The perils of the Z-score: Confessions of an average medical student
I am an average medical student driven mad by the Hunger Games-style, hyper-competitive process of attaining an internship in Victoria. Before you freak out, I am not planning to cathartically list the non-academic reasons why I am actually an excellent student. I have sat through enough of these conversations of late and I am well aware of the numbing frustrations that they conjure. I am just average.
To those who are unfamiliar, the process of applying for an internship in Victoria involves the assignment of a rank to each medical student in the state with exactly half of these exceptionally bright and passionate people being told that they are, in fact, below average.
These below average medical students, from whatever Katniss’ district was, will then be overlooked for interviews at the more prestigious health services in the glittering Capitol while their friends modestly gloat.
No other state in Australia assigns ranks to graduating medical students. Instead, they simply ask where applicants want to work and try to place them wherever makes them happy. How delightful.
This difference adds to the arguably competitive culture of Victoria’s medical system. With the current spotlight on the mental health of junior doctors after the most recent wave of tragedies, it is mind-boggling that this process is deemed appropriate. We have become numbers, not people, and it is time for a change.
First, let us pick apart the infamous Z-score. To set the scene, if a medical student passes their gruelling final exams, they have effectively met a standard that – in the eyes of universities, medical boards and regulatory authorities – deems them safe and competent enough to be a medical doctor. Although these exams incorporate clinical and academic knowledge, the ability of them to predict how competent a graduating student will perform as a doctor remains under debate.
Once they have passed, they are then stamped with a single number that summates every result that they have had during medical school so that they can be compared to the average, and directly to one another.
I hear some of you saying that this is a good thing because it makes the process transparent, and allows you to be more in control of your applications. But for me, I think this assignment of your whole medical degree to a single number and telling exactly half of the graduating class of medical students that they are below average is a terrible thing (I’m not even going to edit out the word ‘thing’ to a better word because I am only an average medical student).
It undermines the exceptional achievement of simply being accepted into medical school, and the incredible standard that has been met by passing your final medical school exams.
To be in this tiny cohort of exceptionally clever people should be enough. In Victoria, there are about 1250 medical graduates applying for internships each year. About 60,000 Victorians graduate Year 12 each year, and there are about 4 million people of working age across the state.
The graduating medical cohort is a tiny group of exceptionally high achieving people. Medical graduates are three grains of sand on St Kilda beach. When telling this tiny group of high achievers that half of them are below average, a culture has been created where just being in this cohort is not enough. We must cut out our personal lives, freeze our friendships and spend every waking hour on a variety of extracurricular achievements if we even stand a chance at being successful.
The next step of the process is to apply for internships to each health service directly and then wait for an offer to interview. This process centres on the shiny and beautiful above-average medical students posting on Facebook and sending hilarious Snapchats of their interview offers, and discussing them in social settings that were previously enjoyed by the less fortunate. This occurs while the below-average students remain painfully silent and are repeatedly encouraged that they too are simply sure to get a job at the hospital on which they have their heart set.
The above-average look down on the below-average with pity, the below-average look down on themselves with the depression of rejection.
The Pygmalion effect of psychological theory suggests a self-fulfilling prophecy where if a student is labelled a low achiever, they perform as a low achiever, and if labelled a high achiever, they will perform as a high achiever. Applying this theory to those starting their first job as a junior doctor is a dangerous concept – not just for their career progression but also for their mental health, feelings of self-worth, and ultimately in the delivery of patient care. Further, there is mounting evidence to suggest that non-graded assessment systems reduce psychological distress in medical students without changing academic or clinical performance.
With the current Victorian system, it feels like prestigious hospitals are able to cherry-pick the best and brightest students to join their institutions based on their academic results. This (arguably) creates a quality divide in the delivery of medical services across the state.
Surely a patient entering an emergency department at midnight in rural Victoria, seen by an intern, should receive the same standard of care as a patient seen by an intern in the big city. If this standard is unaffected, then what point does the Z-score serve other than making half of the graduates feel bad, and the other half feel good?
To be clear, I can see the positives of the Victorian internship allocation. Those that are supremely intelligent and are passionately engaged in research and the medical community can have more say over where they are employed. It also seems like the Victorian system promotes engagement with medical research while at medical school because it is a factor in internship applications. This may be advantageous for Victorian students compared to other states in the setting of future applications to training programs. But why can’t we modify the way we apply for internships to make everyone feel like they are worthy of being a doctor?
Outside of Victoria, final year medical students are assigned an internship based on their preferences, and are not told where they are ranked. They are not treated as below average and are not made to feel like they will be incompetent and unworthy to work at a prestigious hospital. They are treated appropriately to their exceptional achievement of passing medical school.
With the medical community battling through a wave of tragedy with the recent deaths of doctors and concerns over the stress, bullying and disillusionment of junior doctors imprisoned within a fierce culture of competition, we should be celebrating achievements, not condemning results that are only slightly below the mean.
The Z-score could be discarded, but, like jobs outside of medicine, the selection process could continue to involve CVs and interviews to acknowledge other achievements. Surely we can do this in a way that makes us feel like a cohesive cohort of colleagues, rather than a divided pack of animals going in for the kill.
To my fellow medical students, and to those applying for internships in future years, be kind to yourselves. I recommend not checking your Z-score at all. I made a conscious decision to not check my Z-score because I could only see the negative consequences of doing so. Apply to hospitals in the order in which you want to work, not by what you think you are worth based on your ridiculous rank.
Make up a new rank for yourself, if you so please. I created the T-score. It’s a score that I secretly assign people to rank their sense of humour and it’s doing wonders for choosing who to talk to through the internship application period.
To those that do choose to see their Z-score, remember that it is just a silly number.
The views and opinions expressed in this article are those of the author and do not necessarily represent those of the Doctus Project.