Viewpoint
March 23, 2023
Medical School Rankings—Bad for the Health of the Profession and the Public
Holly J. Humphrey, Dana Levinson, Keme Carter
JAMA. Published online March 23, 2023. doi:10.1001/jama.2023.2815
All of higher education sat up and took notice when Heather Gerken, dean of Yale Law School, announced in November 2022 that Yale would no longer contribute data to US News & World Report (USNWR) for the ranking of law schools. The response to this announcement was unprecedented in the immediate and ongoing exodus of multiple other law schools. In January, a similar exodus among medical schools commenced, with Harvard Medical School leading the way. At the time of this writing, at least 14 other medical schools—including more than half of those that are currently ranked in the top 10 by USNWR—have made the decision to opt out of the survey.
This decision on the part of the nation’s most elite law and medical schools—although newsworthy and publicly discussed—was not unprecedented. In fact, for many years, quietly and without fanfare, the Hébert School of Medicine at the Uniformed Services University and 2 of the country’s most venerable medical schools at historically Black colleges and universities—Meharry Medical College and the Morehouse School of Medicine—have chosen not to participate in the commercial enterprise otherwise known as the USNWR Best Medical School survey. What led them, so much earlier than the others, to opt out of the deeply entrenched yet ill-conceived process that reinforces elitist and biased practices?
To gain insight into what they may have been thinking, consider the following words of the president and dean at the Uniformed Services University of the Health Sciences: “After scrutinizing what is known about the process, we concluded that continued participation is a disservice to medical school applicants.”1 This disservice goes beyond giving the imprimatur of legitimacy to the misleading data and flawed process propagated by USNWR. We posit that Hébert, Meharry, and Morehouse medical schools ultimately found themselves unwilling to sacrifice core tenets of their mission to play the rankings game. The way that these schools choose to assess the quality of the medical education that they provide and the excellence of the future physicians who come into their learning environments is completely disconnected from the marketplace that USNWR has created.
The deeply flawed formula used by USNWR has been rigorously critiqued in the academic medical literature2 and was discussed in detail by 2 of us last year.3 We will not repeat those criticisms herein but instead state simply that excellence in medical education cannot be reduced to National Institutes of Health research dollars or reputation scores. Furthermore, although grade point average (GPA) and Medical College Admission Test (MCAT) scores are critically important data points in assessing applicants’ readiness for medical school and ability to successfully navigate the rigorous curriculum, they cannot be isolated from the other characteristics of a future physician. In the several decades that 2 of us have practiced medicine, no patient has ever asked us our GPA or MCAT score. Looking solely at these metrics is a troubling and regressive way to assess the excellence—let alone the potential—of those seeking to join the profession.
What makes a good physician? There are multiple qualities and behaviors, including passion, curiosity, commitment to lifelong learning, scientific aptitude, empathy, resilience, integrity, among many others. There is also strong evidence that medical schools can identify the individuals who possess the attributes, experiences, and foundational knowledge to be successful as future physicians through the holistic review practices espoused by the Association of American Medical Colleges (AAMC).4 This process should not be corrupted by external factors, such as giving far too much weight in the admissions process to slightly higher but often statistically insignificant differences in GPA and MCAT scores or allocating scholarship dollars to manipulate a higher matriculating class median for the purposes of a commercial survey.
Where have such practices brought us? It is clear that the profession of medicine has not historically trained a diverse group of people. Medical schools have struggled to admit classes of students whose identities reflect those of the public that they are being trained to care for. The socioeconomic diversity of the families of medical students has grown increasingly narrow; the highest quintile for parental income is overrepresented for all races and ethnicities among medical students, and perhaps even more striking is that a full quarter of medical students come from families whose income is in the nation’s top 5%.5
Medical school applicants provide a wealth of information about who they are, giving medical schools a significant advantage in admitting students who are aligned with their school’s mission. It is time for medical schools to match students’ transparency. In the absence of meaningful information from medical schools, the USNWR ranking system played an outsized role. We offer another approach.
Pushing back against the development of alternative normative ranking systems is necessary because medical schools have demonstrated that they may behave in ways contrary to their own mission and values to gain an advantage. Just as a medical student’s excellence or potential cannot be captured in a few bottom-line numbers neither should that of a medical school. Students should be encouraged to think about medical schools as they would want medical schools to think about them—ie, holistically. The process of becoming a physician is a challenging, time-consuming, and expensive journey. Similarly, the process of organizing educational experiences and shaping a learning environment is every bit as challenging, time-consuming, and costly for medical schools. Learning environments must inspire and uphold the highest standards of the profession by prioritizing people’s health, promoting an equitable and diverse climate that creates a sense of belonging for all, and providing meaningful experiences and real responsibilities for learners. How can medical schools share the most significant and key qualities of their learning environments with prospective students?
Fortunately, there is no shortage of rigorously collected information about medical schools. Medical schools complete questionnaires for the AAMC, which regularly uses this information along with multiple additional data resources to create comprehensive reports describing individual medical school characteristics, the state of medical education, the physician workforce, and medical research and innovation, among others. Perhaps most importantly, there are ample data that reflect not just what the schools report about their educational programs but what the students who are currently enrolled think about the quality of the education that they are receiving. There are rich data sources of consumer reviews provided by graduating medical students every year in the Graduation Questionnaire administered annually by the AAMC.
From this treasure trove of information, medical schools need to share information that would be most revelatory regarding the mission and outcomes of their school and the important characteristics of their learning environments. From the Mission Management Tool, which the AAMC has released annually since 2009, there are data measures addressing how graduates are contributing to various key missions such as addressing the health care priority needs of the nation, fostering the advancement of medical discovery, and meeting the needs of the community. These data include the number of graduates in primary care, those working in underserved areas, and those serving as medical school faculty, among many other metrics, including the diversity and indebtedness of the graduating classes. From the AAMC Graduation Questionnaire, graduating students report on their experience in the learning environment at their medical school. Students provide information on how they rate the overall quality of their education and their confidence in their ability to care for diverse patients. They assess the availability of mentoring and advising and the responsiveness of the administration in addressing their concerns. They evaluate how the diversity of the medical school class enhanced their training and skills, and they detail if they experienced mistreatment as students. Additionally, medical schools should regularly post their mission, applicant selection factors, MCAT and GPA ranges of accepted students, and matriculant demographics on their respective web pages.
The US is home to many of the finest medical schools in the world. The primary missions of these schools are varied and range from those schools engaged in scientific discovery for novel treatments for acute and chronic diseases and other schools whose primary mission focuses on primary care for patients living in urban or rural communities. To reduce these schools to a zero-sum game through a flawed ranking system shifts resources and attention to the game itself and away from delivering the best possible education. Wouldn’t it be ideal if USNWR’s “perverse incentives”1 could be replaced with incentives that bring additional resources to medical education and that improve the learning environment for medical students? For their sake and for the sake of their future patients, it is time to turn away once and for all from a commercial enterprise that distracts at best and undermines at worst the important work of educating future US physicians.
