Thursday, May 03, 2007

Market Controls and Medical Training Part 2: Applying to Medical School

The application process to medical school is one of those things that shows the true level of absurdity that can be achieved when artificial constraints are mixed with huge amounts of easily accessable money. Having gone through the application process myself, I can honestly say that if someone read on the internet that Harvard liked nudist animal impersonators, there would be 1000 pre-meds disrobing in Harvard Yard while clucking like chickens the next day. Some people's desire to get in almost seems to transcend logic. At times, the insanity and the competativeness will drive people into a mode where they forget why they're doing what they are doing, with the goal of getting into medical school transcending all else. This post will mix the usual economic banter with a touch of pre-med psychology (unofficial of course), in order to truly elaborate on this nearly mystical process for those that haven't had the pleasure of experiencing it.

You might say that some people are just naturally competative, and besides, I'm probably the biggest proponent of market competition on the face of the planet. Both of these things are true, but not all applicants are naturally this way, and this isn't true market competition. In fact, this may be the most sinister stage of the entire process. This is the true med school bottleneck, and beyond this point, even the most cynical students will probably become physicians. The golden handcuffs have yet to make their way to the wrists of all the bright eyed doctors of tomorrow. In general, no one actually understands what it is that they are trying to achieve at this point, but everyone is convinced that becoming a physician is something magical.

There are a couple of major factors that have to be taken into account here. First, the government provides loan money to all who choose to attend medical school. Recent changes in federal law regarding student loans have made it possible for all students to fund their school's arbitrary "cost of attendance" entirely on the government money. This creates more demand for the product, as money ceases to be a barrier. Second, the number of medical schools are limited. This has changed a bit in the last few years, especially with the AOA allowing for-profit institutions to start using its accredidation, but this is new. It is also highly limited. There are still only two institutions that can accredit schools. There are all sorts of government restrictions on what schools have to offer, and all schools have to follow essentially the same format to meet the requirements. This effectively keeps supply far below demand. Thus, government restrictions effectively create shortages.

With shortages in place, competition for limited resources sets in. The limited numbers of institutions have all the cards. Applicants who are at the top their classes in college will fly around the country, begging schools to let them in. These aren't the cushy recruitment interviews that their overachieving counterparts in other disciplines are engaging in. Students will pay for their own coach flights, often maxing out credit cards, in order to sleep on a medical student's couch and pray for acceptance. Some students will repeat this a dozen times in a cycle, with a small number that will apply in multiple cycles, repeating this process for multiple years.

Of course, this is only part of the expense. Almost all schools go through a specific application system called AMCAS. This sort of system imposes a huge amount of added expense on students. The current version of AMCAS' variable fee schedule is $160 for the first school, with $30 per additional school. Remember that spots are limited, so marginal students may actually apply to 50 or 60 schools, shelling out the extra fees. Any school that feigns interest in an applicant will then request a secondary application. This secondary application will then request a series of information, of which 50% is redundant with what they already received through AMCAS. Another fee of $15-$100+ dollars will then be attached to this, making the effective price per school somewhere between $45 and $130. Occasionally, a school will collect the money usually associated with the secondary application and then instantly reject an applicant without requesting a secondary at all. We'll ignore the fact that this looks a little bit like fraud.

Now, I don't pretend that there would be competition in a free market. There will always be institutions that gain a reputation for which people are willing to work. A big wallstreet brokerage firm will have people competing for spots as well. However, everyone who wants to trade stocks doesn't need to compete. My problem is not with competition in and of itself, but with the process that creates only a single, uniform, and expensive method of pursuing medical training. This is generally the same problem I have with healthcare delivery. The standardization is overly restrictive, expensive, and ripe for abuse by parties that find themselves in a favorable bargaining position due to government intervention. I am not implying that all medical schools are evil and corrupt institutions. However, the nature of the application process is definitely shifted in their favor.

I apologize for the long and somewhat disorganized post. I'll do my best to follow it up with an equally long and disorganized post as soon as I can.


Anonymous Half MD said...

Since I serve as the tour guide for my school, you won't believe the asinine things applicants ask me. Some actually believe that their accomplishments in high school will be viewed favorably by the admissions committees. I'm constantly amazed that someone would willingly pay $3000 to apply to medical school without first checking to see what universities are looking for.

11:01 PM  
Anonymous Mr. Hat said...

This is a great post MiamiMed!! Truthfully this is the one thing that really scares me about applying to medical school next year. I think I could stomach rejection on its own if it happens, but the following potential conversation with my wife isn't something I want to deal with:

Me: "Hey honey, remember how I quit my job to go back to school so I could apply to med school?"

Her: "Yeah"

Me: "And you know how we now have crushing debt from school and especially the application process?"

Her: "Yeah"

Me: "Yes, well, ummmm.... unless one of us sells a body part on the black market in the next month, we may be hosed because I don't think my new job as a campground latrine maintainence technician is going to pay enough to even cover the minimum monthly payments from the debt we've racked up. The good news is though, campground employees get to camp for free. Which incidentally, we may be doing a lot of pretty soon here...."

2:14 AM  
Blogger MiamiMed said...

Thanks for all the replies,

I often talk to the applicants at my school as well, and I am also amazed at some of the things that people say and think. Of course, as a near high school dropout, I knew the answer to that question. It seems so incredible to me what people will go through. What makes it even worse, is that many people won't actually like it when they get here.

I'm pretty fortunate, in the fact that I'm enamored enough with medicine in general, that I still feel that I come out ahead when looking at all of the BS involved. I guess you could say that I'm one of those crazy people who would still choose medicine now, regardless of all of my criticisms. However, this isn't the case for many people, which only makes the process seem more degrading. Furthermore, the process only exists because the power is concentrated into a small Oligopoly with government protection.

5:26 AM  
Anonymous wfr said...

The whole thing is rather amazing to me. My roommate and I graduated as engineers, I decided to apply to medschool him to a PhD engineering program. He was flown around the country, wined and dined, and solicited by top schools in the nation. He subsequently was accepted, with a cushy stipend, to the top program in the US for the field. No one licensed them the top program, they are just ranked there and competition is still fierce for a spot. I on the other hand spent thousands of dollars on applications, then spent more on travel, to hope for a spot. One of my favorite experiences was with a DO school which accepted me in Janurary. They gave me two weeks to reserve a spot in the class, their non-refundable deposit? $1500. And they know you have no choice but to pay because you have no idea whether you'll get into other schools till May and you would do anything not to have to repeat the process next year. The schools know how to work the system. I have never felt so entirely helpless and insignificant then when I applied to Medical School. I know to some extent this is supposed to make you re-examine your reasons for applying but at the same time the whole thing seems so damn arbitrary.

1:58 PM  
Blogger MiamiMed said...

It seems arbitray because it is. I take that back, it is the combination of a series of non-arbitrary calculated interests that mold together in spectacular fashion in order to create a seemingly arbitrary fashion. As you pointed out. They know the system.

7:56 PM  

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