Ditch the Bell Curve for the Ballot: The Z Score Should Go for Good
Written by Ross Lomazov
Third year Melbourne University medical student Ross Lomazov argues that the Z score— an aggregate score from your academic record that essentially ranks Victorian students above or below the mean for their cohort— is an ineffective way to judge the competence of a medical intern and encourages a competitive and dispiriting environment in which to learn and grow. Instead, he argues, Victoria should adopt a ballot system to allocate internship placements, akin to other states in Australia.
The state of Victoria likes to boast of its progressive nature. Whether social policy, or Covid-19 cases (at least before the second wave), it aims to always be number one, beating out the other states. Sadly, this competitive mindset permeates the Garden State’s allocation of newly graduated doctors to hospitals via the archaic system known as the Z score.
This past week, communications from the Victorian universities indicated** that, in light of academic disruptions due to Covid-19, the Z score would not be used for the allocation of internships in 2022. However, there was no commitment to a permanent abolition in future years, nor a commitment to not adopting a similar system. So what’s the big deal?
For those fortunate (or unfortunate) enough not to be a Victorian medical student, a Z score is a standardised number allocated to final year students, to compare them against other Victorian medical graduates. The scores come from being graded on a bell curve during their medical degree, that indicates how far below or above the mean a student is. It is a reflection of academic prowess, more specifically of high marks obtained on educational assessments.
Forming a significant component of internship applications— although this year it was dropped to 40% in recognition of the disruptions due to the Coronavirus pandemic— Z scores play a significant role in the beginnings of a medical student’s career; think of it as the ATAR of medicine. The only problem is the Z score is useless. The rigor of medical school exams are such that passing them will ensure a medical student has the sufficient academic knowledge to become a safe junior doctor. There is no evidence to suggest a high Z score is an indication of a good doctor.
Furthermore, Z scores are not comparable between medical schools, due to the differences in how they are calculated, as well as the difficulty of the course and strength of the cohort. No consistency exists. Students and the learning environments they are in are all unique, and the utilisation of the Z score does not factor that into account. An average Z score of 3.5 at one university may actually be in the top quartile of another medical school.
Most concerning, is that the struggle to earn a high Z score contributes to student burnout, stress, and depression, a phenomenon that is sadly all too familiar to us. Students prioritise their academic wellbeing over their physical and mental one – who hasn’t heard of (or been) the medical student staying up until 3 in the morning, or running on 5 hours of sleep? Students cut out extracurriculars, neglect relationships and become isolated in the pursuit of marks. If our patients were engaging in such harmful behaviour, we would be rightfully concerned.
Studies have also found that student well-being is enhanced and objective academic performance is not adversely affected by a pass/fail evaluation system in medical school.
It is important to remember the age-old joke:
“What do you call the person who graduates at the bottom of their cohort?”
“Doctor.”
Victorians often like to think of themselves as the best state, but there are many lessons to be learnt from outside of our (at the time of writing) closed-off borders. In other states, students are not given a rank, and internship allocations are done via a preferential or random ballot system, depending on where you live.
For instance, the New South Wales (NSW) internship allocation problem is based on an algorithm to maximise student preferences. Students submit a list of preferences for their hospitals of choice, and are matched as inline with the choices as possible. Anecdotally, students report a high preference success rate.
Obviously, the Victorian health system is different to that of NSW. Our hospital system is more fragmented, but that does not mean we cannot take inspiration from successful systems of intern distribution from other states.
Most concerning, is that the struggle to earn a high Z score contributes to student burnout, stress, and depression, a phenomenon that is sadly all too familiar to us. - Ross Lomazov
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Medical students in other states have also commented that in addition to relieving some of the pressure and stress, assigning internship positions via a ballot without a competitive grading system, also encourages a greater sense of collegiality between the cohort, surely a desirable attribute to encourage through their medical journey.
There is a reason why all other states and territories don't use the Z score – it’s not a useful indicator of competency and it has an adverse impact on the health and well-being of students as well as the collaborative culture of the sector going up the medical vertical.
For those who are more suited to academic learning and achieve high marks— which are not always an indicator of how much work you put in, but are more often than not, how well you are suited to this style of learning— and in favour of the differentiation achieved by the Z score, I argue that if you believe that being a good intern is actually measurable and reflected via the Z score, such a system encourages an uneven distribution of the ‘so-called’ highest quality interns across the state.
Under the current system, ‘the best interns’ – that is to say, those with the highest Z scores – would be concentrated in the large legacy hospitals. Think Alfred, Royal Melbourne, St Vincent’s, and other institutions of great repute. The hospitals with the high levels of funding, the finest equipment, the most resources, and so on. If you agreed that these junior doctors are more superior to other junior doctors that would result in a disparity of health care quality. All patients, whether located at Northeast Health Wangaratta, Peninsula Health or Monash Health deserve to have access to the highest standard of doctors. A qualification that cannot be determined by their academic rank against their cohort.
The Z score has also further contributed to the stigmatisation of rural health. Who hasn’t heard a side comment about ‘ending up’ rural, a fate seemingly worse than not being employed at all? Due to students with high Z scores clustering in metropolitan hospitals, students who get allocated as interns in rural hospitals are seen to be poor academic performers. This ignores the wild idea that students may choose rural healthcare providers above metropolitan ones – a sensible decision, given the fact that this year’s highest scoring hospital in the AMA’s annual Hospital Health Check Survey was Northeast Health Wangaratta. The year before Peninsula Health took out the highest score. It also ignores the fact the experiences from a rural internship can enhance your chances of getting on a speciality training program further down the track. For example, some colleges such as RANZCOG, awards two points to applicants for completing a minimum of one-year full time as a non-bonded trainee in a rural area.
Even ignoring the massive inequities that arise from using the flawed system, the Victorian medical bureaucracy inhibits any potential effective utilisation of the Z score. Due to the priority groups of applicants, an Australian permanent resident or citizen graduating from a Victorian medical school with the lowest Z score is given a job before an interstate student, or an international student, which is preferenced even further down the line. What’s the point of having a ranking system if the ranks are overridden by arbitrary geographical red tape?
I have also heard the argument that if Z scores are abolished in medical school, how will you differentiate doctors in later years, for example, when applying for residencies or training programs. To that I ask when have you used your ATAR after year 12? We are simply judged using more timely and effective methods of assessment through a combination of exams, references, research, teaching etc.
Victorian universities, Medical Student Council of Victoria, medical school student societies and AMSA must strike while the iron is hot, and advocate for the complete abolition of the Z score, not only for the intern cohort of 2022, but for future interns to come.
Editor's note: The original wording confirmed has been changed to indicated** as the communications used to ascertain the ruling on the Z score were not deemed 'official' at the time of publication. The system which will replace the Z score is still undecided.
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