One of the most fascinating aspects of being a consultant is seeing the workings of the machine that is medical training from the other side. For two years now I have taken part in the specialty recruitment interviews and it is a wondrous thing to behold the organisation that goes into standardising the marking and ensuring the whole event runs with military precision.
During the most recent set of interviews there was a fire alarm and both candidates and examiners had to vacate the building into the freezing snow but even then, when the fire alarm was over, the interviews restarted again and still finished pretty much on time. There were mechanisms for dealing with problem candidates, for keeping to time, for standardisation and even for getting the lunch organised efficiently. The most interesting thing I did notice, however, was the phenomenon of the hawk and the dove.
It is strange that when presented with pretty much the same evidence different people will come to subtly different conclusions. And sometimes not so subtle. The pair of interviewers in the room opposite me joked about how one was a hawk and the other a dove so together they compromised on some middle ground. Why are people so different? The hawk would boast that he held high discipline and was singlehandedly protecting the specialty from corruption by inferior trainees. The dove countered that all the applicants were good people and deserved a chance, hinting that were it up to her she would have given everyone top marks. The hawk then admonished the dove for giving away too many hints while asking the questions.
This reminded me of my fellowship exam. In one or two stations one examiner would be the obvious bad cop while the other would be a good cop. One was determined to trip up a candidate as much as possible, or so it seemed, while the other would put on a bright smile and try and help. With this thought still rolling around in my head I attended specific training at Swansea University to prepare a cohort of us to examine medical school candidates for the admission interviews. For this training two interviews were played out, using actors, and the audience was asked to mark the candidates out of four in five separate areas.
Afterwards a show of hands was used to see how the audience had voted. I thought both interviews had gone quite well but the audience varied enormously between those few who would fail both candidates to those that passed both with a high pass. One actor played the role of an English posh boy and the other a Welsh working-class candidate currently working in a call centre. It was fascinating how different demographics in the audience reacted differently to both performances. There were obvious outliers of course, such as the uber hawkish Dick Cheney of the group, an angry dermatologist, who proudly failed both candidates by reasoning that as they were clearly not behaving like doctors and didn’t have the knowledge of doctors, why should they be trained to be doctors? Doctors naturally emerged from the womb with stethoscope around their neck and prescription for dermovate in hand, of course.
“But the audience varied enormously between those few who would fail both candidates to those that passed both with a high pass”
The lay members were even worse. “I didn’t like the way he said ‘what brings you here today’, I just thought it was very aggressive.” Another would say “I thought how he leaned back in the chair was way too casual”. Then someone piped up with “Ah, but I think leaning back is a good thing in a doctor as it shows confidence”. Then a grumpy clinician replied that it showed disrespect and so he had marked the actor down for that. It became increasingly clear that non-verbal signs were judged just as much as what was said, if not more, and more distressingly again that everyone in the group thought the same action or phrase could range from being very good to very bad. “I thought it was lovely to see a person so down to earth” one lay person said, while a clinician replied that in his opinion being more comfortable speaking to porters than doctors while on placement was absolutely not a great quality to have in a doctor. The chair of the training course emphasised how pleased he was with the variability, as this indicated a cross section of views and those who were consistently hawks were bad and those that were consistently doves were equally unhelpful.
The medical school interviews themselves were a mirror image of that meeting. One candidate stood out as being particularly excellent and I marked him with every mark at my disposal. He didn’t get in, as the academic interviewer trashed him and the average was too low. We like to think we live in an organised world where there is a reason for everything and if we work hard we succeed, but I now sort of realise that this is untrue. The world is random. Too random. People succeed or fail on the tiniest of chances. There is a film called Sliding Doors I watched once, starring Gwyneth Paltrow if I remember correctly, where two possible timelines are presented which divide from the stem depending on whether Gwyneth catches the tube or not. It is meant to illustrate the ‘butterfly effect’, whereby small things can have big ramifications and I now realise that there is a great truth hidden in this most hideous and unwatchable of films.
If a candidate for a medical school entrance interview gets a certain interviewer who appreciates leaning back or hates a broad grin or treats humility with disdain or confidence as suspect is entirely random. It cannot be controlled. If a prospective ophthalmologist gets a combination of doves and hawks or all doves or all hawks is also random. If an FRCOphth exam candidate gets mostly good cops or mostly bad cops is also random. We have controls and checks and balances but there is still too much randomness, and perhaps it always was this way and always will be. Hard work getting results every time is an illusion. We are all here by chance mostly. I feel a bit as if I have been traversing a tightrope over a canyon and looked down for the first time and seen the drop. But I seem to be so much a dove that should I fall I might be able to fly away. And get consumed by a hawk.
These are the views of the author and do not represent those of the editorial board or publisher.