Graduate or direct from school entry

In North America, following the Flexner 1910 Report, students were admitted to medical school as graduates following completion of a college course in another subject. In other parts of the world students can enter medical studies direct from school. There has been a move in some medical schools in the UK, Australia and other countries to graduate-only entry. Other schools have maintained a mixed approach accepting both graduates and school leavers. The issue is a controversial one and the arguments for the different approaches are complex. There is no good evidence to indicate that one approach is preferable to the other, but opting to admit students straight from school does have significant financial advantages and there is no evidence that the product is less satisfactory.

A Range of methods

Different approaches have been promoted in the selection of students for admission to medicine. Until recently the emphasis has been on academic ability and intellectual achievement. Attention has been paid to selecting an individual who will do well in the medical school examinations rather than to selecting an individual who will become a competent and good doctor. The ability to perform well in tests may simply predict later test scores and not performance as a doctor. The ability to answer MCQs correctly does not necessarily indicate that a student will be a good doctor. This does not mean that a choice has to be made between someone who has a good academic record and someone who will become a good doctor. They are not mutually exclusive.

In general, the criteria for good assessment discussed in Chapter 28 also apply to the selection process. This must be seen to be fair and to be reliable and valid. For this to be so, evidence to support the selection decision should be obtained from a range of sources. The motivation of the student to study medicine must also be taken in to account. Whatever approach to selection is adopted it is important that criteria such as academic ability, personal qualities and ethnicity and any weighting given to the different factors are made explicit. When the entry requirements are considered, attention should be paid to the expected exit learning outcomes of the medical school. Evidence that the student meets minimal requirements relating to each outcome domain prior to entry to medicine is advisable. For example, a required level of competence relating to the communication or attitudinal domains may be specified prior to admission. Learning outcome frameworks that can be used for this purpose are discussed in Chapter 8.

Performance at school

Academic achievement and performance at school, as evidenced by A-level achievements in the UK or grade point averages (GPAs) in the USA, have played a major role in decisions about selection. Correlations have been shown between such indicators and students’ performance in medical school, particularly in examinations in the early years.

Aptitude tests

Various aptitude tests have been designed to measure a student’s ability to develop skills or acquire knowledge. Most have a knowledge component. Examples are the North America College Admission Test (MCAT), the Graduate Australian Medical Admission Test (GAMAT) and the United Kingdom Clinical Aptitude Test (UKCAT).

Autobiographical narrative

The application form completed by the student may contain useful information about the applicant that will inform the admission decision. The student may be required to provide an autobiographical narrative to justify their motivation to study medicine. Such forms, however, are at risk of fraud and may be written by a third party.

References

References may be sought from the student’s school, previous employers or individuals with whom the student has been associated. Such letters of recommendation seek to identify personal qualities such as honesty and application. These references are open to bias and tend to be unreliable and ineffective. Laws in relation to disclosure and removal of confidentiality cast additional doubt on their value.

Interviews

Interviews have been widely used to complement assessment of the student’s achievement and aptitude. While questions have been raised about their reliability, they are used to provide evidence that the student has the attributes expected of a future doctor. Structured or semi-structured interviews, where the questions asked are standardised for the candidates and a rating scale is used, have been shown to be more reliable. Interviews, however, are labour intensive and also subject to bias. In one school, when the measurements were taken for refurbishment of the bars in the student union, it was found that the students admitted to the medical school were taller than average. A possible explanation was that the individual in charge of the interview admission process at that time was 6’ 6’’. When interviews are used, training of the interviewer is important.

The multiple mini-interview (MMI)

In recent years, there has been increasing emphasis on more objective assessment of students for the purposes of selection with the use of an OSCE approach. The multiple mini-interview (MMI) consists of a series of 5–8-minute testing stations. A rater at each station assesses the student’s performance in areas such as ethical decision making, effective communication, empathy, manual dexterity, knowledge of the healthcare system and critical thinking. The MMI requires fewer examiner hours than the traditional type of interview that involved a panel of examiners. The evidence to date is that the MMI has more predictive validity. It provides also a stimulus to prompt admission committees to be more explicit about the qualities they are looking for in applicants.