BMJ  2007;335:1072 (24 November), doi:10.1136/bmj.39283.476725.BE

Feature

Head to head

Should all medical students be graduates first? Yes

Institute of Clinical Education, Medical School, University of Warwick, Coventry CV4 7AL

Most people enter medical college straight from school. Ed Peile argues that changing to a single system of graduate entry medical schools would provide the diverse multiskilled workforce needed for the future, but Charles George thinks that there is insufficient evidence to make this a criterion of entry

We must stop the headlong rush of pupils going straight from school into five year long medical courses. Bright teenagers are encouraged by teachers and parents to maximise their potential by aiming for the kudos and earning power of medicine. As consultants in their 20s, they will have little more breadth to their life experience than when they were studying during the week and spending their weekends meeting the unwritten requirements for school leavers to get into medical school—by working in care homes, hiking for the Duke of Edinburgh Gold Awards, and practising for grade VIII cello.

If we do what we have always done, we will always get a niche medical workforce. Selection is a different matter when students have had a chance to prove themselves independently, meeting the challenges of a university setting, and perhaps those of the workplace.

Diversity of the medical workforce has been hampered for too long by the "rhubarb forcing" techniques of secondary schools. Better grades at A levels are a predictor for medical student success, but our failure to nurture talent in deprived schools, coupled with the coaching power of private schools, has ensured that by restricting entry to medical school to those with better grades at A levels we are further disadvantaging some school leavers.¹

Graduate entry medicine can widen diversity

Graduate entry medicine in the United Kingdom was predicated on faster production of doctors and on broadening the field from which they are recruited.² Such courses should make efficient use of existing educational and healthcare capacity to produce more medical graduates and increase flexibility to respond to changing demand.² Graduate medical schools can be especially well placed to draw out the broader range of skills needed by future doctors.³ Students who were underdeveloped at school can get another chance to read medicine after achieving good grades in a first degree.⁴

American doctors progress from high school through university to medical school. Australian graduate entry education was directed towards achieving diversity and moving away from "a narrow secondary education with a bias towards quantitative subjects."⁵ In countries where the graduate entry degree is entirely self funded, medicine enables students to do a self fulfilling first degree in arts or sciences and then a vocational degree with sufficient earning potential to pay back debt after graduation. But graduate entry degrees can only deliver workforce diversity if selection strategies support this aim.⁶

Curriculum for graduate entry education

Around 10% of UK medical school places are on graduate entry courses. Such courses can undoubtedly deliver the education in four years and enable intelligent graduates to move from science or arts learning at university to the level of competence needed for foundation year work in medicine.

Attributes associated with such courses include maturity,⁶ which is related to ability to handle responsibility,^{7 8} and benefits accruing from curriculum design⁹—graduate entry medicine has been an incubator for curriculum development.¹⁰

Other attributes relate to previous university studies.¹¹ Graduates should be at an advantage, as experience helps learners to deal with abstraction. Graduate schemes can concentrate on developing professional study skills rather than acquiring tertiary study skills.⁷

Peter McCrorie, a pioneer of graduate entry teaching, pointed out that for graduate entry medicine to make a difference, courses must be designed specifically for graduates, and "build upon their strengths, motivation, and prior learning."⁷ A student explained, "Graduates have already learnt how to study and how to ration the other temptations of student life in order to keep up with their studies. This makes them better able to handle a self-directed learning approach."¹²

Cost benefits in meeting NHS workforce needs

Cost comparisons are difficult because of the present system of bursaries and charges for second degrees, and such factors as the need to repeat a year on a fast track course or the inclusion of intercalated degrees in conventional courses. A study from South Africa compared data on conventional course costs with projections for a graduate entry course and found similar total years of study, student costs, and costs to society for a four year graduate entry course and a six year undergraduate programme.¹³ The problem of fast track students who end up needing extra time is contentious, and should be determined on the basis of academic progress.

There are not sufficient published data on attrition rates across medical courses to complete the cost comparison, but graduates are probably more likely to complete the course. The age range of entrants to St George's Medical School was 21-44 years in 2003. Age at entry is one factor relevant to length of career service in the National Health Service. The prediction that graduates would make a more informed career choice¹² because of their wider personal experience at university and elsewhere remains unproved. US data indicate that older graduates practice more readily in underserved areas and are more likely to work in primary care. Data from Australia also suggest that graduate entry schemes better prepare doctors for the workplace in some important aspects of patient care and team working, as well as in self directed learning.¹⁴

Although there is little support among UK medical education policymakers for the two cycle Bologna model for medical programmes,¹⁵ a system of graduate only programmes would enable the reclassification of such programmes at masters level.

In conclusion, a change to a single system of graduate entry medical schools in the UK should attract mature learners with high levels of motivation, independence of outlook, and orientation towards hard work. Graduate entrants have the additional maturity and strengthened interpersonal skills necessary to provide the diverse multiskilled workforce needed for the future.

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Competing interests: None declared. EP is responsible for the graduate entry fast track course at Warwick Medical School.

References

1. McManus IC, Smithers E, Partridge P, Keeling A, Fleming PR. A levels and intelligence as predictors of medical careers in UK doctors: 20 year prospective study. BMJ 2003;327:139-42.[Abstract/Free Full Text]
2. Department of Health. Planning the medical workforce. London: Medical Workforce Standing Advisory Committee, 1997. www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=8017&Rendition=Web
3. Horton R. Why graduate medical schools make sense. Lancet 1998;351:826-8.[CrossRef][Web of Science][Medline]
4. Carter YH, Peile EB. Graduate entry medicine: high aspirations at birth. Clin Med 2007;7:143-7.[Web of Science][Medline]
5. Bandaranayake RC. Graduate medical schools in Australia. Med J Aust 1994;160:391-2.[Web of Science][Medline]
6. Powis D, Hamilton J, Gordon J. Are graduate entry programmes the answer to recruiting and selecting tomorrow's doctors? Med Educ 2004;38:1147-53.[CrossRef][Web of Science][Medline]
7. McCrorie P. Graduate students are more challenging, demanding, and questioning. BMJ 2002;325:676.[Free Full Text]
8. Carter YH, Peile EB. Graduate entry medicine: curriculum considerations. Clin Med 2007;7:253-6.[Web of Science][Medline]
9. Hayes K, Feather A, Hall A, Sedgwick P, Wannan G, Wessier-Smith A, et al. Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students? Med Educ 2004;38:1154-63.[CrossRef][Web of Science][Medline]
10. Searle J. Graduate entry medicine: what it is and what it isn't. Med Educ 2004;38:1130.[CrossRef][Web of Science][Medline]
11. Wilkinson T, Wells J, Bushnell JA. Are differences between graduates and undergraduates in a medical course due to age or prior degree? Med Educ 2004;38:1141-4.[CrossRef][Web of Science][Medline]
12. Rushforth B. Life in the fast lane: graduate entry to medicine. studentBMJ 2004;12:368-70.
13. Price M, Smuts B. How many years do students study before graduating in medicine? S Afr Med J 2002;92:609-10.[Web of Science][Medline]
14. Dean SJ, Barratt AL, Hendry GD, Lyon PM. Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. Med J Aust 2003;178:163-6.[Web of Science][Medline]
15. Reynolds T. The course left out in the cold. BMJ 2007;334:1246-8.[Free Full Text]

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