On changes to the MCAT and on what makes a good doctor good

On Friday, one of the headlines in The Chronicle of Higher Education caught my eye: “Medical-Admissions Test to Look More Broadly at Who Will Be a Good Doctor.” The article states that, as of 2015, the MCAT, the nation-wide exam that is administered to students who hope to attend medical school, will be making some significant changes to its format. The writing sample, long the bane of science students but for me one of its most demanding and revealing sections, will be removed, a new section on explanations of human behavior will be added, and a new critical reasoning section will replace the old verbal reasoning section. According to the AAMC, “The new exam is designed to help prepare tomorrow’s doctors for the challenges, advancements, and reformations of our future health care system.” It seems the AAMC is seeking to strike a greater balance between scientific competency and humanistic care, with more weight now falling on the latter.

As someone who spent nearly a decade helping prepare pre-med students to take the MCAT, I have my doubts that the new test will be demonstrably better than the old one. During my tenure as a tutor, I met young kids, seeming adolescents, who had read nothing outside their discipline and knew very little in general; who, for 18 years, had been trained to take standardized tests and had become adepts at that; and who were generally kind, came from well-to-do families, and were more or less harmless. I admit; I liked them. Unlike GMAT or LSAT students, they usually thanked me and were mostly courteous, occasionally apologetic. They answered emails promptly and caught a few of my references and jokes. They could laugh so long as you tossed them a juicy softball. And their parents paid me without meddling or niggling or interfering and, compared with the parents of high school kids, kept themselves well off-stage. No drama, thankfully.

On the East Coast, tutoring is as commonplace as cell phones, both being monthly expenses built into the well-to-do’s family budget. Most students, if not all, were used to having tutors for most, if not all, of their educational lives. (“Mom, I can’t right now, I’m Skyping with my tutor.”) I wouldn’t say that any of them had really lived or felt or suffered greatly. Death, hard times, and setbacks were concepts, mere abstractions, classroom ideas like social justice and Africa. No, I would say that they were… nice, almost to a fault, as if life, having been frictionless so far, would remain frictionless to the end. Having been swept along for 21 years, having some idea that medicine was one of the few remaining noble professions, and having worked assiduously on touching anecdotes with which their personal statements were to win hearts and influence committees, they would expect that hard work would pay off for them again and that, all things considered, helping the unhealthy wasn’t such a bad way to spend a life. Besides, there would be plenty of interesting cases.

Hard work was what they lived by, hard work and a deep trust that a decent life lay quietly before them. While others partied, they studied; while others played it safe, they went all in. And yet if there were only one problem with this picture, it would have to be that hard work, helpfulness, scientific competence, test-taking prowess, and being generally decent are neither necessary nor sufficient conditions for being a good doctor. If the MCAT has never been a good measure of a student’s readiness for med school, then revamping the MCAT is unlikely to plug the hole.

It could be asked what makes a good doctor good. This is a matter I’ve discussed with my medical doctor friends on more than a few occasions, the latest occurring over email this past weekend. Below, I’ve clipped a part of that conversation out of a longer exchange I had with one estimable doctor friend. In my reply, I second his praise of Yale Medical School as being good preparation for residency.

Dear Anton,

I think we two believe in apprenticeship. That is what I take from your Yale example. The rest of it–the labs, the grades, the recommendations–is but guesswork. Show me how he talks to patients. Let me see his hands and eyes. Ask her whether she has read Chekhov.

I am reading Chekhov’s My Life, the excellent translation by Pevear and Volokhonsky. The prose is lovely but the existence is heavy. (‘Twas ever thus with Chekhov…) I think when you and I first met a year ago the “struggle for existence” was very much with me. Now, I struggle rarely and think the “struggle for existence” should be reserved, for those of us fortunate enough to be living in the developed world, only for those times when we’re muddled and trying to slog through. If our lives are to go well, however, they must be made graceful and just; we must make them so. I can’t say the same of those living in the developing world. For them, it’s doubtless a veil of tears, and Chekhov their earnest muse.

Good students should know about the veil of tears. Good doctors should attest to it. Good persons should know and have experienced both struggle and grace, should have made both their own.


A letter written by a Doctors Without Borders friend of mine upon arriving in South Sudan

The following is a letter a friend of mine wrote about her first experiences as an obstetrician and surgeon working  for Doctors Without Borders in South Sudan. Her letter gives the reader a good sense of the state of medical care in some of the harder hit areas of central Africa. D.H. Lawrence is said to have written about new places before he knew anything about them. He was more concerned, he said, with the freshness of his impressions than with their accuracy. In the case of my friend, her thoughts reveal both a freshness and an accuracy. She remains in my thoughts.

Philosophy flourishes in gardens. It can only begin once the hands are free and the belly is full. A good plant rises up to the liquid sky; so does a good life.

Note: Names have been left out, changed, or removed for security reasons.

Dear friends and family,

I have arrived in South Sudan and finally have a free afternoon to sit down and write. I’m doing well and adjusting to life here about as quickly as can be anticipated. It’s been a busy and full couple of weeks, partly due to all of the traveling (it’s quite a lot of work to get this far into the middle of Africa) and partly due to a high work volume—also, everything always takes longer when it’s new, regardless of where one is or what one is doing.

After finally arriving in Uganda, where I spent a few days briefing, I flew by commercial air to South Sudan. The MSF [Doctors Without Borders/Médecins Sans Frontières] field operations are run from here (coordinating supplies, people, paperwork, etc.). Here things are bustling with a sense of their own newness. Here the pride and anticipation felt  among the people after the Comprehensive Peace Agreement was instated in July is palpable. After a night in X, I flew with a MAF (a Christian aviation mission that MSF has a contract with) to Y. On the plane were 6 people and boxes and boxes of supplies. We each had to step on a scale with our luggage (they even weighed my yoga mat) so the appropriate flight calculations could be made. We didn’t have enough weight allowance for gas to make the 4 hour flight to Y so had a lay-over in Z to refuel and then another hour or so to our final destination. The landing strip in Y is just as you’d imagine: a red dirt strip with potholes worse than a midwestern highway in the wintertime and lined with grass-thatched huts and teeming with children running out to meet us. A white Land Cruiser (the ubiquitous vehicle in these parts) met us and drove us through town to base.

The town here seems to be quite impoverished. People live in mud huts called tukuls with palm-thatched roofs. As far as I can tell from a few walks about the city, there are groups of a half dozen or so tukuls with a community fire pit and some sort of latrine and city blocks are made up of 6 or so of these communities. Outside of the market (which sells very little), there is essentially no commerce and very little agriculture as the people in this area were ranchers and herdsmen by trade.  In the town, electricity and running water are rare (making the stars shimmer at nighttime!) and plumbing appears to be sparse.

Our compound is not bad at all. There is a large mango tree (sadly, it’s not mango season) in the middle of our tukuls and there are small patches of flowers. Everyone has her own tukul and there is plenty of filtered water and lovely showers. There are 20 or so of us who live here plus the 20 national staff who work as security guards, drivers, cleaners, and cooks. The living area is directly adjacent to the offices, which have moderately reliable and fairly speedy internet access via old school Ethernet. And there is a volleyball court as well. We’ve played every Sunday and I have two skinned knees (cement chips hiding in the sand) to prove it!

The food is pretty bland – nearly every meal gets a healthy dose of a spicy Thai chili garlic sauce that’s imported from Paris. And every meal is the same. Breakfast is surprisingly good – a piece of bread flavored like a pita but fluffy like ciabatta with Kenyan peanut butter (or, for the more adventurous, Happy Cow cheese – that stuff is everywhere! – or Nutella, the other ubiquitous flavor sensation) and of course, Kenyan coffee. Definitely my favorite meal. The beer fridge is the only thing that is reliably full. We mostly drink a Kenyan lager called Tuskar.

Our compound is about a 10 minute walk (or 10 minute drive in the Land Cruisers) from the hospital. The hospital is quite well-equipped with its own clean water supply and generator. There’s a very reasonable selection of medications and all necessary supplies such as suture, IVs, and the like.  There is as little portable ultrasound that is quite nice but no EKG or x-ray and minimal lab tests available. The main hospital is maternity and pediatrics and there is a special section of the hospital reserved to treat malnutrition both for inpatients and outpatients. As you might imagine, the beds are nearly always full, sometimes with 2 patients sharing a bed and make-shift beds on the floor. The maternity staff consists of me, 2 ex-pat midwives (one from the West Coast and the other from Australia), 6 “medical assistants” (who are more like midwives or interns), a handful of “nurses” (who are more like nursing assistants and have never actually gone to nursing school), and plenty of interpreters (mostly Dinka but some Arabic as well). I’m mostly responsible for gynecologic problems and surgical or more complex medical obstetric problems. In addition to more basic cases such as cesarean sections, I’ve had at least one fairly complicated surgical case a day including a ruptured uterus and a ruptured bladder (both from prolonged labor) as well a finger amputation on a little boy (axe accident) and a reattachment of a finger on a little girl (hoe accident). Who knew I’d be running a pediatric hand surgery practice! Oh yes, and I can’t forget to mention the gun shot wound to the back and the innumerable malaria cases. It’s been a crazy couple of weeks.

There are about 16 or 17 expatriate staff working here. Most are in their 30s and 40s. There are 5 doctors – a Family Medicine doctor from Vietnam, a Pediatrician from Japan, an Intensivist from Czech Republic, and an Internist from Kenya. The others are nurses, midwives, logisticians, a pharmacist, and an administrative person. There are 4 Americans here and 4 French, but everyone else is from around the globe. Much of our evening conversation consists of traveling and favorite foods!

So hopefully this gives you some sense of what my life for the next few months will be like. I’ll be sending updates as often as I can. Your emails and letters are always appreciated!

With love,

Further Reading

Adam Hyde, “After South Sudan: Integrating Africa,” Open Democracy (August 22, 2011).