What Makes a Medical School Great?

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The medical school interview season has just concluded. Each year, approximately 45,000 students vie for approximately 20,000 first-year positions at U.S. M.D.-granting medical schools. Most of these students will not have gained admission, and if they wish to become physicians they will need to seek medical education outside the U.S., pursue an alternate degree such as a DO (doctor of osteopathy), or improve their grade point averages and test scores and apply again next year. At the other end of the spectrum, many fortunate students face the task of choosing between multiple schools.

With only 20,000 new M.D.'s emerging each year to help care for a nation of over 310 million people, these are momentous choices. Every graduate counts,! and where students go to school can powerfully shape the kinds of physicians they become. What factors should count the most in choosing a medical school?

A thriving medical school will have strong commitment to the health and well-being of its community, and its students will be actively engaged in volunteer activities to help their neighbors.

One important factor is clearly reputation, often expressed in the form of rankings. A number of publications and websites purport to rank the 140 U.S. M.D.-granting schools on factors such as research funding, publications by faculty, selectivity in admissions, the average grade point averages and test scores of accepted students, and a difficult-to-quantify prestige factor associated with the school itself or the larger university of which it is a part. While it is fashionable to downplay such rankings, many schools, particularly those that are highly ranked or moving up, tend to! trumpet them loudly.

Such rankings do mean something! . For one thing, being associated with an elite institution probably opens doors throughout the remainder of a physician's career, and there is real benefit to training with top students. In some cases, however, the reputation exceeds the reality. Education is not the only factor in the rankings, and research prowess does not necessarily equate to teaching excellence. And while there may be a real difference between the number one and number 100 schools, it is questionable whether there is any real difference between the number 20 and 30 schools.

Another increasingly important factor is cost. The median cost of a 4-year medical education is now over $265,000. Over 85 percent of students graduate in debt, and the average indebtedness is over $160,000. Due to accumulating interest on loans, most students will need to pay back considerably more. There is some evidence that this high level of indebtedness is influencing students' decisions about which medical fields to! enter, placing a premium on ones that offer a higher income and steering students away from fields in which the need is greatest, such as the primary care specialties.

The most important issue in choosing a school should not be cost but value: the ratio of quality over price. Some offshore medical schools that function as "last resorts" are able to charge very high tuition. On the other hand, the tuition at some top-flight public medical schools is relatively low. Of course, tuition isn't the only factor contributing to cost, and students also need take into account differences in cost of living between locales. Also, many students get married or have children during or shortly after school, which can further magnify the importance of the cost factor.

Students and their families and advisors tend to spend too much time thinking about rankings and costs, in part because they are easily quantified. Whether such quantitative factors are really valid or not, ! the numbers seem to make it easy to compare schools against each other.! But merely relying on an aggregate value score (ranking/cost or something to this effect) would leave out vital features that deserve to be taken seriously. For lack of a better term, we aggregate these factors under a general category that we call "culture."

Are students treated to some degree as colleagues who can assume increasing degrees of responsibility not only for patient care but for charting their own professional futures?

Some might assume that, because culture cannot be quantified, it is somehow soft rather than hard, subjective rather than objective, and ultimately, far less reliable than quantitative measures. Yet we should bear in mind that though many of the most important aspects of our lives are similarly non-quantifiable, we do not rely on them any less. For example, imagine choosing a spouse based strictly on quantitative measures. What would we measure -- body mass index, IQ, and expected lifetime ear! nings? Most would find any such ranking ridiculous.

Though difficult to quantify and relatively infrequently discussed, culture is very real and very important. Just as factors such as personality and character heavily influence relationships, they should also play an important role in selecting the best school for a particular student. One such aspect of culture is the type of career for which a school tends to prepare its students. Is it more conducive to the formation of academic or community physicians? Is it more inclined to specialization or primary care? Does it place more emphasis on test scores or clinical competence?

Culture also encompasses the roles students play in their own education. Are students at the school like passengers on a bus, merely staying in their seats as they progress relatively passively through four years of their own education? Or are they actively engaged in helping to determine what they will learn, how they will learn it,! and how they will be evaluated? Are students isolated in silos, or do ! they work in groups? Are students challenged to be creative, to take risks, and to develop in ways that accentuate their own distinctive talents and interests? Or does the school, like the dairy industry, emphasize a model of homogenization?

A major cultural factor is respect. Are students treated to some degree as colleagues who can assume increasing degrees of responsibility not only for patient care but for charting their own professional futures? Are they regarded as valuable collaborators in education, research, and service to the community and the profession? Do both students and faculty demonstrate a high degree of respect both for patients and their non-physician colleagues? A school where people do not hold one another in high regard is unlikely to foster high standards of professionalism.

There are several effective ways to "biopsy" a school's culture. One is to inquire about its student-run health clinic. Does it have one? If so, how many studen! ts are involved in it? What are the interactions between its students and faculty like? In general, a thriving medical school will have strong commitment to the health and well-being of its community, and its students will be actively engaged in volunteer activities to help their neighbors. More than mere platitudes, participation in such programs teaches the lesson that a great physician is dedicated to serving others.

A second way to biopsy a school's culture is to ask students to describe their best teachers and role models and ask faculty members to describe their best students. If students have difficult identifying a best teacher, or if they for example laud instructors who do not require them to attend class, this is a bad sign. Likewise, if instructors define their best students in terms of their grades or test scores, it suggests a lack of real human engagement. In a thriving medical school culture, the countenances of both students and teachers should bri! ghten as they describe their favorites.

Another quick indicato! r of culture is to ask faculty and administrators to describe what they are proudest of about their school. Do they immediately repair to indicators such as clinical revenues, research dollars, or publications? Or do they refer to particular programs and people that are making a difference in the lives of students, faculty, and patients? In a thriving culture, people should be ready and enthusiastic to relate their contributions to the work of their school, and the contributions their school is making in the lives of those it serves.

There is no need to beat around the bush. Just ask them straight away. "What difference are you making in the lives of your students? What different are you making in the lives of your patients? In what distinctive ways would this school help me to become a better physician, enabling me to make a bigger difference in the lives of my patients? What is the school doing to nurture the human side of medicine?" Merely posing such questions is important. For one thing, it helps students to glimpse more clearly their true priorities in becoming physicians! . Equally importantly, it sends a powerful message to medical schools a! bout what really matters most to our future physicians.