Year : 2018 | Volume
: 6 | Issue : 1 | Page : 147--151
Student selection for medicine: Still a “Thorny” issue
Marita Lynagh1, Graeme Horton1, Balakrishnan (Kichu) Nair1, Marjorie Walker1, Brian Kelly1, David Powis2,
1 School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW 2308, Australia
2 School of Psychology, The University of Newcastle, Callaghan, NSW 2308, Australia
Dr. Marita Lynagh
School of Medicine and Public Health, The University of Newcastle, University Drive, Callaghan, NSW 2308
Despite the growth in literature and concerted efforts on many fronts to improve the selection process for medicine, there remain a number of contentious issues. Medical schools worldwide need to consider the often disparate priorities of multiple stakeholders when selecting students. They seek to recruit students who are likely not only to succeed in their program but also need to meet their own and often their government's agenda to meet equity and workforce targets. Academic performance prior to medical school predicts academic success at medical schools and beyond, but if weighed too heavily will restrict access to disadvantaged groups. This article outlines the various components of medical student selection and describes the different contexts in which they are used. We aim for this to be an informative article for reference as medical school selection committees worldwide constantly evaluate whether admissions processes are fulfilling their criteria. Discussion among medical schools must surely improve efficiency and cross-cultural understanding in the global medical education environment to provide suitable doctors needed for the 21st century.
|How to cite this article:|
Lynagh M, Horton G, Nair B, Walker M, Kelly B, Powis D. Student selection for medicine: Still a “Thorny” issue.Arch Med Health Sci 2018;6:147-151
|How to cite this URL:|
Lynagh M, Horton G, Nair B, Walker M, Kelly B, Powis D. Student selection for medicine: Still a “Thorny” issue. Arch Med Health Sci [serial online] 2018 [cited 2023 Feb 6 ];6:147-151
Available from: https://www.amhsjournal.org/text.asp?2018/6/1/147/234105
The establishment and review of selection criteria for entrance to medical schools are both contentious and fiercely debated. Each of the following stakeholders has vested and differing interests: candidates – due to the high number of academically qualified applicants and limited number of places; universities – to attract capable students compatible with the values of the institution; governments – to ensure that their medical workforce is well-trained and reflective of national agendas such as equity targets and balance of workforce; and for the community – doctors who will understand the local health needs.
There is much to be gained from medical school selection committees sharing experience and strategies about how best to select their ideal students. Yet, there is no “one-size fits all” solution. Medical schools worldwide operate in vastly different contexts regarding educational and health-care systems. Even within countries, medical schools will have different admission criteria, some admitting students directly from high school, while others admit only postgraduate students or a mix of both. Some will place greater emphasis on academic performance, while others seek to select those with desirable personal qualities. Some seek to recruit only students who are prepared to work in particular communities. Some medical schools are private institutions which receive limited or no government funding and require the students to pay much of the cost of their tuition.
Deciding What Makes a Good Medical Student
A number of organizations have made progress in articulating desirable qualities of medical students and exploring how best to measure these attributes., The Australian Medical Education study in 2007 identified independence, motivation, confidence, compassion, and insight as some of the key attributes required for success in medical school. The Australian Medical Association also lists a core set of values or attributes in their position statement on medical professionalism. Competencies for students entering medical school published by a Working Group of the Association of American Colleges included the following: ethical responsibility to self and others, reliability and dependability, service orientation, social skills, capacity for improvement, resilience and adaptability, cultural competence, oral communication, and teamwork. Universities in the UK are now guided in their admissions by the Medical Schools Council consensus statement on core attributes of a good doctor.
In most countries, however, there is no national agreement on what core attributes are required in students selected for entry into medicine. Individual medical schools currently are, and arguably should remain, free to select students on the basis of distinct desirable qualities and outcomes. Nevertheless, where the level of public contribution to the costs of medical education and hence investment in the student (and doctor of the future) is high, accountability exists to the broader community to graduate doctors with skills and attributes aligned to community needs. Similarly, many would argue that there is a moral responsibility of universities to ensure the population of students and graduates is reflective of the needs of the population, – i.e., through affirmative action to promote pathways into medicine for underserved populations. While having a set of common attributes enables medical programs to share strategies and potentially simplify or streamline admission processes for both medical schools and applicants alike, different medical programs may need to produce different types of doctors. In addition, medical schools must consider the compatibility of student personal qualities with differing types of curricula and teaching methods.
Medical degrees attract many more applicants for each available place. Reasons include the wide variety of fulfilling careers available to medical graduates, perceived prestige of a medical career, and in some instance a relatively assured high income upon graduation. In our own experience, approximately 4–5 eligible candidates are interviewed per available place. Universities must, therefore, pick and choose those students most likely to succeed in the program and meet institutional goals which can include equity targets. Some universities seek to increase funding by enrolling fee-paying local and/or international students, while others try to build their reputations by fostering elite researchers. Governments may further seek to achieve health-care workforce targets by influencing admission strategies. For example, Australian medical schools must have 30% of domestic places filled by students from rural backgrounds to receive government rural workforce initiative funding. A number of medical schools in Canada, Europe, South Africa, and Australia  focus on promoting rural experience and rural medicine to “close” the gap between urban and rural practice access for the community.
A Multifaceted Approach
Most medical schools utilize a range of selection tools including previous and/or current academic performance measures, cognitive skills tests, and semi-structured or multiple mini interviews (MMIs) in an attempt to assess a range of cognitive and non-cognitive skills or qualities considered important for a future doctor. These different components of the selection process can be used to develop an aggregate score, or they can be used as sequential steps with individual thresholds that “filter” candidates at each step of the process. We will separately discuss different components of selection strategies which are available to medical schools.
Academic thresholds can be based on general academic performance across many disciplines (e.g., ATAR scores in Australia) or on performance in specific science-based examinations as occurs in India. Collaborations of medical schools in the US have together determined the optimal mix of content in the MCAT examination across a range of the natural, social, and behavioral science disciplines as well as incorporating assessment of critical analysis and reasoning. An outcome of this is that medical schools can target the content of the medical school entrance examination to the requirements of the curricula. Success in medical school and in medical practice, however, requires qualities other than academic achievement alone. In addition, there is strong evidence that academic scores are socioeconomically biased. For example, that those at fee-paying private or independent schools attain higher grades than those at state or public schools.,,
Assessment of personal qualities
In recognition of the importance of broader personal and professional attributes of graduates, fundamental to medical practice, assessment of personal qualities is widely recognized as a key component of student selection. The focus on such attributes is also driven by the desire to ensure maintenance of professional conduct and standards of graduates, recognizing that failures in professionalism can often be tracked to earlier problem behaviors by students, and personal qualities that may be identifiable at the selection. Other personality traits have been linked with poor performance, failure to progress, and/or more serious issues. Assessment of such attributes is often performed using psychological tests, by interviews, or by assessment of portfolios, personal statements, referee reports, and curriculum vitae. Many medical schools decide whom to interview by excluding candidates on the basis of preliminary assessment methods to reduce the number of applicants. In the US, a significant amount of screening occurs before the interview process. For example, in 2011, the average applicant submitted 14 applications and received fewer than two invitations for interview. Koenig states that many of the tools providing data about personal competencies such as “standardized evaluations of performance” or “accomplishment records” need further evaluation for reliability, predictive validity and whether they can be administered in a timely and efficient way.
A number of medical schools in countries including Australia, Ireland, the UK, and New Zealand utilize common cognitive and psychological tests as part of their admission pathway. This has the advantage of having a readily available ranking of candidates at a predictable time in the selection calendar. Situational Judgment Tests (SJTs) are included in the UKCAT test in the United Kingdom and utilized by Monash University in Australia, although the use of these tests is subject to considerable variation. SJTs have been shown to be a valid predictor of medical school performance; however, recent evidence suggests they may have low and inconsistent reliability, below recommended levels for high-stakes selection  with validity influenced by scoring methods.
In general, the higher the performance on each of these tests, the more likely an applicant is to gain entry to a program, or to progress to a further step in the selection pathway such as the interview. Notably most admission processes for medicine are centered on “selecting in;” however, distinguishing and measuring undesirable attributes can also play an important role in “selecting out.” The Joint Medical Program of the Universities of Newcastle and New England, Australia, integrates this approach into its admission process through the use of the Personal Qualities Assessment (www.pqa.net.au) to deselect applicants on the basis of undesirable personal qualities. This is consistent with the model proposed by Bore et al. and trialed by medical schools outside of Australia such as Hull York Medical School in the UK.,
Interviews can be semi-structured utilizing a single panel of interviewers, or multi-station, resembling an Objective Structured Clinical Exam (OSCE). In most cases, interviewers are usually academic members of staff and/or clinicians, though some institutions such as the Universities of Newcastle and New England, also utilize community members as interviewers (in our case the ratio of community to staff members is 1–2). Medical schools in a number of countries have adopted the MMI, typically comprising of eight to ten highly structured stations of 6–10 min each. A systematic review of MMIs has reported moderate-to-high reliability, that MMI scores did not correlate with traditional admissions tools scores or pre-entry academic qualifications and that they were predictive of performance in OSCEs and medical council examinations. Applicants and interviewers generally perceive the MMI to be fair, transparent, and free from gender, cultural, and socioeconomic bias; however, the authors of the review recommended further research into its appropriateness in different cultural contexts.
Strategies to Promote Equity and Healthcare for Underserved Populations
There is often a “social contract” between medical schools and the community to graduate doctors that reflect local community populations to better meet community and population needs. In addition to training future doctors, medical schools also have a role in ensuring that the health-care workforce is able to meet the needs of its populations. Hence, most of the universities have adopted policies of widening access and affirmative action to increase diversity among its student body. The rationale being first, that increasing the diversity of the medical workforce will improve healthcare for underserved communities based on the notions that “like would treat like.” Second, students are better able to provide healthcare to people with sociocultural backgrounds different from their own and further it facilitates social mobility of disadvantaged groups  which in turn improves health outcomes. How medical programs do this varies widely between countries. In India, a lower cutoff score on the MCQ-based entrance test on which admission to medical school is partly based is applied to minority groups as a way of countering disadvantage. In Canada, the Northern Ontario School of Medicine established in 2005 under a social accountability mandate, has reported that 92% of all medical students are from Northern Ontario, a vastly under-served rural part of Canada. About 7% of students are indigenous and 22% are francophone students, although in this program, all students apply through a common admissions pathway.
James Cook University in Australia preferentially selects applicants from rural and indigenous backgrounds by combining rurally adjusted academic achievement with structured interviews and written statements to assess attributes deemed important to rural medical education. As a result, 61% of their student cohort come from outer regional, remote, or very remote areas and have been found to perform equally well in the later clinical years and are more likely to practice in rural areas. Other medicals schools such as the University of NSW offer premedicine entry programs for students who are Aboriginal and/or Torres Strait Islander as part of unique selection processes to address the imbalances in access to medical school by indigenous applicants and in the indigenous medical workforce. The Miroma Bunbilla Residential Admissions Pathway of the Universities of Newcastle and New England in Australia was successfully implemented in 2015 and resulted in an intake of 19 Aboriginal and Torres Strait Islander Year 1 students in 2016 among a cohort of 140. This pathway coincided with a marked drop in attrition of Aboriginal and Torres Strait Islander student across the program.
While the emergence of these more diversified approaches to selection for medicine gives promise that we have made some advances in widening access, there is still a long way to go. There is likely to be little difference between Australia and the UK where only 7% of successful medical school applicants are from the lowest SES groups compared to 45% of the general workforce. An exemplar of widening participation in the UK is from Brighton and Sussex Medical School through the use of the “BrightMed” taster course available to State school students. This has had considerable success, with 25% of the 2016 “BrightMed” cohort receiving offers to study medicine after completing the course. While it is known that high scores in A-levels are positively associated with performance in medical school in the UK, overall performance of the schools in which A-level achievement occurred has been shown to be inversely related to performance (i.e., if you perform relatively well in a poor school you will perform very well in medical school compared to those from top performing schools). These findings have led some to suggest that admission to medicine should make allowances for the type of school attended.
There remains a scarcity of data on the diversity of medical students with regard to other affirmative action groups such as “ first in family,” “language other than English,” and disability. In the US, bans on affirmative action in medical schools in six states have led to a significant decline in racial/ethnic diversity of medical students in those states. With reports that many selection tools have low effectiveness in promoting widening access, such inequities need to be offset by selection tools or processes that provide for greater diversity in medical student selection. It is also important to acknowledge other relevant forces in student selection that operate far “upstream” from the selection process itself including the personal and social factors that shape future students aspirations to study medicine and progression to application.
Sharing of Experience and Expertise
Sharing information between medical programs about their selection process and how they increase their applicant pools in target populations may promote informed and effective practice. This exchange of information could occur by way of national databases or through international research collaborations including studies to explore the impact of different affirmative action strategies on student diversity. Clarity and transparency in this area could further assist potential students in their application choices by allowing comparisons between medical schools.
Medical student selection is often closely scrutinized when discussions turn to the qualities of medical graduates. Naturally, the outcomes of medical school education reflect not only the qualities students bring with them but also the curriculum (both overt and hidden) that shapes the learning and development of the student over the dynamic trajectory of their student experience. This is a critical issue in the evaluation of student selection and research in this field, that is, recognition of the likelihood that qualities at selection may have a partial impact on graduate outcomes, yet still remain important in identifying those best suited to the study of medicine, and the “longitudinal continuities” in skills and attributes over time.
We acknowledge that medical schools worldwide operate in very different environments. Medical school selection committees need to be clear about their aims and objectives and constantly evaluate how their selection criteria are serving them. The quality of graduating doctors will also be influenced largely by the curriculum being oriented to graduate outcomes, but who gains entry to medical school is a key determinant. Medical schools have the unique challenge of needing to adjust student selection processes in light of lessons from the international literature which apply to their context and at the same time listening to their local community about what constitutes a good doctor.
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Conflicts of interest
There are no conflicts of interest.
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