Let’s all play doctor

Do you have what it takes to get through the Multiple Mini Interview?

090915_gradschool_doctor_slideIn the late 1990s, medical faculty at McMaster University in Hamilton were growing increasingly frustrated with the interviews used to evaluate medical school applicants. Even the most conscientious interviewers, it seemed, were biased, and there was often no correlation between the interview process and the subsequent performance of students. “The way we were admitting students was approaching being unethical,” explains Jack Rosenfeld, a professor emeritus in pathology and molecular medicine at McMaster. “The interview process was letting in people who should not have gotten in and excluding people who should have.”

So Rosenfeld and his colleagues proposed a radical new system called the Multiple Mini Interview (MMI). Instead of rattling off prepared responses to typical interview questions, applicants would have to work through 10 to 12 eight-minute stations where they’d respond to carefully scripted actors, tackle ethical dilemmas or try to solve hands-on problems—all under the watchful eyes of a group of interviewers.

The MMI was a success: a 2004 study published in the journal Medical Education found that it succeeded in diluting the effects of interviewer bias and provided valuable insights into an applicant’s abilities. A 2007 follow-up study found significant correlations between MMI results and later performance on clinical clerkships and national licensing exams.

Now, five years after McMaster implemented the MMI—in the face of aggressive resistance from the health care establishment—12 of Canada’s 17 medical schools have adopted the practice. In fact, the MMI that McMaster pioneered has spread to universities in England, Australia and New Zealand.

How applicants are judged remains a closely guarded secret. Medical schools provide little information on how to prepare, and at most universities anyone taking the MMI is required to sign a confidentiality agreement. Med schools are serious about keeping the mystery in how the MMI works; one applicant who snuck into a training session for judges (specific questions were not discussed) was banned from applying for seven years.

Happily, Maclean’s is under no such restrictions. We spoke to medical school faculty, successful and unsuccessful applicants, and people who served as MMI judges to find out what happens during the interview process—and what kind of person med schools are looking for.

How to prepare
While the MCAT (medical college admission test) exam reveals an applicant’s knowledge base, the MMI is designed to assess “soft skills”: communication, problem solving, judgment, life experience, ethics, professionalism, empathy and so on. Of course, being empathetic is not something you can simply study up on in the month before the interview. And that’s why the MMI is famously difficult to prepare for.
Common approaches include practising example questions that are posted online and reading up on medical ethics issues in academic journals. Some schools offer mock MMI sessions, but at least one successful applicant interviewed for this article chose not to take it. “I think I did well because I was just myself, genuine. I didn’t have formulated answers,” said first-year McMaster med student Rachel Lamont. “A lot of people had what they were going to say planned. That’s not natural.”

Rosenfeld also cautioned against practising. When asked how best to prepare, he quoted his colleague, a high-profile American neuroscientist: “The only way to prepare is to start reading when you’re 15, and read everything that you can.”

Door No. 1
The buzzer sounds. An applicant, standing with her back facing the interview room, turns around, finds a piece of paper posted to the door and has two minutes to read and think about this scenario: “Dr. Blair gives his patients sugar pills. He acknowledges that he uses the placebo effect. His reasoning is that it does no harm and makes people feel better. Consider the ethical problems that Dr. Blair’s behaviour might pose.” The buzzer sounds again and the applicant enters the room, introduces herself to the interviewer and begins discussing the problem for up to eight minutes.

This example is typical of MMI questions because it has no correct answer. Rosenfeld explains: “You can go either direction because some doctors use the placebo effect very effectively, very skilfully.” What’s important, he adds, is that applicants demonstrate an ability to consider and articulate both sides of an argument, then come to a position and be able to defend it.

The judges
Who is listening to the applicant wax on about the ethics of the placebo effect? Not expert profilers, but rather a mix of members of the local community, medical students and medical professionals.

The interviewers are given a general overview of how MMI works a couple of weeks in advance—but they don’t receive their specific MMI question and background information until a couple of hours before the interviews start. “We can’t risk giving those stations out ahead of time,” Rosenfeld explained. “If some applicant somewhere catches a glimpse of a station, there will be the devil to pay.”

Because interviewers aren’t experts on the topic they are assessing, they aren’t looking for in-depth knowledge from applicants. “One of the most important things is the attitude of the applicant and their mannerisms,” said Jeremy Hernandez, a second-year MD/Ph.D. student at McMaster, who has been an MMI applicant twice and an interviewer once. He stressed that how applicants communicate is just as important as what they say. “[The MMI] shows the person that you are, instead of the person you can practise to be,” he says.

Door No. 2
The buzzer sounds. Scenario: “Your company needs both you and a co-worker (Sara, a colleague from another branch of the company) to attend a critical business meeting in San Diego. You have just arrived to drive Sara to the airport.”

“Sara” (an actor) is debilitated by fear of flying. No matter what approach the applicant takes to urge her to get on the plane, the actor challenges the applicant. The hysterical and irrational Sara may accuse the applicant of patronizing her or, if the applicant is aggressive, Sara may start crying. The interviewer silently observes how the applicant reacts.

“I personally found it very difficult since it involved interacting with the actor as though they were my friend, relative or co-worker,” Hernandez recalled of the acting stations. “In the back of my mind, I knew that the situation was not real.” Almost every applicant interviewed for this article agreed that acting stations are the most challenging. “You could be a horrible actor, but does that mean you will be a bad doctor?” one applicant asked.

What mistakes do applicants make in acting stations? Some broke down crying or responded angrily when they got frustrated. But according to Rosenfeld, one of the most serious errors an applicant can do is to look at the interviewer instead of exclusively dealing with the actor.

Door No. 3
The buzzer sounds. Scenario: “There has been much debate in universities regarding the optimal size of classes. One side argues that smaller classes provide a more educationally effective setting for students, while others argue that it makes no difference, so larger classes should be used to minimize the number of instructors required and costs to universities. Discuss.”

In this scenario, applicants demonstrate their critical thinking abilities. Lamont’s advice: “Don’t be narrow-minded. Think critically about what you’re saying. Explain both sides. If you have an opinion, explain. But show that you see all the perspectives.”

Again, like the ethical and acting stations, there is no correct answer to this scenario. So how to prepare? Rosenfeld cautions applicants against enrolling in the expensive MMI preparation courses that have popped up in recent years. “I don’t think people get value for their money. You can practise all you want and the interviewer is going to go after you anyway.”

Some final advice
“You should be looking at yourself in the mirror and asking about the kind of person you are,” says Rosenberg, “and really be honest with yourself.”

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