Selection of medical students
BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7347.1170 (Published 18 May 2002) Cite this as: BMJ 2002;324:1170
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Sir,
Many of your correspondents concur that academic performance prior to
medical school entry is a poor predictor of whether a student will make a
good doctor (or indeed complete training at all). Various suggestions have
been offered to try to improve the ability to predict at age 18 year how a
student will develop and progress over the next 5-6 years. The common
underlying assumption continues to be that a selection must be made at age
18 when candidates are likely to have had little or no experience of life
outside the school environment.
Many non-medical health professionals are now required to undetake
full-time undergraduate courses (nursing, biomedical sciences,
physiotherapy etc.). I propose that a common biomedical science core
curriculum be developed to be undertaken by applicants for training in
medicine or any of the related professions. After this introductory
curriculum, possibly one to two years in duration, students would apply
for a place on a medical or other specialist course. In carrying out
selection for specialist courses, the selectors would have the benefit of
one to two years knowledge of the candidate and students would have a much
clearer idea of the nature of the various possible careers (and it is
highly likely that at least some of them would change their plans).
The period of shared initial study would eventually lead to health
services at all levels being staffed by men and women who have chosen, and
been chosen for, their specialist training in a more solidly evidence-
based fashion. It may be hoped that this would lead to a higher proportion
of round pegs in round holes and square pegs in square holes. It would be
likely also to eventually lead to an improved working relationship between
colleagues - when all health professionals share a common grounding in
their education it is likely that this will enhance the level of mutual
respect. Given careful design of the introductory and specialist training
modules there is no reason why such an approach need result in a
significant lengthening of overall training.
It has been suggested to me in the past that a proportion of would-be
doctors would not enter any training program which does not guarantee them
a place in medical school. Candidates with such an attitude are arguably
not those to whom places should be offered. An academically strong, well-
motivated candidate, who has shown dedication and commitment throughout
the common course is likely to succeed in obtaining a place on whichever
specialist course they apply for. If such an approach to selection results
in a change in the proportions of entrants from various backgrounds into
various health professions, that change will be based on the performance
and commitment of candidates, not on social engineering interventions.
There is a widespread agreement that the present approach to
selection of medical students is failing in many respects. It is time to
consider truly radical changes in the system - the present situation
brings to mind the old cliche about "re-arranging deck chairs on the
Titanic". At a time when the Government is committed to an expansion in
the number of medical school places, it is more important than ever that
we select the right candidates for such training places.
Competing interests: No competing interests
Dear Sir
The editorial, Selection of Medical Students (Tutton & Price, BMJ
2002; 324:1170-1171) raises important issues, but some aspects of their
argument need challenging.
Firstly, can we select better medical students? "Surely we can",
they write, but there is no mention of how, or in what way, they believe
current medical students are deficient. They then suggest that whatever
is done in selection should "do no harm" to our medical education
programs? Surely selecting better medical students, that is those more
suitable for a career in medicine, would cause no undeserved upset to
medical education.
The authors revisit selection territory that is very well covered in
the literature: what qualities should be sought in prospective medical
students? Their observation that prior scholastic success has 'generally
served medical schools well' is probably more a reflection of the
inappropriateness of some medical school curricula than of potential
professional excellence. Perhaps Tutton & Price might agree that such
medical education programs should have harm done to them!
The authors are inappropriately dismissive of the aptitude tests
currently in use for medical student selection. Dr Tutton should be aware
of the added value of the Undergraduate Medicine and Health Sciences
Admissions Test (UMAT) in assessing personal qualities other than academic
achievement - the instrument is used in the medical school in which he is
co-chair of the admissions committee.
The authors appear to be unaware of the large volume of literature on
the interview and its use and usefulness in selecting medical students
(Morris JG. The value and role of the interview in the student admissions
process – a review. Medical Teacher 1999; 21: 473-481). Fourteen years
ago, the BMJ published a description of the predictive validity of a
structured interview for medical student selection (Powis DA, Neame RLB,
Bristow T, Murphy LB. The objective structured interview for medical
student selection. BMJ 1988; 296: 765-768). This publication played a
considerable part in almost all of the Australian medical schools adopting
such an interview for the purpose of medical student selection, usually in
conjunction with a battery of aptitude tests: either the Graduate
Australian Medical Schools Admissions Test or UMAT.
We question the basis of the statement: "even when the playing fields
are levelled, students from disadvantaged groups will not gain access in
the numbers desired…" This implies that the playing field has not been
levelled?
We agree with the last sentence in the editorial that “selection
instruments should be appropriately validated for the purpose before their
use”. Unfortunately the need for this step dissuades many medical schools
from altering their student selection method from the procedurally simple
reliance on academic scores.
David Powis, Assistant Dean, Teaching and Learning, Faculty of
Health,
and John Marley, Pro Vice Chancellor, Faculty of Health, University of
Newcastle, NSW 2308 Australia
(david.powis@newcastle.edu.au;
john.marley@newcastle.edu.au )
Brooke Murphy, Educational Consultant, 19 Gilbert Crescent, North
Ward, Townsville Queensland 4810 Australia
(brooke.murphy@bigpond.com )
Competing interests: No competing interests
Editor,
Tutton and Price in their editorial on the selection of medical
students1 raise several points that need to be clarified. They rightly
offer the opinion that scholastic achievement, aptitude tests and
selection interviews can all be faulted as means of selecting students for
a career in medicine, but seem to agree that general intelligence is a
good predictor of achievement, allied with emotional stability and social
integration.
The main thrust of the editorial, however, is to advocate affirmative
action to increase the intake of students from lower socio-economic
groups. The justification for this is to “redress inequities from the
past” and admit students who have “genuine, rather than apparent, merit”.
To further this end at Witwatersrand University in South Africa, where Dr
Price is the Dean, interviews have been abandoned because those in low
socio-economic groups scored badly in criteria of teamwork, leadership and
social involvement. It can only be assumed that prior scholastic
achievement is ignored also. Selection can then only be made on the
criteria of social class and perhaps some kind of personal statement.
This attitude is now prevalent in the UK, where the minister for
higher education, Margaret Hodge, has stated “nobody can think that middle
class children are brighter than poorer children” and the Higher Education
Funding Council for England is putting pressure (including financial) on
Universities to admit students on the basis of a number of “access
indicators” including the post code and the social group of their parents.
A discussion about whether different socio-economic groups in this
country have varying abilities is a very difficult and obviously
politically charged debate. For those of us that have put our children
through the state primary education system, seen the problems, and
discussed them with teachers, there is little doubt that children do vary
significantly in their inherent abilities.
So is it necessary or desirable to institute affirmative action? The
experience of many of my colleagues whose families came from the Indian
subcontinent and whose parents were classified in the lowest socio-
economic groups on arrival is pertinent. Without affirmative action they
have come through the system to become articulate, intelligent and
respected doctors. Affirmative action requires medical schools to
preferentially take students with lower academic achievement and
communication skills than they do at present. Do British medical schools
have the resources to turn these students into well-rounded and competent
doctors? The experience in the United States is that “many of the
preferentially admitted students from minority groups could not pass their
licensing examinations, despite greater resources being directed towards
helping them than other students”3.
This is social engineering. Can and should medical schools be
expected to reverse the deficiencies of the school and social system? We
have been harangued by the politicians about the problems of supposedly
inadequate doctors. How can medical schools produce good doctors if
political dogma restricts their freedom to select those they feel are most
able?
David Howes
Consultant Anaesthetist
Royal Orthopaedic Hospital,
Birmingham B31 2AP
DMHowes@Blueyonder.co.uk
1 Tutton P, Price M. Selection of medical students. BMJ 2002;324:1170
-1 (18 May)
2 HEFCE website. www.hefce.ac.uk
3 Charatan F. Minorities get preferential admission to US medical
schools. BMJ 2001;322:1563 (30 June)
Competing interests: No competing interests
We read with interest the editorial on the Selection of Medical
students.1
We believe that the best way to help those from disadvantaged
backgrounds who wish to apply for Medicine is to adopt a scheme which will
bring them up to a level enabling them to compete with other applicants on
a level playing field. To this end, and with Government backing, we have
developed Sheffield's Outreach and Access to Medicine Scheme (SOAMS) which
is an extension of the University of Sheffield's very successful Outreach
and Compact Schemes which have both been running for nearly 12 years. For
entry into the scheme students must be in the first generation of their
family to go to University, come from a low income family, and have
personal or family circumstances which may affect their aspirations,
expectations and potential academic achievements. Students are targeted
at Year 9 (Phase 1, 13/14 to 16 years) and the aim is to involve 100
students per year at that stage. Information is provided for students,
parents and teachers and a series of lectures provided to explain what is
involved in studying Medicine. Provided students successfully complete
Phase 1, they proceed to Phase 2 having been given advice on suitable A
Levels. In Phase 2 we provide community service projects, work
experience, medical conferences, and a residential summer school. In
addition we provide advice on how to apply to Medical School via UCAS and
practice for interviews. We hope that by the end of Phase 2 to have
produced around 25 suitable candidates out of the original 100. Those who
do not make the grade will be advised and fully supported for other career
options. Those who do make the grade will be formally interviewed in the
usual way. Financial support is provided during the course.
We believe that a scheme such as SOAMS is the correct way
forward. As suggested by Tutton and Price, we believe our progression
scheme is sensitive and welcoming and is designed to bring out the best in
those from under represented groups who would have never seriously
considered Medicine as an option.
1 Tutton P Price M. Selection of Medical Students. BMJ.
2002; 324: 1170-1
Andrew T Raftery
Sub Dean for Admissions
Sheffield Medical School,
Sheffield
S10 2RX
Email address: andrew.raftery@sth.nhs.uk
Allan Johnson
Head of Outreach and Access
University of Sheffield
Recruitment and Admissions Office,
Sheffield
S3 7QX
Vicky Hargest
SOAMS Education Liaison Officer
University of Sheffield
Recruitment and Admissions Office,
Sheffield
S3 7QX
Competing interests: No competing interests
Ever since the country became independent state run and aided medical
schools adopted the policy of affirmative action and selected students
based on their socially and economically disadvantaged class. Broadly
speaking this resulted in two classes of students. One, those who got
admission entirely based on merit which also included those from the
disadvantaged class and second, those who were admitted based on their
[backwardness]. Even in this group the most merited were selected. This
system prevails more or less even to this day.
This has resulted in certain serious problems. These disadvantaged
sections of the populace who thus gained admission to professional
colleges and did well in life have retained their backward tag and passed
on the advantages of this ‘reservation’ to their progeny there by denying
the positions to other more disadvantaged in the same back ward
communities. This class has come to be called as creamy layer. And this
creamy layer is India’s super Brahmins today and are directly responsible
for the failure of the policy of affirmative action in our country. This
can be remedied only by denying the privileges to the children of those
who have benefited and give it to those who have not got it. This way one
can thin the cream and help lot more of the disadvantaged.
The rich have taken recourse to the backdoor entry through the privately
funded professional institutions which has resulted in the change of whole
range of attitudes of the professionals towards the sick and suffering
and we are seeing the effects of these lopsided policies in the poor state
of nations health.
Competing interests: No competing interests
Drs Tutton and Price deserve wholehearted endorsement for their
proposals to make medical school selection more transparent and equitable.
One factor they have understated, however, is the extent to which medical
schools differ in their selection criteria, as we demonstrated seven years
ago.1 It will take many more years for medical schools to implement the
admirably scientific selection procedures proposed in this editorial. In
the meantime, can medical schools at least attempt the easier task of
publishing grouped data on the candidates they have selected, including
the particular applicant variables each school considers to be most
important?
Reference List
1. Fazel SB,.Hughes MW. Sixth formers gamble over medical school
choices (letter). BMJ 1995;310:1531.
Competing interests: No competing interests
Dear Editor, Having taught and examined medical students for 20 years
and as a former Clinical Associate Professor of the University of
Queensland, I remain skeptical about the new admission system in our
medical school.
I have until recently, taught students even in my private rooms and
observed the following; a strong science bias in students, an appalling
lack of general knowledge, the lack of a fluency in second language
despite a highly multi-cultural society, the total absence of students of
Aboriginal background, the selection of students who have had the
financial wherewithall to take the gamble of doing a primary (usually
science-related) degree in the hope of eventually running the gauntlet of
the GAMSAT, the paucity of students with a humanities background. Doctors
sons and daughters are still well represented in the course as well as
students from top private schools(personal observations only). Many
doctors send their children to southern universities where they can enter
medicine directly from school. Such entry always favours the wealthy and
those with high TE scores, usually maths and science based. To
disadvantage humanities students further,languages carry les weight in the
TE score that maths or science subjects. Keats or Checkov would not have
been accepted into medicine in Australia.
When I entered Medicine at UQ in 1970 we had no interview and went
directly from school and there were no university fees. The entry level
was much lower and many students came from relatively poor families
succeeded, and made excellent doctors many of whom are still practising in
the country. The desire to be a doctor and serve the community as well as
vocational aptitude were common themes. Today many would not have been
accepted even for some science courses because of low Tertiary Entrance
scores. Some of my student friends dropped out of the medical course
because of social immaturity.
The present ridiculously high Tertiary Entrance TE score required at
university courses means that highly intelligent people get into medicine
and end up as disillusioned general practitioners bored to death in a
subusrban shopping mall in a 9-5 practice.
The failure of our educational system to encourage a high level of
fluency in another language sets Australia and probably the other
Anglophoe countries as cultural and liguistic deserts unlike our European
counterparts where most educated professional can speak at least one or
two other languages other than their mother tongue.This also leads to a
myopic view of medicine, science and culture and a linguistic angolphonic
arrogance of which we Anglo's often (undeservedly) accuse the French.
The current trend in medical litigation world-wide I believe is due
in part to our neglect of the basic Art of Medicine from a socio-cultural
point of view, our inability to recognise that much of medicine is
humanities-based rather than science-based and our selection and education
sadly reflects this.
There are now courses in Brisbane on how to talk nicely to patients!
I have experienced the product of medical education; the patronising
English surgeon and the ante-deluvian class system of the English, both
good examples of the gulf between the doctors at the top of the food chain
and ptaients being the bottom dwellers.However the bottom dwellers have
risen up in Australia and are eating the doctors legally at least (1789?).
it is not surprising that the highest litigation areas in medicine is not
only where procedures are done but where proceduralist abound. I believe
this may be just as much a product of the interpersonal skills (or lack)
of those testerone-dominant individuals selected for highly science
orientated surgical traineeships (eg orthopedics, neurosugery etc). Some
are almost autistic when it comes to communications even with thier peers
let alone patients.
The teachers of the students and the people involved in universities
here are also science orientated mostly, many living in the cloistered
vales of Academia,most mono-lingual anglosaxons who have never seen an
aboriginal settlement, worked in a third world country or who have any
interest in the arts.This is the sheltered work-shop, bunker mentality of
embattled departments, the publish or perish ethos, coupled with a total
lack of feed-back or interaction with the growing number of busy unpaid
clinicians who teach in a vacuum in their own time at outpatients, in the
wards and in their own private rooms, to keep the whole degenerating
system running while the bean counters think of another way to cut costs
(Ref 1).
It is no wonder the selection and training of medical students has a
long way to go. I believe the desired end product should be a
compassionate, vocationally dedicated, culturally literate individual who
has a healthy synicism for scientific dogma and who recognises that
medicine will always be more and art than a science. I can only applaud
journals such as your Medical Humanities.If only the message could trickle
through before it is too late for our disillusioned profession. What
proportion of Australian medical academics are bi- or tri-lingual, write
literature or poetry or even care about such trifles(2,3,4,5).
Yours sincerely,
Dr Roger KA Allen MBBS (Hons 1stQld)FRACP,FCCP,Ph.D(Melb)
Sometime Clinical Assoc Prof.
References
1. Allen RKA. Ars gratia artis and the morganatic marriage: 'Let us not to
the marriage of true minds...' Intern Med J 2001;31:554-555.
2.Allen RKA. Intensive care bed. Studio 1996;62:25
3. Allen RKA. Poetry and medicine:healing for the healer. A call for
a literary supplement. Intern Med J 2001;31:426-427
4.Allen RKA. UN Military Hospital, Dili,East Timor. Dog Day. A poem
about a day in the life of a military physician. Aust Mil Med 2001;10:15-
19
5.Allen RKA. Au-delà de l'ordinaire. Poésie et Médicine:guérison pour
le guérisseur.Le besoin d'un supplément littéraire. Info Respiration
2002;49 sous presse.
Competing interests: No competing interests
Re: Selection of medical students
To the Editor:
An often ignored and negative dynamic in medical student selection relates to the high rates of success among Asian applicants. The consensus appears to be that barriers are being unfairly raised to stem the tide of Asian student admission into prestigious universities. However measurable selection criteria such as exceptional high school grades, test scores and academic honors do not necessarily predict future college academic performance, course completion, successful and importantly satisfying work lives. These parameters cannot gauge how well-suited an applicant is for their intended profession. Gaining entry into a sought after college place is only the beginning of a long journey.
As a physician, I know patients want to be cared for by a competent and knowledgeable professional. However they place equal if not greater value on empathy, altruism and excellent communication. None of these qualities correspond to a grade or test score. Although susceptible to interviewer bias, personal judgement and leanings, the medical school interview is indispensable in gaining insight into an applicant’s maturity and suitability for a life of caring for the sick. These desirable human qualities cannot be exclusively distilled into a set of standardized scores. Perhaps non-Asian applicants with lower test scores are being admitted on the basis of better performance at interviews that assess their life perspective. This possibility dilutes the deafening argument that Asian college applicants are being systematically or deliberately disadvantaged. These could underlie informed debate on non-scored criteria used in medical school admissions.
Competing interests: No competing interests