negatively correlated with academic success. That one seems pretty obvious. One of the subsections of the HDS, the ‘Diligent syndrome’, were found to be positively correlated to higher exam scores. The Diligent syndrome is students who have a tendency to be attentive and good with details, orderly, rational, careful and well organized.

What about here in the US? The folks at Jefferson Medical College are the only ones who have studied this. Hojat, et al(8) studied six personality measures. They also asked about the students' relationships with their parents and their general health. They compared these assessments with global faculty ratings of competence in the clinical clerkships (family medicine, internal medicine, obstetrics and gynecology, pediatrics, psychiatry and surgery). The ratings used a 4-point scale (‘high honours’, ‘excellent’, ‘good’, ‘marginal competence’). The students in the lowest group had significantly lower levels of self-esteem and sociability, they were lonelier, and had less satisfactory relationships with their parents.

So, what should we do? Conscientiousness seems to be an important predictor of success in the preclinical years, but it may also lead to vulnerability to stress. And it is related to worse performance in the clinical years. Extraversion, self-esteem, and sociability seem to be more important in the clinical years. Maybe we should do like the Australians did and have every applicant fill out a personality profile. I am not sure how this was used, but it does not seem that it was used to choose students. Next time, I will write about some of the ways to screen incoming students.

References
(1) Smith S. A Recipe for Medical Schools to Produce Primary Care Physicians. New Eng J Med 2010; 364(6).
(2) Sade M, et al. Criteria for selection of future physicians. Ann Surg. 1985 February; 201(2): 225–230.
(3) Firth-Cozens J. Doctors, their well-being, and their stress. BMJ 2003;326:670–1.
(4) Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among US and Canadian medical students. Acad Med 2006;81 (4):354–73.
(5) McManus IC, et al. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a 12-year longitudinal study of UK medical graduates. BMC Med 2004;2:29.
(6) Ferguson E, et al. Pilot study of the roles of personality, references, and personal statements in relation to performance over the five years of a medical degree. BMJ 2003;326 (7386):429–32.
(7) Knights JA, Kennedy BJ. Medical school selection: impact of dysfunctional tendencies on academic performance. Med Educ 2007;41 (4):362–8.
(8) Hojat M, Callahan CA, Gonnella JS. Students’ personality and ratings of clinical competence in medical school clerkships: a longitudinal study. Psychol Health Med 2004;9 (2):247–52.