Rapid Responses to:
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a critical situation 
Rapid Responses: Rapid Responses published:
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Realism as a confounder
- Ian D Wacogne (11 October 2002)
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medicine and myth
- douglas salmon (11 October 2002)
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Medical school applications - not a critical situation
- Steven A Burr (12 October 2002)
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The legacy of a failing service
- Charles O. Lister (12 October 2002)
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Other opportunities
- ABDULLAH MA SHEHAB (13 October 2002)
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Encouraging potential medical students - ways forward
- Beryl A De Souza, Chris Dey, SHO Plastic Surgery ; Nigel Carver, Consultant Plastic Surgeon (16 October 2002)
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Medicine will become less popular
- Sushant Varma (17 October 2002)
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Medical students are overqualified to be GP's
- James Sherifi (18 October 2002)
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Re: Medical students are overqualified to be GP's
- Andrew S Thornton (18 October 2002)
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Don't drop the standards but broaden the range
- Cornelius L Katona, Philippa M. Katona, Margaux E. Katona (18 October 2002)
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Student progression, performance and variation in A level scores
- Wiji Arulampalam, Dr Robin Naylor and Dr Jeremy Smith (30 October 2002)
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Other considerations
- Samuel J Leinster (14 November 2002)
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McManus is right but for the wrong reasons
- Chris Bundy (17 January 2003)
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we need to be a desirable profession !
- Chris F.L. (19 January 2003)
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Ian D Wacogne, SpR Paediatrics Department of Paediatrics, North Staffs Hospital, Stoke on Trent, ST4 7LN
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I read Professor McManus' article with interest. But I wonder if there is the further confounding issue of better realism from the applicants. I know of some schools in the past - often fee paying - where good projected A level grades have resulted in significant pressure on pupils to apply to either medical school or law school. I would hope that this is now becoming a thing of the past in the UK. In the UK our teenagers have a better idea of what they want from life, and how they are going to set about getting it. This means they are able to make better informed decisions about important life issues such as applying to medical school. The remaining candidates would be those who were more likely to be accepted in the first case. The "Golden Age" of the early seventies might have been quite the reverse, with a whole cohort of candidates miserable at having to make the effort to enter a course that they didn't want in the first place - or, worse still, successful in gaining access and ending up miserable in their career. |
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douglas salmon, gp partner birmingham b20 3he
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That Britain needs more Doctors is a myth, a myth which arises, in part, from the need of the professions to protect existing structures and institutions from change. Much of medical care can be broken down into discrete tasks, tasks that do not require the training and costs associated with Doctors, or even Nurses. We do not need more Doctors, we need more clarity in thinking about processes and outcomes. The present expansion of Medical Schools is a disaster; an expensive solution that will lock many bright and capable people into unchallenging jobs and deprive the wider economy of a considerable source of talent and enterprise. |
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Steven A Burr, Research Scientist School of Biomedical Sciences, Queen's Medical Centre, University of Nottingham, NG7 2UH
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EDITOR - While the statistics on selection for medical school entry presented by McManus are very interesting, I must disagree with his conclusion that medical school applications are reaching a critical situation.1 I feel that McManus has neglected two critical factors that lead me to the opposite conclusion. Firstly, McManus clearly believes that A level qualifications are - and should be - the gold standard for entry.1 Secondly, that the projected expansion in medical school places in the near future will diminish the pool of potential applicants.1 Any research that links A level grades to performance at medical school, in final examinations, or success at postgraduate membership examinations, has an obvious flaw. Almost all medical school entrants have 3 ‘A’s at A level, and those that do not are either graduates or have some exceptional quality that gains them entry. How then can we make valid comparisons of performance between those with ‘A’ grades and those with lower grades at A level? I agree that “medical students and doctors can be neither too intelligent nor too well qualified”. 1 (Although it is a mute point that many who are highly intelligent will become disillusioned by the mundane activities that will take up much of their professional lives.) However, there are other qualifications that should rival A levels. In particular, life experiences which enable these students – as doctors – to relate to patients. For example, those students from poorer socio-economic backgrounds may well not have had the privileged education that permits 3 ‘A’s at A level, but they would probably better understand and represent the interests of a wider section of the community (especially those people in the community that need medical help most). It follows that some of the most important attributes such as communication skills are underrated and difficult to assess, but we should not be deterred from trying to measure what is important. We use A levels as entry criteria because of historical precedent and convenience. A levels ‘worked’ for most of those practicing in the profession today, but that does not mean that A levels are the best. Therefore widening the entry requirements to include students with lower A level grades might not be such a bad thing after all. Thankfully a large proportion of the projected expansion in medical school places will be for graduates, so A levels will count for nothing. In addition, many entrants will be non-science graduates, and we can support these students with all the science education they need at medical school. Widening entry in this way includes students that would otherwise have been excluded from the profession forever. This inclusion will widen the experience base of the profession as a whole, and surely that is a good thing. There is very large body of untapped graduates to select from. Over the next few years we will begin to see whether they really do become better doctors – based on clinical competence - than those with a privileged science schooling and 3 ‘A’s at A level. I for one will be surprised if graduate entry does not eventually replace A level entry. Very soon the evidence will start to speak for itself. 1 McManus IC. Medical school applications – a critical situation. BMJ 2002;325:786-7 (12 October.) |
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Charles O. Lister, Retired
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Professor McManus's article begs the question, why has there been this fall-off in medical school applications? As one who entered medical school in the 1950s, may I suggest an answer. The image of medicine as a career has been tarnished - particularly in the past 20 years or so. For many medical students, mdicine as a career was seen largely as a vocation , 50 years ago. State interference was relatively minimal, medicine as a career enjoyed an enviable reputation, whilst the financial prospects were reasonable for all and attractive to the more ambitious. In most parts of the UK a good house could be purchased for £5000 or less - about twice one's annual income within 5 years of qualification for most young doctors. Aspiring GPs could realistically contemplate the purchase of surgery premises. Today a similar house is likely to cost in excess of £250,000, 50 times as much as 40 years ago, but incomes have not risen at the same rate. Early retirement has become the norm for many, who have tired of overwork, the huge increase in paperwork and bureaucracy as well as an ever more litigous public. Interminable waiting lists in almost every field of medicine and the attendant publicity have labelled NHS medicine a very second class service. This picture of medicine has gradually filtered back to schools and parents, and a medical career is no longer seen in the same light as 50 years ago. It is small wonder that medical school applications have fallen, the more so as ther is no evidence of a brighter future in prospect. Only quite radical change is likely to restore a career in medicine to the staus it enjoyed 50 years ago. Reputations once tarnished are hard to regain, and our political masters show little sign of having found the will or the way to do it. |
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ABDULLAH MA SHEHAB, Lecturer and SpR in Medicine University of Birmingham B15
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It is unfair to compare current medical school training to 50 years before. I believe the prestige of medical school still and will remain high in people's life. Clearly the vast expansion in other non-medical specialties and their attractive future career have diverted those who would have applied to medical school. I also believe widening the criteria for medical school acceptances to include attitude, skills and knowledge in general not solely academic would help to re-attract candidates back to medicine. |
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Beryl A De Souza, Plastic Surgery Registrar Department of Plastic Surgery , St Bart's & The Royal London Hospital NHS Trust, Whitechapel, London, Chris Dey, SHO Plastic Surgery ; Nigel Carver, Consultant Plastic Surgeon
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As McManus's editorial indicates that there is going to be a growing problem with low numbers of science students and the massive university expansion in the United Kingdom (1). Another fact to bear in mind is that a recent BMA survey discovered that 80 per cent of the 2001/2002 medical student intake came from professional backgrounds (2). There is at present an active campaign to encourage applicants from non-traditional backgrounds. In our Plastic Surgical Department we feel we can offer college students, sixth formers and school students a "taster" of medical life by providing a three day or a five day timetable in our unit. The time table allows the student to shadow a doctor on the wards, to sit in an outpatient clinic and to help out practically in a dressing clinic. As plastic surgery is a broad specialty, we deal with children and both young and old adults. It gives the student an opportunity to experience medicine as it really is. We are in the process of setting up a school and college liasion project for our local community to encourage potential medical students. We think it important and feel it is something other departments in teaching hospitals can easily set up. The advantages to our department is that it will encourage teaching and mentoring skills in our juniors. References 1. McManus I. C. Medical school applications - a critical situation. BMJ 2002;325:786-787. 2. Access all areas. BMA News 7 Sep 2002. |
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Sushant Varma, on leave North Cheshire Hospitals NHS Trust WA7 2DA
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Dear Editor I regret to say that medicine will become less popular for sixth formers. With the abolition of grants and introduction of fees a medical student who has no parental income will be £35000 in debt on graduation. This can easily be worked out as the maximum loan for a level one student is about £4000 for a forty-week course. Thus the student accumulates £100 debt per week. As a result for a 262 week course the student will owe £26200 to the student loans company. When one adds the figures from the transition from pre-clinical to clinical, the elective, the final year and the 12 week gap between graduation and the first pay cheque it comes to £35000. It is a pity as it is obvious that doctors from poorer backgrounds interact better with patients from poorer backgrounds. A full explanation of this together with the implications for the profession will soon appear on www.undercovermedicine.com and is currently on (www.studentdebt.batcave.net) This can be emailed to anyone should they require it. Sushant Varma
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James Sherifi, independent consultant Euromedica, Histon, Doctors are overqualifiedCambridge CB4 9ZR
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Professor McManus'report perpetuates the myth that academic excellence at the age of 18 years translates into medical excellence at the age of 30 years, by which time most students will be set on a specific career path. Whilst I agree that this may be so for those pursuing an academic or research based discipline with a service commitment within a teaching hospital, for the vast majority of the remainder it can be a definite hindrance through raising expectations of an intellectually demanding future. For example, GPs constantly rail at the lack of scientific stimulation in daily general practice. Those who have entered the profession from less esoteric and perhaps less academically gifted backgrounds, if given the opportunity to do so, often make the best family doctors simply through their ability to empathise with their patients needs. Medical schools need to climb down from their lofty perches and recognise that they are training doctors for the community--not for their own ranks. |
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Andrew S Thornton, Full time GP Northlands Surgery, Calne SN11 0HH
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James, I quite agree. I achieved grade A in chemistry A level with a merit at S level in 1968. I have been a GP for the last 20 years, and I'm sure that my knowledge of chemistry has been the least essential part of my intellectual armoury. The medical profession is shooting itself in the foot by demanding that all doctors need an A or B at A level chemistry, by irrationally limiting the number of applicants and by excluding applicants with other qualifications that are more appropriate to many branches of medicine. |
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Cornelius L Katona, Professor of Psychiatry of the Elderly, Royal Free and University Medical School Dept. Psychiatry and Behavioural Sciences, Wolfson Building, 48 Riding House Street, London W1N 8AA, Philippa M. Katona, Margaux E. Katona
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McManus (1) suggests that the only ways to increase the pool of medical school applicants are to lower A-level requirements or to increase the pool of A-level chemistry candidates. We would argue that a better pathway to recruiting successful medical students is to appeal to a much larger pool both of able school pupils and of (mature, older) graduates and health professionals. Selection from this enlarged pool should be based on overall academic ability, which predicts both likelihood of ‘staying the course’ and ultimate success more powerfully that having science A-levels (2, 3) and assessment of the personal qualities required to be a good doctor (4). The real challenges are of affirmative action (making medicine seem like an attractive career to the many young people with the appropriate potential but not currently considering it) and of tailoring undergraduate curricula to meet the needs of students with the necessary scientific reasoning abilities but without the science knowledge base. Specific
elements of such a strategy would include
Competing interests
REFERENCES 1. McManus IC. Medical student applications – a critical situation. BMJ 2002; 325:786-7 2. Arulampalam W, Naylor RA, Smith JP. A hazard model of the probability of medical school dropout in the United Kingdom. Coventry: University of Warwick. www.warwick.ac.uk/fac/soc/Economics/research/twerps.html (accessed 14 Oct 2002) 3. Ferguson E, James D, Madeley L. Factors associated with success in medical school and in a medical career: systematic review of the literature. BMJ 2002;324:952-7 4. Hurwitz B, Vass A. What’s a good doctor, and how can you make one? BMJ 2002; 325:667-8 5. Pritchard L. Access all areas. BMA News 7 September 2002 |
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Wiji Arulampalam, Professor of Economics Department of Economics, University of Warwick, Coventry CV4 7AL, UK., Dr Robin Naylor and Dr Jeremy Smith
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Although statistical analysis of student progression and performance in general finds prior school attainment to be a significant determinant (1,2,3), there seems to be considerable doubts about the validity of this finding. This is generally based on the widely-held view that medical students who entered medical school on the basis of A-Level qualifications all (or virtually all) scored 30 points (4). If this were true, then it would indeed be impossible to infer any statistical relationship between A -level performance and later outcomes of medical students. However, crucially and importantly it turns out that there is a surprisingly large degree of variation in the A-level scores of medical students. Our own work (2,3) exploits administrative data on all UK medical students completing a medical degree in the UK between 1991 and 1997 and contains, amongst much else, precise and complete information on their pre- university qualifications. These data were obtained from the Universities' Statistical Record (USR), which was the central depository for individual student-level data collected from the administrative records of all UK universities - and their associated medical schools. This is an administrative data set on all students beginning a medical degree in the UK between 1980 and 1992 and the only one currently available for the full population of students in all the medical schools and enabling us to look at trends over time. Looking at the population of students in the English medical school, one finds that 94% of students in these medical schools entered with A/AS level qualifications as their main entry qualifications in 1985. There has been a very small decline overtime to 90% among the 1993 entrants. Of these students, only 28% had a full 30 point score (AAA) in 1985. This increased to a figure of 33% in 1993. The percentage achieving a score of 26 to 29 (22 to 25)decreased slightly from 44% (24%)in 1985 to 42% (20%)in 1993. This variation in the A/AS scores enables us to look at the effect of varying entry qualifications on dropout behaviour of the students. The USR dataset does not contain information on the criterion by which students with A-level scores significantly below 30 points, were accepted onto a medical school degree programme. However, if there were some compensating factors demonstrated by the student in, for example, an interview, which truly offset lower A-level performance, then these students would be expected to have the same dropout probability as a student with higher A-level scores. The fact that we observe a significant negative relationship between a students’ dropout probability and A-level score, once we have controlled for other observable personal and university characteristics, suggests that any compensating factors do not truly compensate for poor A-level performance. Therefore, appropriate support programs must, necessarily, accompany any policies aimed at widening participation by lowering entry qualifications. REFERENCES 1. McManus IC. Medical student applications – a critical situation. BMJ 2002; 325:786-7. 2. Arulampalam W, Naylor RA, Smith JP. A hazard model of the probability of medical school dropout in the United Kingdom, University of Warwick. www.warwick.ac.uk /Economics/research/twerps.html (accessed 14 Oct 2002). 3. Arulampalam W, Naylor RA, Smith JP. Factors affecting the probability of first-year medical student dropout in the UK: a logistic analysis for the entry cohorts of 1980-1992', (Robin A Naylor & Jeremy P Smith)(2002) www.warwick.ac.uk/Economics/arulampalam/research/medics_tscs.pdf 4. Burr SA. Medical school applications – not a critical situation. BMJ 2002 (12 October 2002). |
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Samuel J Leinster, Dean of School of Medicine, Health Policy and Practice University of East Anglia, Norwich NR4 7TJ
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Professor McManus may have been over-pessimistic in his assessment of the attractions of Medicine as a career. It is dangerous to predict trends based on limited data but the latest figures for applications to medical schools which had arrived with UCAS by the 15th October deadline show a 28.1% rise compared with the same point last year. This is the second year in which there has been an increase. The number of applications is 14,040 for a target of 7,135 places giving a ratio of 1.97 applicants for every place despite the rise in the number of places. Arulampalam et al also display an unwarranted pessimism. While it is clear from their data that a higher percentage of individuals with lower A level scores drop out, the number of drop outs even in this group is low and the data can be interpreted to show that the majority of individuals with lower scores succeed. Should we prevent them from entering the profession or should we be looking for better selection criteria that identify who is really suited to a career in medicine? I would wholeheartedly endorse the view of the Katonas that broadening the range of applicants does not mean lowering standards and provides a potential pool of applicants which might maintain the number of applications even if Professor McManus's prognostications prove to be correct. Competing interests: Sam Leinster is Dean of the School of Medicine, Health Policy and Practice at the University of East Anglia. This School is one of the 2 new Schools of Medicine to open this year and is actively looking at alternative selection criteria for medical students. |
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Chris Bundy, Head of Behavioural & Social Sciences University of Manchester, Medical SChool
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The editorial by McManus (BMJ 2002;325) and subsequent letters to the BMJ on the issue of medical school applications misses the point. The falling selection ratio may well be a blip at teh admissons stage but the year on year reports of stressed and disillusioned graduates underperforming or leaving the profession is more worrying. There seems to be a poor person-environment fit in medical education at present. The most able A level students are encouraged to apply for medicine because of the perceived status being a Medical Practitioner affords. Furthermore, those advising them to do so are working with an outmoded, almost characature of medicine that is better suited to the last century. Students who are good at chemistry and physics may well make good physicists and chemists but do not necessarily make good Medical Practitioners. Lowering the A level grade to allow more of the same kind of student in to medical education will do nothing to challenge the perception of what medicine is really about. We need students who have psychology A level, mature graduates from the arts and social sciences and health professionals who want to 'cross the floor'. We also need those teaching medical students in the formative years (largely biological scientists) to stop trying to make medical students mini-biological scientists. Of course there are different kinds of medicine but in general medical practice is a combination of biological and behavioural sciences, in equal proportions and students need this clear image at the A level stage in order to make the appropriate career choice. Only then will we attract those who have a more realistic view of what their training is preparing them for. Competing interests: Christine Bundy is a Health Psychologist teaching medical students. |
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Chris F.L., clin asst. winchester
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Dear sir, most of the proposed remedies for falling interest amongst the best and the brightest young people in a career in medicine are either nonsense or plain dangerous. contemplating to lower the entry level requirements will speed up the departure of the best and brightest and lead to long term desaster. what needs to end immedialtely is the disgusteing discrimination against kids from a middle class background. we will all suffer if the standards are lowered. what we need to have is a profession that is so attractive that it convinces the best and brightest young people of joining! yes, we want to be perceived as a scientific and brainy faculty were the elite studies - because this are the kind of people we want to have as doctors. what we must restore is the spirit that convinces this elite that it is worth their while to invest the effort required. the profession must make a stand - against the ridiculous social engineering experiments that are being conducted in the health service - the health service must be in the hands of the doctors. once this is visible the students will return all by themselves. Competing interests: None declared |
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