IT IS LATE in November, and much too late at night. As she finally falls asleep, my daughter Annie cranks out "Somewhere Over the Rainbow" on her music box one last time, and the tune sets the stage for my nocturnal labors. I sit huddled among heaps of medical school applications, sipping strong coffee to stay awake, reading and evaluating. As the admissions process at George Washington becomes more frenetic, I am becoming a bit manic myself.
We have already been deluged by more than 6,000 preliminary applications for the 150 places in our September 1985 entering class. By next May, the admissions committee will have to interview more than 1,000 of those people, trying to decide who would be well suited to a career in medicine that starts at George Washington.
Tomorrow the committee will be considering the applicants whose papers I'm mulling over tonight, and for some of them, dreams really will come true. They will receive letters of acceptance into a system which has traditionally been able to confer upon its graduates guaranteed respect, independence and financial success along with an M.D. degree.
But I have begun to ask myself whether that particular dream will survive a coming doctor glut, cost-cutting measures and an industrialization of medicine that could conspire to turn a doctor's work into assembly-line production.
And the other thing I have to ask myself, looking at some of these applications, is whether the right people are ending up practicing medicine.
Speculation about what will happen to medicine is certainly nothing new. In fact, we ask applicants to predict their futures if they become doctors. Sometimes, the answers we get help convince us they might do better in other careers:
"I think medicine will become very sophisticated with lots of technology embodied in great big metal cases."
"I anticipate being highly motivated by the highly vibrant component of medicine."
Or, the wistful:
"I hope that the rizing (sic) cost of medical care will be combated (sic) with governments' (sic) greater increase of subsidies."
The predictions we take more seriously, however, have turned drastically gloomy. In 1974, when I was accepted at George Washington, new medical schools and larger classes had sprung up all over the country to fill what had been described as an urgent need for more doctors. Before I'd even finished residency training, a federal commission projected that by 1990 there'd be 70,000 excess doctors.
We have been told that private practice may not be an option for new physicians. The doctor glut and attempts to control soaring costs will limit earnings and push new doctors into corporate structures like health maintenance organizations (HMOs). In these organizations there will be large quotas of patients to see each day and strict review by peers to make sure time and services are not wasted.
Many of us practicing medicine would not be deterred from doing what we like best by less income. But to have to limit the time I spend with each person, to have to meet quotas, to be forced by circumstance to offer more depersonalized service (trusting relationships are not easily built in 15-minute visits) would bother me a lot. Would it be possible to get the same satisfaction from doing a job in a "health-care industry" as one can get from serving in a profession that I was taught is "caring"?
We say it in our admissions brochure: Caveat emptor. We tell these young people that the cost of a four-year medical education may run $100,000. Loans are expensive. They come due too soon. As more people graduate, there will be proportionately fewer opportunities, particularly in certain specialties, If you have your heart set on being an orthopedist or an ophthalmologist, you've got problems.
We warn and we worry, but the applicants keep coming. Some are there in ignorance of the writing on the wall; others in defiance. Still others want to forge a place in the new order as researchers or physicians for the burgeoning number of elderly.
Some were dissecting frogs and snails on the kitchen table before they learned to peel a potato. Others were editors or scientists or teachers who decided to change careers. Our applicants include those looking forward to joining a father or grandfather in practice in Boston; Thai and Vietnamese boat people; the children of immigrants from Mexico and the Middle East, and Americans who grew up in barrios and ghettos. One even talked eagerly about returning to Ethiopia to practice. In Ethiopia, the patient-doctor ratio is 75,000-to-1.
George Washington is known for accepting and encouraging nontraditional applicants. So the average age of our first-year students is 25, and there are usually several dozen people over 30 in each entering class. We've learned not to blink an eye when football players, photographers, artists or actors file in for interviews. In fact, among the students on the admissions committee this year are a former female firefighter, a former high school teacher and a computer whiz who came to us from industry.
We on the admissions committee like these Friday and Saturday interviews. One reason is simply that it's fun to get to meet so many interesting young people. And we like to think it will help us identify those people who can bring something special to medicine, while weeding out those who would be dangerous to the profession and to the public. We're never sure how well we succeed at either. For example, several years ago one young man's interview ratings were as good as anyone ever gets. Yet he was dismissed from medical school after it was discovered that he had falsified his transcripts.
You never know. Yet our sessions remain lively and they make the decisions we have to reach much more personal, more human. Despite the four to six hours a week the work demands for most of the year, people eagerly seek to serve on this important committee. The 21 who currently volunteer their time include some on the medical center staff, and others from busy private practices around the city. The six medical students among us are full voting members and certainly earn the right -- their commitment in time and effort is what makes the entire interview process run smoothly.
At 9:50 a.m. on a Saturday, I arrive a bit early for an interview session.
The medical students responsible for orchestrating the session have not yet arrived. The room is dark, and more than 20 applicants are sitting silently in the shadows. The light switch is in plain view, but no one has touched it.
"Why were you all sitting around in the dark?" I ask one of them, later on.
"You never know," he shrugs apologetically. "It might have been some kind of test."
Applying to medical school is so anxiety- ridden that I wasn't really surprised by the answer. Anecdotes abound about traumatic medical-school interviews -- like the one about an interviewer who supposedly asks applicants to open a window which he has, in fact, nailed shut.
Another old favorite involves the quick- witted woman applicant who was asked by a tasteless interviewer who declined to be impressed by her excellent record to tell him about her recent sexual experiences.
"I'm not sure that I can come up with a particular instance that's amenable to description," the young woman replied, "but I get the feeling I may be being screwed right now."
She was admitted, the story goes, the next day.
That student's fear that the dark room might have been deliberate reminded me of an episode a few years earlier when an applicant attempted to unnerve every other person interviewing with him that day. He asked each cheerfully about his record, then, finding a weak spot, said gently, "How nice of them to interview you -- but you know of course they never take anyone here who has a B on the record," or something similar.
Both the concern about being manipulated and the intentional sniping at other applicants seem to manifest the dark side of what some people call "premedical syndrome."
Those who think it exists suggest the syndrome begins with some undergraduates believing nothing is worth doing unless it improves their chances of getting into medical school. Ignoring the potential benefits of a broad liberal arts education, such students focus narrowly on the sciences, signing up for "gut" courses outside their field to pad a grade-point average or satisfy a humanities requirement.
It's a longstanding joke at Yale, I've been told, that whenever premed students encountered a particular football player in one of their new courses, they would stand up and cheer. He was notorious for picking easy classes, and if he showed up, they knew they'd chosen a winner.
These students are said to spend all their odd moments volunteering in hospitals or nursing homes to "prove" their sincerity. They compete -- instead of cooperating -- in the laboratories. And they overflow the preparatory courses for the Medical College Admissions Test (MCAT), which theoretically tests a persons capacity to handle the medical school curriculum. Then they scramble to submit applications to a dozen or more medical schools to make certain they'll get a place.
Why would bright, talented young people behave like that? Some claim admissions committees foster the syndrome by rewarding people whose credentials reflect a narrow range of achievements; other suggest it results from high anxiety in extremely goal-oriented people, and from misconceptions about the difficulty of getting into medical school.
In fact, 35,200 people applied to U.S. medical schools last year, and 17,209 were accepted. This is one out of two, nationwide, which is not really bad. Yet the average number of applications from each person was 9.1 -- more than 319,000 applications in all! A person who focused on that last number might well begin to think that chances of getting in were slim.
Then there are a few people who complain that those interested in medicine, for the large part, are like that -- dull, uninteresting, looking for security or prestige.
Others argue with conviction that the syndrome does not exist at all, that most of these students will bring to medicine the same energy they show in everything else.
My own feelings about it are mixed: we do see anxious, unpleasantly unidimensional people during our interviews, but they are the ones our committee tends to frown on in favor of those with more eclectic interests and fuller lives. And these generalists have not fared badly in other medical schools, either.
In 1979 and 1980 -- though the total numbers involved were small -- two-thirds of music majors who applied to medical schools were accepted, as were 56 percent of philosophy majors. This compares to only 44 percent of biology majors and 43.7 percent of zoology majors.
An important new report has added some spice to the controversy about who ought to be in our medical schools. "Physicians for the 21st Century," issued this summer by the Association of American Medical Colleges says:
"To be an informed participant in contemporary society requires understanding of its politics, history and economics. To appreciate the many dimensions of human experience requires informed reflection upon the literature, the philosophy and the arts that are included in the cultural heritage of all people in our society."
It recommends choosing people who demonstrate -- along with academic ability -- problem-solving skills, the ability to learn independently and the kinds of values and attitudes essential for people in a caring profession. It stresses these broad goals because today, medical knowledge is a rapidly moving target. We can not afford to graduate people simply because they have memorized what there is to learn. Today's facts may be obsolete five years from now. So will be the person who does not know how to continue an active, independent learning process after he leaves school.
That's a pretty steep order. The group suggests people be required to write an essay as part of the Medical College Admissions Test in order to demonstrate their thinking and writing skills. But that does't guarantee a person can think independently any more than do humanities courses listed on a transcript, or the letters of recommendation we count on now to get a better sense of what candidates are like.
One applicant this year was praised to the skies by an English literature professor for his sensitive approach to, and appreciation of, the short stories read in a class. The applicant was interviewed by one of our committee members who had not -- as is our policy -- had access to the candidate's file. Quite independently, the interviewer reported that the student, when asked what had interested him outside science courses, said he liked short stories -- but could not recall the name of a single story or author he'd read, and could not say why he liked reading them.
Do we supplement the MCATs with psychological testing to identify values and personality characteristics likely to produce people who fit the new mold? Do we evaluate people after four years when they've barely begun to learn clinical medicine? Or at the end of 10 years in practice, when flexibility and problem-solving skills are really being tested, as everything memorized in medical school has probably become obsolete?
And how do you measure success? On a standarized exam? By testimonials from patients? The admiration of co-workers?
Our admissions committee is split -- as I think it ought to be -- about whether brain power, personality, motivation, communications skills or scientific acumen ought to be the basis for the decisions we reach. For each hard hat on the committee who endorses those who raise themselves up by the bootstraps, we need a soft touch for a convincing sob story. Sitting beside him will be an academic martinet, and next, an analyst intent on understanding motivation. Before a committee like that, anybody ought to be able to get a fair hearing.
It's after midnight, and all the applications are finally back in their folder.
Time to get a few hours' rest before Annie sounds her 6 a.m. alarm. Falling asleep, I dream of committee meetings:
We are hearing about a 30-year-old woman applying for the third time. Her college grades (she was a language major) were so-so. But -- we are told by Soft Touch, who is presenting her case -- she didn't realize until she was in the Peace Corps in South America that she was really interested in medicine. She came back, took science courses locally and did pretty well, but her MCATs were still mediocre after three tries.
"What's she done to improve herself since her last application?" Martinet asks.
"And why does she really want to go into medicine?" Analyst probes. "Are you sure she doesn't think she's going to save the world?"
"She's been teaching school. And her interviewers say she has her feet on the ground," Soft Touch interjects. "She's solid."
"But look at those scores -- you know if she doesn't get through the first year she's $20,000 in debt," Realist breaks in.
"She's a three-time loser," someone adds.
"Or a third-time winner!" someone else replies. "She's persistent -- she'll make it."
Many sighs. "Ready to vote?" I ask? "Those in favor of admitting her, raise your hands."
I roll over, wondering how things will turn out.
Carole Horn is a Washington internists who is chairman of the admissions committee at The George Washington University Medical School. At the request of Outlook, she is writing periodically this year about her life in the health-care industry, which is now consuming almost 11 percent of America's GNP.