Immerse candidates in a quick series of 10 or so ethical and clinical scenarios and rate how they do. An emerging trend in medical school admissions, the multiple mini-interview (MMI) is just beginning to take hold in osteopathic medical education, with a handful of DO schools using or testing the protocol.
Developed in 2001 by McMaster University’s school of medicine in Hamilton, Ontario, the MMI has been embraced throughout Canada and by a growing number of U.S. medical colleges. In the United States, the emphasis on improving health care quality by training compassionate, patient-centered physicians is driving interest in this assessment tool.
The traditional interview process, in which applicants spend a lot of time with a small number of interviewers, does not accurately predict medical school performance, according to McMaster’s Kien Trinh, MD, chairman of admissions. The MMI format is more scientific and fairer to candidates, he says, noting that many studies attest to this.
“Over the past several years, we’ve been looking at predictability, to see whether the MMI correlates with subsequent test performance of Canadian medical students,” Dr. Trinh says.
“We’ve found that the MMI correlates quite highly with the objective structural clinical examinations that are used in medical schools. The applicants who did well on the MMI also have performed well on Canadian medical board examinations.”
The MMI does not assess premeds’ cognitive abilities, as does the Medical College Admission Test, but rather such traits as communication skills, empathy, honesty and conscientiousness. Although traditional interviews also aim to gauge applicants’ interpersonal skills, they don’t do so in an evidence-based way, Dr. Trinh contends.
For example, a poor first impression in a traditional interview can ruin the entire interaction. During an MMI sequence, in contrast, a candidate can flounder in one scenario but recover by excelling in others. The MMI format also helps prevent the halo effect, in which a great first impression causes an applicant to be assessed too highly as he or she responds to subsequent questions.
The MMI process is much more objective and meaningful than traditional interviews, agrees Cory Banaschak, OMS II, who attends the Marian University College of Osteopathic Medicine (MU-COM) in Indianapolis, which has been using the MMI interview format since the school opened in 2013.
“I was on my toes for probably two hours, being interviewed by multiple faculty members,” Banaschak recalls. “The different scenarios you are placed in make it difficult to spout off a preconceived list of things you want to say about yourself. Instead, the scenarios give the interviewers more of what they want to know about the student.”
Although that description might give some prospective med students the willies, Banaschak says he preferred the MMI format over the traditional interviews he had at other medical schools.
“The scenarios help provide more of a conversation rather than the awkward question-and-short answer situations I found myself in during other interviews,” he explains. “And having multiple interviewers is another aspect of the MMI that I preferred. Each faculty member’s impression is considered. I found the MMI to be much less subjective than a single interviewer, who may not consider a student after one wrong answer.”
Another MU-COM student, Heather Chouteau, OMS II, found the mini-interviews enjoyable. “Prior to my interviewing at Marian, I had experienced a panel interview as well as longer one-on-one interviews. Those interviews were intimidating and felt very formal,” she says. “At Marian, it was refreshing to be presented with multiple opportunities to share my interests, my values and my experiences in a unique format. And I felt more at ease knowing that if one station didn’t go as well as I had hoped, I still had several others I could excel at.”
The MMI is used at some of the best MD schools in the United States, points out Bryan Moody, director of enrollment at MU-COM. “The reason we use the MMI at Marian is that the traditional interview format is guided by the interviewer, who may ask questions that are important only to that interviewer,” he explains. “It doesn’t do a very good job of predicting the likelihood of that candidate being successful as a medical student and a physician.”
MU-COM uses the MMI to assess many noncognitive skills. “In a physician, you want someone who is going to make good ethical decisions that are sound, taking in vast amounts of information and categorizing it in a way that makes sense to a patient who doesn’t have all of that highly scientific knowledge,” Moody says. “You want someone who can communicate with you, who can understand and listen and answer questions and speak with you in a way that you can relate to and feel comfortable with.
“Above all, you want someone who has empathy. Patients come to physicians at their lowest possible moment in life, when they are sick and tired and scared and confused and hurt. And they just want answers.”
Testing the multiple mini-interview
The Michigan State University College of Osteopathic Medicine (MSUCOM) in East Lansing will pilot the MMI format in October, when the school interviews candidates for fall 2015 admission.
“The MMI has a lot more research behind it regarding its effectiveness than does the traditional interview,” says Katherine Ruger, MSUCOM’s director of admissions.
The multiple, module-based situations have been shown to provide a more complete picture of a candidate’s character, Ruger notes.
“By placing the applicant in a succession of scenarios, we’ll be able to test things like a student’s resilience, emotional intelligence and a team approach that we can’t necessarily appropriately test in the traditional interview process,” she says.
At most schools that use the MMI, each scenario takes place in a different room. The applicant has two minutes to read a card on the door describing the scenario, then enters the room, plunging immediately into the situation. Sometimes the prospective med student will engage in a one-on-one discussion with the interviewer and sometimes a role-playing exercise with a standardized patient. Typically, the scenarios last five to eight minutes.
The intent is not to assess the applicant’s clinical knowledge but rather his or her resourcefulness, judgment, integrity, and ability to think quickly and act calmly under pressure, according to Dr. Trinh. Interviewers rate candidates relative to other applicants being interviewed, taking into account communication skills, the strength of the arguments displayed and suitability for the medical profession.
According to McMaster’s manual for MMI interviewers, one scenario might involve responding to the actions of a colleague who recommends homeopathic remedies to his patients, knowing that they are not evidence-based but believing that his patients might find them reassuring for nonspecific symptoms, such as fatigue and muscle aches. The manual discusses many different ethical issues arising from this scenario and potential responses. For example, the applicant could tactfully take the physician to task for acting paternalistically, underestimating the intelligence of his patients.
The scenarios aren’t necessarily related to health care. A Canadian premed blog has posted dozens of sample MMI questions divided into three categories: ethical decision-making, critical thinking, and problem solving and conflict management. The first ethical question involves counseling one’s best friend, who has just admitted to killing a pedestrian in a drunk-driving hit-and-run.
“The MMI situations that Marian uses aren’t related to health care,” Moody notes. “We don’t want someone who has a family member who is a physician or someone who has worked in health care to have a leg up on other applicants.
“So we use regular, everyday scenarios that you should be able to identify with just by being alive.”
Dr. Trinh maintains that the MMI is most reliable when eight to 12 assessment stations are used in evaluating applicants. Nevertheless, many medical schools adapt the tool to their own purposes.
A college can use multiple mini-interviews as a supplemental screening tool, as is the case at the Western University of Health Sciences College of Osteopathic Medicine of the Pacific (WesternU/COMP) in Pomona, Calif.
“We elected to keep the traditional interview because oftentimes candidates have a story they would like to tell, and we felt that they deserve an opportunity to tell it,” says Kenneth Lay, Western University’s standardized patient educator. “But we didn’t want to put all of our eggs in one basket.” In addition to the traditional interview, WesternU/COMP has prospective students take part in two MMI scenarios with standardized patients.
The candidates are rated by the standardized patients on a scale of 1 to 5 based largely on the six traits that constitute the National Board of Osteopathic Medical Examiner’s humanistic domain: listening skills, respectfulness, empathy, professionalism, ability to elicit information and ability to provide information.
In its fourth year of using the MMI, WesternU/COMP has weeded out many potentially problematic students, Lay says. “As in a public elementary school, just two or three disruptive students who don’t fit in can wreak havoc on a class,” he observes.
Approximately 12% of the hundreds of candidates interviewed each year at WesternU/COMP receive a “Do not recommend” rating after their MMI performance.
Lay remembers a call he received last year from the admissions committee, which was meeting about a particular student with stratospheric MCAT scores and other impressive credentials. “Because he got a ‘Do not recommend’ from us, I was asked to provide additional details from the MMI,” Lay says. “As a result, that candidate was not admitted into our college.”
How to prepare
The Internet abounds with information on how to prepare for traditional med school interviews. It is too easy nowadays to research what medical schools are looking for in candidates and rehearse as if one were about to debut on Broadway. But beneath the polished exteriors of some applicants lie contraindications of their suitability for medical school and patient care. This partly explains why multiple mini interviews have gained traction, Dr. Trinh says.
Premeds can’t really prepare for the MMI process by practicing answers to typical interview questions. That’s a plus, according to MU-COM’s Chouteau.
“The great thing about the MMI is that much of the preparation is informal and something you are doing daily,” she says. “To prepare, just strike up conversations with people—professors, strangers at Starbucks, whatever works,” she says. “Read and watch the news on TV to stay up-to-date on current events. And do some research online for sample MMI questions and talk them through.”
Chouteau offers these additional tips for applicants:
“My strategy when presented with a situation or dilemma was to take a stance, support my stance, but then also offer up alternatives or attempt to empathize with other sides of an argument,” she explains. “I think it’s important to show that you can analyze multiple sides of an argument but still support your decision-making. As physicians, we will be charged with this task daily.
“By doing this, I was able to anticipate many of the interviewers’ follow-up questions, which left us with more time to chat and get to know each other within the time allotted.”
The multiple mini-interview process favors well-rounded students, Chouteau points out. “The MMI gives applicants the opportunity to showcase their empathy, teamwork, ethical background, value and maturity—without reference to specific details of their application,” she says.
But that advantage can also be a weakness, according to Chouteau. “I do think it is important to be able to discuss your academic record and extracurricular activities,” she says. “Fortunately, Marian recognizes this and includes a 20-minute station where students can showcase their academic and extracurricular strengths as well.”