Med school entry more than marks

OTAGO University is facing (and opposing) a legal challenge to its selection processes for medical school.

Within each of the three major groups of entrants — Health Sciences First Year (HSFY), Graduate, Alternative (e. g. from other healthcare disciplines) — its ‘‘Mirror on Society’’ policy, in order to improve medical care of demographic groups underrepresented in New Zealand's medical workforce (Maori, Pasifika, rural, low socioeconomic, and refugee), gives, in accordance with the Education Act, priority to students from those groups, if they achieve 70% in all their HSFY papers.

Other HSFY and Graduate applicants must score adequately in the University Clinical Aptitude Test (UCAT), and then those scoring highest in HSFY and degrees gain entry.

But is very high marks in exams the best criterion? A high minimum academic level is obviously needed: all medical students must be capable of completing the course. Using competitive marks as a selection tool, though, is less straightforward.

The main point of medical school isn't to provide a route to personal fulfilment: it's to provide doctors to care for the population.

As David Powis, of Newcastle University, NSW, has remarked, high academic ability and cognitive and decisionmaking skills are necessary, but so are high ethical standards, interpersonal and communication skills, and the ability to empathise with patients.

Doctors must be able to function professionally under stress, have selfcontrol, and not be prone to taking inappropriate risks in their work. They need mental resilience, emotional stability, and the ability to evaluate and reflect on their professional practices (and to walk on water?).

A researcher writing in The Lancet in 2010 ‘‘found consistent evidence that performance in the premedical sciences is inversely associated with many of the personal, noncognitive qualities so central to the art of medicine’’ and that lower achievers showed greater consonance with the personal qualities considered desirable in doctors, e.g., poised, progressive, relaxed, easygoing, tactful, warm (as opposed to forceful, hasty, irritable, awkward, conservative, painstaking, shy).

It's tempting to suggest not selecting the very high scorers, but that raises the spectre of candidates gameplaying to score highly, but not too highly, in exams. Would it be better just to draw lots among those scoring over 70%?

In 1944 the Goodenough Committee, which reviewed medical education for the UK government, reported that ‘‘[some students] though able to pass examinations, have not the necessary aptitude, character, or staying power for a medical career’’. Since then the literature has continued to show that medical schools are still selecting some unsuitable students. For Otago, the UCAT screens for mental ability — verbal reasoning, decision making, quantitative reasoning, abstract reasoning, and situational judgement. But is that enough?

Prof Powis argues that an important function of selecting medical school entrants should be to exclude applicants potentially unsuitable for a medical career, by considering their personal qualities. He has some suggestions.

Confidential references may identify some of the unsuitable. A ‘‘Multiple MiniInterview’’ process may help by identifying students about whom several of the interviewers raise concerns regarding attitude or behaviour.

Newcastle University has trialled noncognitive Personal Qualities Assessment of medical school applicants, scoring them on four continua — moral orientation (libertarian to communitarian); resilience (vs inability to cope with stress, emotionally volatile, ‘‘neurotic’’); selfcontrol (conscientious, orderly, restrained, industrious vs disorderly, unrestrained, unreliable, impulsive, permissive, antisocial); involvement (empathetic, cooperative, agreeable vs aloof, narcissistic, disagreeable, manipulative) — proposing that those in the 2.5% at either extremity of a continuum should be excluded from entering medical school.

Prof Powis proposes a model for medical student selection based on two independent sets of tests: one for ability; the other for character.

Select IN for academic ability (academic record), cognitive skills (‘‘aptitude’’ test), communicative and interpersonal skills (interview). Select OUT (noncognitive tests) those who show traits of psychological vulnerability, high neuroticism, low conscientiousness, extreme detachment or extreme involvement, high levels of impulsiveness and permissiveness.

Selecting by marks is easy. But not, perhaps, the best way.