Thank you Dr Reilly for the interesting piece (and also the plug for King's WP!) I've been thinking about these questions a lot in regard to medical school admission. Especially, after reading "The Tyranny of Merit" by Professor Michael Sandel (which I'd thoroughly recommend).
For me, it's a question of establishing what the minimum standard is for a colleague or student to be successful on a programme and the creation of a culture of excellence. This minimum standard could still be a very high standard. However, we could still allow for the inclusion of a lottery into the process.
For example, in the case of the core training placements it could be that those placements which are the most competitive have additional criteria to be entered into the lottery pool. E.g., a higher score on the selection exam and also evidence of having published academic research. This way we capture the best of both meritocracy whilst also embracing the humility that comes with including some degree of randomness.
Otherwise, we are putting a huge amount of belief in our selection processes. For example, the UCAT scores to gain admission to medical schools are growing higher and higher as more students are interested in applying to medicine and dentistry, and it's not entirely clear that the UCAT is the best (and should be the only) measure of whether an applicant is suitable for medical school. As you mention, courses like the EMDP show that being more flexible on criteria does not affect how well students then do on completing their medical degree and the culture of excellence at King's.
I think this is a big discussion though and is at the heart of how we organise as a society! (Which Professor Sandel discusses in his excellent book).
Thanks for this comment Jake. I'm genuinely impressed by how much work you do for widening participation at King's and of the standard of students who come through these programmes. For me, this is the way to do it!
Even if the selection process is flawed though, shouldn't we try to improve it (e.g. through contextual admissions, which King's does offer) rather than throwing the baby out with the bathwater by turning it into a lottery?
Definitely wider questions for society, not just medical training.
Thanks so much Tommy! We are very grateful to have your support every year.
It's a good point, although I think it's possible to combine both meritocratic standards with randomness. Another good example is the interview process for medical school. The standard is extremely high as there are so many candidates. Unlike a job interview the panel (or those asking a question for an MMI) will be made up of a lots of different people. This means that candidates could be unlucky or lucky with their panelists for that particular interview session (they might overall be more lenient or harsher).
If we set a standard score which students had to achieve (alternatively, a set of competences that they have to show so it could be a yes/no answer) e.g., realistic understanding of the profession, sound and logical argument in clinical scenario, understanding of the skills required of a doctor, etc. Those who are able to demonstrate the competences are then put in the lottery for a place. Again, the standard could be high. However, the lottery minimizes the issues in the process.
I think it's a very interesting question balancing aspiration, merit, contextual factors, and error.
Disagree that research is the criterion of excellence, it is of dubious use and quality, does not benefit patients, only doctors, while docs who prioritise good patient care are dismissed. I would grade all doctors on ebay style patient ratings and if they want to take time out to do research, fair enough, but they would not be eligible for benefits based on this, or indeed any non direct patient care activity such as audit, yuck, and would be considered second class doctors. Agree the the lottery idea is just demoralising for anyone who wants to be excellent. And yes I am a Consultant Psychiatrist
Great article. Some people are attracted to meritocracy, some aren't. Initiatives like this will inevitably change the temperamental composition for who choses to do psychiatry, and, in the longer term, medicine.
I think it's telling that the authors of that article forgot to mention one thing: patients.
I expect that many patients outside of London may be glad that their psychiatrist completed their training at centre of excellence. It's therefore a pretty good idea to have junior psychiatrists complete their training in London (a fun place to be in your 20s and 30s, with complex caseloads and specialist clinics to boot), before working as a consultant elsewhere. Psychiatry training is 6 years, while you might work as a consultant for 30 years or more, so the vast majority of clinical decisions, especially the complex ones, are going to be made by consultants, not their juniors.
But it's the NHS, so quality must be sacrificed at the Altar of Equity.
Isn't random allocation among those who meet minimum requirements/a set percentile/other applicable cutoff a proposed method of reducing the signalling-over-substance rat-race of grant applications? Do you also oppose that application, or do you think trainee placements are different in a way that is unsuitable to this alternative?
(I'm assuming either applicants could self-sort to favor clinics most relevant to their career goals, as you note about Maudsley, and/or that the algorithm could be pseudo-random, with weighting for relevant experience, as opposed to a strict dichotomy.)
I think grant application are different because they suck time and opportunity costs from scientists. Medical student or doctors getting involved in research or studying for exams are benefitting their CV but these activities have inherent worth in themselves.
I’d prefer a system which tries to suit candidates’ interests with a training posts or weights allocation by relevant experience - but this seems to be verging back towards just selecting the best candidate for the job!
Thank you Dr Reilly for the interesting piece (and also the plug for King's WP!) I've been thinking about these questions a lot in regard to medical school admission. Especially, after reading "The Tyranny of Merit" by Professor Michael Sandel (which I'd thoroughly recommend).
For me, it's a question of establishing what the minimum standard is for a colleague or student to be successful on a programme and the creation of a culture of excellence. This minimum standard could still be a very high standard. However, we could still allow for the inclusion of a lottery into the process.
For example, in the case of the core training placements it could be that those placements which are the most competitive have additional criteria to be entered into the lottery pool. E.g., a higher score on the selection exam and also evidence of having published academic research. This way we capture the best of both meritocracy whilst also embracing the humility that comes with including some degree of randomness.
Otherwise, we are putting a huge amount of belief in our selection processes. For example, the UCAT scores to gain admission to medical schools are growing higher and higher as more students are interested in applying to medicine and dentistry, and it's not entirely clear that the UCAT is the best (and should be the only) measure of whether an applicant is suitable for medical school. As you mention, courses like the EMDP show that being more flexible on criteria does not affect how well students then do on completing their medical degree and the culture of excellence at King's.
I think this is a big discussion though and is at the heart of how we organise as a society! (Which Professor Sandel discusses in his excellent book).
Thanks for this comment Jake. I'm genuinely impressed by how much work you do for widening participation at King's and of the standard of students who come through these programmes. For me, this is the way to do it!
Even if the selection process is flawed though, shouldn't we try to improve it (e.g. through contextual admissions, which King's does offer) rather than throwing the baby out with the bathwater by turning it into a lottery?
Definitely wider questions for society, not just medical training.
Thanks so much Tommy! We are very grateful to have your support every year.
It's a good point, although I think it's possible to combine both meritocratic standards with randomness. Another good example is the interview process for medical school. The standard is extremely high as there are so many candidates. Unlike a job interview the panel (or those asking a question for an MMI) will be made up of a lots of different people. This means that candidates could be unlucky or lucky with their panelists for that particular interview session (they might overall be more lenient or harsher).
If we set a standard score which students had to achieve (alternatively, a set of competences that they have to show so it could be a yes/no answer) e.g., realistic understanding of the profession, sound and logical argument in clinical scenario, understanding of the skills required of a doctor, etc. Those who are able to demonstrate the competences are then put in the lottery for a place. Again, the standard could be high. However, the lottery minimizes the issues in the process.
I think it's a very interesting question balancing aspiration, merit, contextual factors, and error.
Disagree that research is the criterion of excellence, it is of dubious use and quality, does not benefit patients, only doctors, while docs who prioritise good patient care are dismissed. I would grade all doctors on ebay style patient ratings and if they want to take time out to do research, fair enough, but they would not be eligible for benefits based on this, or indeed any non direct patient care activity such as audit, yuck, and would be considered second class doctors. Agree the the lottery idea is just demoralising for anyone who wants to be excellent. And yes I am a Consultant Psychiatrist
Agree that research isn’t the only marker of excellence and definitely doesn’t trump good clinical care!
Great article. Some people are attracted to meritocracy, some aren't. Initiatives like this will inevitably change the temperamental composition for who choses to do psychiatry, and, in the longer term, medicine.
Thanks Matt!
I think it's telling that the authors of that article forgot to mention one thing: patients.
I expect that many patients outside of London may be glad that their psychiatrist completed their training at centre of excellence. It's therefore a pretty good idea to have junior psychiatrists complete their training in London (a fun place to be in your 20s and 30s, with complex caseloads and specialist clinics to boot), before working as a consultant elsewhere. Psychiatry training is 6 years, while you might work as a consultant for 30 years or more, so the vast majority of clinical decisions, especially the complex ones, are going to be made by consultants, not their juniors.
But it's the NHS, so quality must be sacrificed at the Altar of Equity.
I think Consultant vacancies are pretty bad outside London, presumably trainees would be more likely to settle where they trained.
You're right though, they didn't mention patients at all.
Isn't random allocation among those who meet minimum requirements/a set percentile/other applicable cutoff a proposed method of reducing the signalling-over-substance rat-race of grant applications? Do you also oppose that application, or do you think trainee placements are different in a way that is unsuitable to this alternative?
(I'm assuming either applicants could self-sort to favor clinics most relevant to their career goals, as you note about Maudsley, and/or that the algorithm could be pseudo-random, with weighting for relevant experience, as opposed to a strict dichotomy.)
I think grant application are different because they suck time and opportunity costs from scientists. Medical student or doctors getting involved in research or studying for exams are benefitting their CV but these activities have inherent worth in themselves.
I’d prefer a system which tries to suit candidates’ interests with a training posts or weights allocation by relevant experience - but this seems to be verging back towards just selecting the best candidate for the job!