Say It Without Saying It

Back when I took the MCAT, one of the sections of the exam was a “writing sample.” I have heard that this section subsequently ceased to be, but checking their website it seems that reports of its death may have been exaggerated. Not too surprising; it has become rather trendy to take massive, academic-milestone tests and routinely overhaul them so examinees will be as clueless and anxious as possible.

Around my MCAT time, the writing sample was known to be the least important aspect of the test. By “least important,” I mean that it only had the potential to doom your medical-school applications should you perform poorly. Doing well would not help you score interviews. Typically, the examinee would be presented with some sort of debatable position-statement, such as “Healthcare is a basic human right.” Instructions were to first write in agreement with the statement, next in disagreement, and then to offer some sort of reconciliation of one’s preceding scribblings.

Having gone through twelve grades of education and nearly three years of college, I had done more than a little bit of reading and writing, and this flew in the face of much of what I had been taught. An essay, I had learned, was typically a brief chance to convey a point of view held by the author. Arguing both sides of an issue and, then, concluding that neither won seemed…well, dumb. I, therefore, had mixed feelings when I wound up scoring highly on my writing sample.

I’m not sure that it was the MCAT-writers’ intent, but I have since found that the ability to verbosely entertain opposing sides of an issue and ultimately come up with no conclusion whatsoever is, in fact, quite useful in our healthcare system. This has not occurred without the help of the medical-malpractice industry, an ever-growing healthcare bureaucracy, and now the Quality Assurance (QA) machine they helped bring about.

For instance, suppose I receive a generic belly-pain CT to interpret, and there is nothing really abnormal about it. If all I care about is doing a good job, properly diagnosing the patient and communicating my findings effectively to the clinician and the patient’s record, the report I generate will be a few sentences long. Straightforward, answering the clinical question (assuming one was asked).

But that ideal world is not what the MCAT was prepping me for. Instead, I am best served by arguing both sides of every conceivable issue. A 1 mm pulmonary nodule in a preteen? Could be a granuloma, but could be a tumor of some kind. An area of fluid where the patient had surgery a few days before? Probably a seroma or resolving hematoma, but cannot exclude abscess. If I dare not to mention every imaginable sort of pathology, no matter how extremely unlikely, I’m just begging to get zinged with a peer-review demerit.

Of course, I would like to say what I really think and be helpful to the referring docs…but there’s no mechanism to incentivize such behavior. Our medical malpractice and peer-review systems are focused on playing “gotcha!” with us. If every single ER doctor and surgeon in my hospital held the opinion, hands-down, that my reports were routinely the most helpful they saw-thanks to a lack of hedging, doubletalk, and vagueness-but my QA stats were slightly worse than the rest of my department, guess what I’d hear from my superiors? Dollars to donuts, it wouldn’t be complimentary.

So, ultimately, I suppose I have to be grateful to the MCAT folks who developed the “writing sample” section which helped ensure I had what it takes to be a successful radiologist now. Or maybe I’m still resentful and carrying a grudge. I could argue both sides of the issue.