Saturday, June 29, 2013

A thought about medical school admissions and the Bakke case.

I have been reading about The Regents of the University of California vs. Bakke. Bakke, a former Marine in his early 30s applied for medical school at UC Davis. The school admitted 100 students per class, setting aside 16 places for a special competition
to (1) reduce the historic deficit of traditionally disfavored minorities in medical schools and the medical profession, (2) counter the effects of societal discrimination, (3) increase the number of physicians who will practice in communities currently underserved, and (4) obtain the educational benefits that flow from an ethnically diverse student body.
Applicants for medical school are a pretty elite lot. Last year there were more than 600,000 applications but less than 20,000 matriculants in the schools. Thus there is an obvious problem that the schools face in selecting students to admit.

Clearly schools should not admit students who will not become physicians, dropping out for some reason or another. The schools maintain that they seek a composition of every class that will contribute to the quality of the education for all, and that makes sense to me since students have considerable influence on what their fellow students learn. Moreover, students from different backgrounds may help their classmates better understand and prepare for the diversity of patients that they will meet in practice. Unfortunately it is hard to predict the success students will have in a four year program, and I suspect harder still to predict the best combination of 100 students from hundreds of applicants. Test scores are unreliable and don't tend to predict into the distant future; there are known biases in that students from deprived backgrounds tend to do better when admitted than their ex ante test scores would indicate. Subjective judgement based on personal interviews is also unreliable.

Still the objective must be to select people who will graduate and become productive members of the medical community. Ideally the new entrants to the medical profession should match the needs of the patient population that are less served by the existing medical community. Note that the poor are more often sick, and often have less access to medical attention. Moreover, there is a general need for physicians in family practice to work in under served areas. Of course, there is a continuing need for physicians in other specialties, and for physicians everywhere. One of the issues that occurs to me is that patients often are better able to communicate with physicians with whom they do not face huge cultural or class differences. A physician that speaks the patient's native language is a plus.

Of course, medical students not only spend years in medical school, they spend more time interning, and most these days go on to specialize. Many find their vocation during this lengthly training, Thus it is hard to choose students who will not only be good physicians on completion of that training, but who will fill needs in the community.

Anyone who has worked with physicians will tell you that different specialties have different qualifications. Someone with limited vision might not be able to do some kinds of surgery, but might be fully capable of psychiatry; very few people are suited for the stress of pediatric oncology;  the personality that makes for good surgeons seems to differ from that found in most pediatricians or most pathologists. It is not only the case that medical schools must seek to provide basic medical education for people who will fill all these roles, but having people preparing for all these different specialties in the same class probably will help them as future practicing physicians to work effectively with physicians of other specialties.

In the case of the University of California, in which the state subsidized medical education, there was a legitimate interest to produce doctors who would stay in California and return services to the people of the state in return for the subsidy on their education. UC Davis is located in the California Central Valley, and would seem to have special responsibility to train professionals to work in that region and serve its population.

On the other hand, the University of California was established as a land grant institution with federal funding, and enjoys considerable federal funding in its operation. Thus the UC Davis Medical School also has an responsibility to fulfill national obligations.

I conclude that:
  • It would have been very difficult for UC Davis Medical School to articulate accurately and fully the criteria for selection students;
  • The actual selection process would necessarily only approximate the ideal, and would be based on heuristics rather than any algorithmic approach that would maximize fit of student body to school objectives.
  • Probably intensive review by medical educators is the best approach to the selection process.
The court
ruled unconstitutional the admission process of the Medical School at the University of California at Davis, which set aside 16 of the 100 seats for "Blacks," "Chicanos," "Asians," and "American Indians".
Most judges in their decisions found that race might be used as a criterion for admission under some circumstances, while others found that that question was not germane to the case.

The court also ordered that Allan Bakke be admitted to the school. Allan Bakke was clearly a superior student, who had served his country as a marine in Vietnam. He successfully completed medical school, graduating at age of 42 in 1982. He apparently became an Anesthesiologist, implying he went on to a residency and practiced in Minnesota. He apparently is now retired. I can only assume that the people of California would probably have gotten more medical service from their investment had they trained a different applicant than Dr. Bakke, one who was younger and more likely to practice in the state, especially one serving populations in need.

Perhaps courts should not substitute their judgement for that of medical faculties in making individual admission decisions.

1 comment:

John Daly said...

From an article in the Economist:

"On affirmative action, the court was more cautious, sending a high-profile case back to a lower court to decide, with some extra guidelines. The case was brought by Abigail Fisher, a white woman denied admission to the University of Texas at Austin (UT), who contends that the university rejected her because of her race while admitting minority students with worse academic records. UT argues that its use of race as one factor in admissions is consistent with the rules laid out by the Supreme Court in three previous cases.

"The first, California v Bakke, outlawed quotas, but allowed colleges to consider race as one of several factors in admissions. It held that any racial classification must serve a compelling state interest. Attempting to redress past acts of discrimination did not qualify, but fostering a diverse student body did.

"The second, Gratz v Bollinger, struck down a scheme used by the University of Michigan, which ranked applicants on a 150-point scale and automatically awarded 20 points to black, Hispanic and Native American applicants. The court found that system failed to meet the standard laid down in Bakke, which required individual consideration of each applicant.

"The third, Grutter v Bollinger, said universities may consider an applicant’s race only if that consideration is narrow, flexible and does not lead to “an applicant’s race or ethnicity [being] the defining factor of his or her application”.

"Ms Fisher’s team did not challenge Grutter directly, preferring a more narrow argument directly targeting UT’s admissions process. They may now be regretting that strategy.

"Grutter was a 5-4 decision written by Sandra Day O’Connor, now retired and replaced by the more conservative Samuel Alito. The justices disagree as to whether Grutter was correctly decided. Antonin Scalia, a conservative justice, wrote a separate one-paragraph concurrence saying that the only reason he was joining the majority was because the plaintiff “did not ask us to overrule Grutter’s holding” that diversity permits the use of race. And Clarence Thomas, another conservative, called arguments in favour of diversity “a faddish theory”; he noted their similarity to old arguments in favour of racial segregation.

"In a 7-1 decision on June 24th, the court let Grutter’s central holding stand. But it ruled that universities must show that their use of race is essential: that there is no race-neutral way to achieve a diverse student body. That will be hard. Several states have outlawed racial preferences; they keep their campuses diverse using race-neutral practices, such as favouring applicants from poor homes or admitting all students above a certain level in their high-school classes.

"Fans of racial preferences consoled themselves that the court had stopped well short of banning them. But such preferences remain unpopular: polls consistently find that most Americans disapprove of them"