This work demonstrates that that the process of selection has a strong influence on how applicants respond to questions used in medical school admissions. Applicants were observed to be conforming to the expectations of the selection process in ways intended to maximize their chances of acceptance. Applicants admitted to giving answers perceived to be the most acceptable to the school, and to having a shared understanding about the "unwritten rules" of acceptable conduct in the process. These findings suggest the existence of a "hidden curriculum" at work in the admissions process, by which applicants understand how they must behave to gain entry. This parallels a similar phenomenon previously noted in premedical education and beyond [
19-
23] which has been described as "a set of influences that function at the level of organizational structure and culture", "commonly held understandings... and taken-for-granted aspects of what goes on", "implicit messages... about what the institution considers important" and "implicit rules (used) to survive the institution" [
21,
24]. In this case, we propose a set of influences arising from the selection process through which applicants gain an understanding of what the school desires and how applicants must behave in order to gain admission. Some of the "unwritten rules" of this hidden curriculum may be similar to those expressed by applicants in this study: "figure out what they want to hear", "sell yourself--make them want you", "exaggerate but don't get caught", "do whatever you have to do to get in".
Gaining admission to medical school is highly competitive: pre-medical education has been described as "a series of obstacles to be overcome on the way to the elusive goal of medical school admission" [
19], with applicants possessing "a fiercely contentious desire to prevail over others, and at all costs get into this or that or any medical school" [
25]. As pointed out in a recent review, this competitiveness has an effect on the selection process: "Trust no-one. Do not trust the applicants. When stakes are high, the likelihood of cheating increases; the stakes for medical school admission are very high" [
26]. Others have observed medical school applicants "buffing up the application form" [
27], and similar phenomena have been noted in the selection process for residency [
28].
A number of theories of human psychology are relevant to our findings. Social learning theory suggests that applicant response will be determined by consideration of expectations, consequences, rewards and punishments occurring within a complex social system [
29]. Theories of impression management and self-presentation also relate to our work, as they describe goal-directed conscious or unconscious processes in which people attempt to influence the perceptions of others by regulating and controlling information in social interaction [
30]. Work on social desirability bias also bears on our findings, as it describes the tendency of respondents to reply in a socially-acceptable manner that will be viewed favorably by others, instead of responding with their own opinions, a phenomenon known as opinion conformity [
31]. Applicants may infer from a question a socially-desirable "expected response" with which they are required to conform in order to obtain reward (admission to medical school) [
32]. Conforming to the expectations of the application process may well be the first step in a longer, more sustained process of conforming which occurs throughout medical school and beyond. As Coles states: "we let (students) know by our admissions practices what kind of person we desire" [
25]. It is interesting to speculate that problems relating to unprofessional behaviour may originate in messages sent to applicants at their entry into medical education [
33,
34].
It can be argued that behaviours such as "exaggeration" and "selling" are simply an accepted part of any competitive selection process which operates "in the real world", although such behaviors have not been acknowledged in the literature on medical school admissions to date. It may be that we expect applicants to be "responsible for knowing when (and how) to break the rules" [
35]. Such an approach creates inherent unfairness and bias against those who are operating under different assumptions, and creates a dissonance between what schools intend and what is experienced by applicants [
36]. It is important to remember that applicants are only responding to the pressures of selection created by the processes that schools have chosen to employ [
32,
36].
Selection might be improved by taking steps to make the "hidden curriculum of admissions" more explicit [
23]. Addressing pre-medical culture and preparation is important [
19], and we suggest the selection process should include discussion about applicants' perceptions of the pressures of the process, and about the conflict between needing to "sell yourself" while trying to remain genuine [
23]. Steps such as these may assist in demystifying what is a high-pressure process, and may reduce anxiety and dispel incorrect beliefs about the process obtained from the "admissions rumor mill" [
3,
20,
28,
32,
34,
36]. The nature of the questions used in selection is also important: other studies have suggested that self-declared values should not be used in admissions decisions [
37], a finding very much in keeping with our core variable "What do they want me to say?" Answers to questions about the self should be treated with much caution in the selection process; as Siu and Reiter advise: "Avoid self-reporting... to expect the bad apples to weed themselves out on the basis of self-reporting goes beyond Pollyanna into self-delusion. All observations about the candidate should be made from a more remote position than the applicants themselves" [
26].
This study was limited as it considered the selection process at only one school in one year, it examined essays written both online and in person, and involved only a subset of applicants and assessors in interview. We hope that our findings will spur other investigators to consider this under-represented part of the literature, and to determine if these effects can be observed elsewhere.
Our observations on the effects of the selection process are expected to be provocative, as they reveal a side of the admissions process which appears well-understood by applicants but which has not been reported in the admissions literature to date. We anticipate that this study will make uncomfortable reading for those engaged in the admissions process, as it considers the acceptability of the behaviours which are required to gain entry to medical school. As Hafferty has written: "until we come to accept that medical training is, at root, a process of moral enculturation and... medical schools function as moral communities, the reform that is needed--the reform that the public deserves--will remain both elusive and enigmatic" [
21].
1 Keith Brownell,2 Jean-Francois Lemay,3 and Jocelyn M Lockyer4
publication history
