J R Soc Med 2002;95:18-22
doi:10.1258/jrsm.95.1.18
© 2002 Royal Society of Medicine
Can we improve on how we select medical students?
Patricia Hughes MSc FRCPsych
Admissions Office, Hunter Wing, St George's Hospital Medical School,
London SW17 0RE, UK
E-mail:
p.hughes{at}shgms.ac.uk
 |
INTRODUCTION
|
|---|
Getting the right policy for admission to medical school is
a balancing
act: be fair to society by choosing people with
the potential to be good
doctors; and be fair to the applicants—that
diverse group of people who
for many reasons want to set out
on the long road to a medical career.
Selection is not an exact
science but we must use what evidence we have to
ensure that
we do our best by all concerned. There is widespread agreement
that
we should select future doctors on wider criteria than scores
of academic
success
1,2,
though in practice many medical schools
have valued pre-admission academic
scores at the expense of
other
considerations
3.
There are recognized drawbacks to the
use of school exam performance even as a
measure of intellectual
competence. One study has shown that a major causal
determinant
of A level results is social class, independent of
ability
4,
and some
would-be medical students elect to focus on sciences
for their school leaving
exams because very high marks are more
easily achieved in the physical
sciences than in the
humanities
5.
The
conviction that only exam results give valid and reliable
data has been
trenchantly dismissed as a ‘seductive but
fallacious’ belief in
the precision of quantitative
tests
6.
We are
reminded that
all selective instruments depend on subjective
judgments
and each must be accountable to the rules of reason, fairness
and
public scrutiny
7.
However, if we decide to consider non-cognitive
criteria, a legitimate concern
is that the many specialties
of medicine need diverse skills and they must not
be too narrow.
We also want to be reassured, if we include noncognitive
characteristics,
that we can assess them reliably and that such evaluation can
predict
personal character over years of practice.
While we need to maintain diversity of skills and personality, there are
some characteristics which we demand in any doctor. Enough intellectual
ability to do the job, plus honesty, integrity and conscientiousness, must be
at the heart of good
practice8.
Helpfulness and willingness to cooperate come close
behind8, while
patients give high priority to interpersonal skills and
empathy2. The
personal welfare of the profession is another
consideration9.
Doctors are more vulnerable than comparable professional groups to alcoholism,
drug abuse and
suicide10,11.
Burnout is well recognized, and has a high cost for the individual, for
colleagues and for the quality of service that patients
get12. One answer
may be better support for psychologically vulnerable
doctors12,13
(together with improved working conditions for all doctors), but perhaps we
should try to evaluate ability to deal with stress right from the start.
|
ARE PERSONALITY CHARACTERISTICS STABLE OVER ADULT LIFE?
|
|---|
If we seek to identify the personal characteristics we want
in a medical
student, can we have any confidence that they tell
us anything about future
personality or adjustment? Studies
that assessed medical undergraduates and
followed them up for
between 15-30
years
12,14,15
indicate that doctors who are psychologically
well in middle age had good self
esteem as students, had an
open, flexible approach to life, enjoyed a warm
relationship
with their parents, and had little anxiety and depression and
low
anger under stress. In contrast, doctors vulnerable to later
substance abuse,
to suicide and to burnout in middle age had
significantly poorer measures of
psychological health as undergraduates.
Other long-term studies of stability
of personality characteristics
have shown that personality traits exhibit high
test-retest
correlations over intervals of 6 to 45
years
16,17,18,19.
These
findings signify a substantial continuity of personality disposition
in
adulthood, suggesting a stable tendency to be either happy
or unhappy, well or
poorly adjusted.
|
WHAT FACTORS GENERALLY PREDICT FUTURE JOB PERFORMANCE?
|
|---|
There is relevant research both within medicine and outside
it. Useful
information comes from industry, where serious money
has gone into finding out
what makes a good
professional
20.
They
measure outcome in hard cash and find that the most productive
people are
about 40% better than average, while the least are
40% worse than
average
21. Is this
too different from medicine
to be relevant? Look around: we all know who gets
the work done
and keeps up to date, and who slips through life doing the
minimum.
These are not the only criteria for a decent doctor but they
matter.
There is consistent evidence that, for work involving
complex tasks, the best
predictor of effectiveness is some measure
of mental ability or IQ, and the
higher you go up the professional
scale the more IQ matters. At the highest
managerial level it
accounts for almost 70% of performance
variability
22. So
in
demanding evidence of high IQ (even in the form of exam results)
we have
got something right. Predictability can be improved
by including some measure
of other factors. Further factors
consistently found to add to prediction of
performance are integrity
and conscientiousness: these do not correlate with
IQ
23. No
additional
predictability comes from the number or nature of
outside interests; years of
education adds little to predictive
validity; and the
number of
courses a person has been on is
of no value (so much for how we measure
‘continuing professional
development’). Previous job performance
adds to prediction
for those already in the profession, but adds nothing at
entry.
Some of these results are counter-intuitive: this is because
IQ
overlaps with other things. So a quick learner will have
good performance in a
previous job which will correlate so highly
with IQ that it adds little to
predictive
validity
20.
|
WHAT FACTORS PREDICT ACADEMIC FAILURE IN MEDICINE?
|
|---|
The first thing that strikes anyone exploring the work on predictors
in
medicine is that we are obsessed with exam results: by far
the largest number
of papers examines predictors of passing
exams. This may be justified because
of the economic and personal
waste of losing students who begin a medical
degree but fail
to complete, with loss from schools that select at entry, both
in
the UK and elsewhere, generally reported between 8% and
10%
24,25,26,27.
However,
most studies assess ‘failure’ in broad terms to
include
all students who re-take an examination, as well as
those who are excluded
from the course, so predictors should
be treated with caution. Although
virtually all students are
high academic achievers at school, from the top
0.4%
8 to the
top
10%
29, school and
medical exam scores do correlate, with
contribution to variability reported
between 16%
29 and
58%
30.
Some UK
studies show that certain science A levels predict exam
success, variously
putting biology, chemistry or physics in
prime
place
31,32,33,
and research from outside the UK reports
associations between performance in
physical sciences and in
medical
exams
34,35,36.
Generally this association falls later
in the course, with no difference to
longer term success or
failure
37,38,39,40.
Non-academic factors also predict exam success or failure. Some researchers
report that older students are more likely to fail
exams36,38,41,
but others have not found
this42. Several US
studies found higher failure rates among women and ethnic minority students,
although most eventually
graduate36,38,41,
and one school reported that students admitted through affirmative action were
as likely to graduate as those admitted by use of traditional
criteria43.
Proficiency in English is important for students for whom English is not their
first
language44,45,
and in the US, reading skills of disadvantaged minority students have been
shown to predict academic
success46.
Non-cognitive factors are stronger predictors for women and ethnic minority
students than for white men in the US. For women, interview ratings and
previous relevant experience were more predictive than previous exam
scores47, while for
ethnic minority students, locus of control and ability to self-evaluate were
predictors48,49.
One US study showed that different cognitive and non-cognitive factors
correlate with academic success in different schools, so different cultures
and teaching styles influence
outcome50.
It has been argued that we cannot reduce loss
further51, because
some failure is inevitable and we cannot avoid a few students' wanting to
change career. However, two medical schools have shown that careful selection
and good support can have a positive impact. In Newcastle, New South Wales,
for five years 50% of students were selected on academic marks alone but
underwent a lengthy structured interview which was not used for selection. As
a result, some students were admitted with very low interview scores. The
remaining 50% were selected from a wider band of academic performance but
scored high in interview. Analysis after ten years showed a significant
correlation between low interview score and later drop-out but no correlation
between academic score at entry and drop-out. Reasons for dropping out were
academic failure or a variety of personal reasons, including lack of
motivation for study or for
medicine28. Another
example of low drop-out comes from McMaster University in Ontario, which also
invests heavily in selection and in addition offers ‘remediation’
for students having academic difficulty. In one five-year period in a class of
100 students, only one student was excluded because of academic failure, 3
changed careers, while 8% had remedial
help52.
|
WHAT PREDICTS GOOD CLINICAL PERFORMANCE?
|
|---|
Investigators looking for early predictors of what makes a good
clinician
generally use reports from clinical clerkships and
from the house officer or
intern year. However, we should note
that drop-out will mean that some
unsatisfactory students will
have left before the house officer year. Clinical
performance
is not generally predicted by pre-entry academic
scores
1,35,53,54,55,56,57:
the
one report of correlation between matriculation scores and clinical
performance
noted that matriculation scores included 50% contribution from
school
teacher
assessment
58.
Neither age nor gender predicts clinical
performance, nor does previous study
of physical sciences, but
there is evidence that previous study of English and
humanities
correlates with better clinical
performance
5,34,59.
There are
some reports of association between clinical performance and
admission
interviews
55,56,60,61,
although
others reveal no
correlation
54,58.
In a school that carefully
evaluates applicants, empathy and motivation to be
a doctor
were found particularly important in predicting both clinical
and
academic
success
62.
|
WHAT ARE THE MOST RELIABLE PROCEDURES TO ASSESS PREDICTORS OF FUTURE
PERFORMANCE?
|
|---|
If we can agree that there are certain characteristics that
we want to
select in prospective doctors, what is the best way
of doing this? Research
shows that, if we want to add usefully
to a measure of intellectual ability in
predicting later job
performance, our best instrument is the structured
interview.
While an unstructured interview adds about 8% to prediction
of
subsequent performance, the structured interview adds around
24%
63.
Psychometric
tests to measure desirable personal characteristics
do predict future
performance, but their validity may be compromised
if they are used as a
selection tool: the desired answer is
not usually difficult to identify, and
applicants who lack integrity
are the most likely to manipulate the
results
64. However,
some
schools have applied psychometric tests at the point of entry
rather than
using them to select, and have found correlation
between these tests and
scores given in
interview
65,66.
This
suggests that a well conducted interview may give similar information
and
that, if constructed to assess desired characteristics such
as
conscientiousness or helpfulness, it will give a reasonably
reliable
evaluation
20.
Character references from a previous employer or tutor have potential to
add to prediction. However, legislative changes in the US in the 1980s meant
that an employer giving an adverse report could be sued by the employee: as a
result, the predictive validity of personal references in the US has fallen to
almost zero20. The
reliability of UCAS references in the UK may be similarly threatened. The
motivation of the referee is uncertain: some tutors may feel their first
loyalty to their student, others may feel compromised by recent data
protection legislation that removes the confidentiality of previous years. One
medical school in New Zealand has adapted the traditional reference system by
writing to head teachers with specific questions, and requesting a rating of
the candidate's qualities against the level the head teacher believes to be
desirable in a doctor. The long-term predictive validity of this method has
not been published, but the school believes it provides valid information and
correlates well with other non-cognitive indices (and not at all with academic
scores)35. Some
schools, particularly those which do a lot of small-group work in the course,
use an assessment of performance in small groups as a ‘live’ way
to assess interpersonal
skills29,52.
Evaluation of students in this setting correlates highly with interview
scores, and is reported to predict both problem-solving ability and group
interaction52.
|
WHAT CONSTITUTES CURRENT BEST PRACTICE?
|
|---|
In summary, the evidence is that we need to select students
with good
intellectual ability and that examinations, despite
limitations, have some
validity. For some candidates—e.g.
older applicants, or those from
disadvantaged social backgrounds—we
may want to look for reliable
measures of intellectual ability
other than the traditional A levels. We seek
individuals who
are conscientious and have integrity, who are empathic and
motivated
to become doctors, and who are psychologically robust enough
to
enjoy a successful medical career. Some medical schools,
mainly outside the
UK, have already recognized best practice
and have put great care and resource
into their selection procedures,
with well-planned structured interviews,
focused reports from
schools and evaluation of interpersonal behaviour. As
detailed
above, there is evidence that this investment is worthwhile
in terms
of the suitability of students selected, and economically
in terms of student
loss during the course.
|
AND WHERE ARE WE IN THE UK?
|
|---|
The greatest single barrier to a more careful selection process
in the UK
is the amount of resource that each school has to
invest. At present, would-be
medical students apply to up to
four medical schools. All but four of the UK's
present twenty-four
medical schools interview about 500 to 1000 applicants for
their
five or six year MB BS courses. Many interviews are still unstructured,
and
not all schools require their interviewers to be trained. It
is unusual
for the interview to be more than 15 or 20 minutes,
and while brief interviews
may be reliable
67
the validity of
a 15-minute interview is
doubtful
68. The
fact that many candidates
are interviewed four times underlines the
wastefulness of our
present national procedure, but the cost to individual
schools
to improve radically would be prohibitive. Our present system
does not
offer society the best practice available: at present
we almost certainly turn
away people who would make good doctors
and accept some who will be mediocre
or poor. We could probably
reduce loss from the medical course, and so save
money and save
personal distress among those who were allowed to make an
unwise
choice. We could also be more just to applicants, and begin
the process
of education by showing that we are very serious
about the kind of personal
qualities that we want in a doctor.
The Civil Service, the Armed Forces, and many business corporations have
had selection boards for many years: the Civil Service believe these to be
money well spent, and industry has gone further and demonstrated their cost
effectiveness20.
Those medical schools which invest heavily in their selection procedures admit
that it is not cheap: on the other hand, it is not cheap to lose students
unnecessarily or to employ a poorly motivated or unhappy doctor. There is a
strong argument for pooling resources so that applicants get one good
assessment instead of four poor ones. This does not preclude medical schools'
maintaining individuality and some degree of choice, and candidates will
continue to visit schools and attend open days. However, it is time that UK
medical schools got together to collaborate in setting up a first-class
selection process that is fair to society and fair to all those people who
hope to be the doctors of tomorrow.
|
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TOP
INTRODUCTION
ARE PERSONALITY CHARACTERISTICS...
