Mature entrants to medicineBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7109.2 (Published 13 September 1997) Cite this as: BMJ 1997;315:S2-7109
Alan Woodall and Mark Pickard discuss education and career choices for medics who aren't just straight from the sixth form
Almost 5% of British medical students are mature students, most of whom are graduates. These range from students entering immediately after a degree to those who have already pursued other careers. Compared with A level entrants, mature students in Britain have a lower dropout rate,1 better preclinical academic performance,2 and find it easier to communicate with patients in clinical years.3 According to Peter Richards, the former dean of St Mary's medical school, mature students “make a significant contribution to the stability and maturity of their immediate year and more widely in the medical school.”3 They often provide advice to younger students with problems who are reluctant to approach staff. In addition, some graduates with research backgrounds undertake research alongside their medical studies to the benefit of their school.
It is difficult to enter medicine as a mature student in Britain, as the majority of places are for A level entrants. Few applicants over the age of 30 are admitted, on the grounds that they have less time to serve the NHS. Similar arguments were once used to limit the entry of women. Some medical schools interview all mature entrants to assess their commitment, while offering A level entrants places solely from their UCAS form, and yet mature students often have a greater awareness of what constitutes a career in medicine.4 Today many people pursue multiple careers and use previous life experience to enhance their current profession. The current recruitment policy on mature students appears outdated and based on subjective cost-benefit “analysis.” Few attempts are made to address the needs of mature students in terms of medical education or careers advice: they are simply required to fit into a system designed for A level entrants. If the recruitment of mature students is to continue in the profession then the financial, educational, and vocational needs of these students should be examined.
Mature students rarely receive any financial support. Some medical schools have increased their fees for mature entrants recently, making it prohibitively expensive to enter for all except the wealthiest. The proposal in the Dearing Report5-to make students contribute £1000 each year in fees-will make mature entry yet more difficult. Mature students and their families already make considerable financial sacrifices; but if Dearing is implemented students undertaking a first degree followed by a medical degree would face debt of around £32 000. Mature students from poorer socioeconomic backgrounds will be dissuaded from entry, and the amounts involved would undoubtedly influence the career choice of the rest. Such decisions should be based on aptitude and personal interest rather than meeting debt repayments. One way to alleviate this financial stress is to reconsider the length of medical training required for mature entrants and develop a flexible medical curriculum.
British medical schools give few course exemptions to mature students regardless of their experience. Graduates with successful careers in dentistry, biomedical research, pharmacy, nursing, and related health professions often find themselves forced to attend a costly five year course despite having covered many areas of the curriculum previously.6 Medical education is moving towards a problem based learning, a skill many mature students have already acquired. More effective training could be provided for these students by accrediting prior experiental learning (APEL)7 to reduce course length.
Increasing entry options
Britain has a poor attitude towards recruitment of medical students other than direct school leavers compared with other nations. By 1997, 40% of medical school entrants in Australia will be graduates undertaking a 4 year course instead of the 6 year course for entrants direct from school.8,9 Only one British medical school formally offers a course reduction (by six months) for graduate entrants. A symposium on medical education held at St George's Medical School proposed a shortened course for graduate entrants to improve access to medicine.10
British medical schools should provide such alternatives instead of a single system of medical education applied to all comers. This would allow experienced students to qualify sooner and apply previously acquired skills rather than wasting them; it would also address the argument of their “reduced” NHS service. The recruitment crisis in academic medicine may be eased if medical schools encourage,through more progressive educational policies, graduate entrants with research backgrounds to continue research while at medical school. Equally, mature students are often keen to enter general practice, another area with recruitment problems. Creating course structures that accelerate mature student medical education could help to attract more people into these areas.
Staff in medical schools often forget that the personal responsibilities of mature students can exceed those of A level entrants. Mature students often have study and family commitments, and make many personal sacrifices to attend medical school. Living an extended student life itself creates many problems: loss of earnings and its associated lifestyle, strains on maintaining personal relationships, and enduring societal views of the eternal student are factors more likely to result in drop out than academic failure. In clinical years, mature students with children can find it difficult to be on residential placements. Medical schools could appoint advisers with responsibility for mature students to provide assistance in dealing with such problems. A tailored graduate course could overcome such handicaps and increase accessibility.
What careers do mature students choose?
Debt, family demands, spouses' careers, and length of postgraduate training all affect mature students' choices, often to a greater extent than younger graduates. Specialties such as general practice are attractive because of the short training period and early chance to settle into family life.11 If mature students surmount the hurdles placed before them at medical school, they can proceed rapidly up the career ladder in many specialties, particularly if they have backgrounds in research. As they progress up the career ladder mature graduates also face different challenges. Age may be a factor which discourages some GP partners from recruiting older graduates, possibly less willing to take on the burden of on call, although with recent changes in out of hours commitments this should be less of a problem. Recognition of these factors by staff providing careers advice would make things easier.
As the NHS moves towards a more primary care led service, increasing numbers of doctors will find themselves working in this field. Patient care will be improved if doctors are attracted, rather than coerced, into primary care provision. An early survey of graduate entrants showed that most of them had plans to work in general practice, teaching, or research.12 Analysis of the literature suggests that students who are older, married, female, or have a broad experience of life are particularly attracted to primary care,13 so admissions officers who wish to ensure adequate numbers of primary care doctors should “note the profile of students more likely to enter primary care described above, and select a wider range of entrants than the predominantly young with science backgrounds.”14
Little information is available on the choices mature students actually make, and yet it is recognised that tracking medical graduates according to their career preferences is valuable.15 Do mature students show uneven distribution in specialty choice compared with other students, and if so, why? Would increased recruitment of mature entrants into medicine alleviate the manpower shortages that are developing in less “glamorous” specialties such as general practice and provide a future supply of doctors happy to work in these fields? Such information is crucial if medical staffing targets are to be met effectively in the future.
We believe that it would benefit the medical profession to increase the proportion of mature students entering medical school. This will become more difficult unless flexible options are devised to provide medical education. Shortened graduate medical courses are one possibility. This would increase the percentage of mature entrants to the profession and reduce their financial debt and wasted time incurred by following a conventional five year medical course, particularly when it overlaps with other courses followed or prior work experience. Research is required to monitor clinical performance, career routes, and retention rates of doctors according to their age and experience to better plan future medical recruitment.
We thank Brian Jolly and Mary Lawson for advice during the preparation of this article.