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BMJ. Oct 24, 1998; 317(7166): 1149–1150.
PMCID: PMC1114119
How to do it

Select medical students

David Powis, assistant dean, undergraduate education

The analysis on p 1111 by McManus of some of the factors affecting whether a candidate is offered a place at medical school in the United Kingdom1 shows clearly that selectors haven’t yet got it right.

What follows is a brief guide that might help medical schools and doctors to determine what they want from a selection procedure—that is, what knowledge, skills, and attributes need to be sought in potential medical students, and why. This determination requires data, specifically, on the progress rates of medical students and the reasons for failure or premature withdrawal. With such knowledge the guide may be used to show how admissions committees should devise and operate an appropriately objective student selection procedure.

Summary points

  • The selection of medical students is often an arbitrary process, with the criteria for selection often being undefined
  • The selection procedure should be an objective exercise based on defensible criteria with transparency of process and freedom from bias
  • This article describes the steps entailed in establishing a suitable procedure and how to operate it
  • The procedure is based on collecting pertinent data in academic, cognitive, and non-cognitive domains by the most appropriate methods
  • A key recommendation is to dissociate the selection event from the interview
  • The interview should be used only to collect data; selection is performed later by administrative staff, who enter the data gathered by all means into a predetermined algorithm

Assumptions

Medical school admissions procedures are often not selection procedures but an administrative exercise to limit the number of entrants to the number of places available on the course by means of a movable marks threshold. The assumption is that the greater the number of applicants for places in the medical school the higher the marks threshold needs to be set to limit entrance.

A true selections procedure should try to match applicants with the course of study to maximise the chance of successful completion and to produce a competent and effective graduate professional.

I have assumed in this article that the medical school curriculum is entirely appropriate for its purpose of educating and training future doctors.

Determining the qualities required in medical students

A list of essential and desirable qualities with the required extent of each defines the profile of people sought for entry to medical school. To maximise the chance of students successfully engaging with the curriculum and completing the course we need to ask eight questions.

What subject knowledge is required?—

For example, do applicants require chemistry, physics, and biology? If so, at what level of achievement? Do high marks in science subjects correlate with success in important aspects of the medical school curriculum? Do studies in arts subjects (the humanities) lead to improved outcomes? Clearly, grades at A level are often used as the primary selector, those with the highest grades being selected in preference to those with lower grades. If this procedure is to be maintained students with high grades must be shown to be more successful in medical school and afterwards.

What other cognitive skills are required?—

How important are logical reasoning, problem solving, and critical reasoning?

What non-cognitive qualities are required?—

For example, should medical students show empathy, flexibility, maturity, honesty, and common sense?

What excessive behaviours should be recognised?—

Examples might include introversion and extroversion, compulsive behaviour, and poor motivation.

What desirable attributes and behaviours should be recognised?—

How important is the capacity for self education and being an independent and critical thinker?

What level of verbal and written communication skills is required?—

Should candidates have to demonstrate good understanding and use of formal and colloquial language verbally and show that they are concise, accurate, and logical in writing?

Are team skills required?—

What quality of interaction skills are required? Are tolerance, patience, and cooperation important?

Are psychomotor skills important?—

Should hand-eye coordination and manual dexterity be assessed?

Selection instruments and procedures

The next task is to choose the most appropriate techniques to obtain the information required. Selection instruments and procedures must be valid, reliable, and appropriately used. They should also be objective.

Academic record

provides information about breadth and depth of subject knowledge, but it does not usually indicate other cognitive skills.

Report from school principal

may give information about cognitive abilities and about attitudes and behaviours, but it may be biased. It may also omit uncomplimentary material. Comparisons between candidates are difficult.

Referees’ reports and testimonials

are usually of limited value.

Self reports and resumés

may show a candidate’s achievements and interests, but objective comparisons between candidates are difficult.

Written psychometric tests

are available or can be constructed to measure cognitive and non-cognitive skills and attributes that are difficult to assess objectively in any other way. They are comparatively expensive to set up, maintain, and administer, but the data are robust and data gathering is free from bias.

Structured tasks

to assess manual skills, reasoning skills, and creativity are expensive to organise and are not likely to be cost effective in selecting medical students.

Observed group activity

assesses verbal, interaction, debating, and team skills but is expensive to organise.

Personal interview

can be used to assess verbal reasoning, language and interaction skills, and attitudes. An interview should not be used as the selection event (see later). Interview is valid only if it is structured, and reliable only if it is performed by trained staff. Objectivity and reliability are increased when the qualities sought are predetermined and constant, the questioning strategy is established and focuses on qualities that can be directly assessed, and a calibrated scale exists to grade answers. Interviewers’ training should include general interviewing technique, specific interview content, practice in scoring video excerpts from staged interviews and calibrating the scores against standard criteria, and reaching consensus with another interviewer. To reduce bias interviewers should not be given any information about the candidate that is not pertinent to the data gathering exercise—essentially just his or her name. The interviewers’ task is to provide an appropriately derived score for each of the qualities being assessed. They should not investigate other areas.

Possible selection sequence

The following is a proposed sequence for selecting medical students.

Apply the appropriate academic threshold

Determine the prerequisite and desirable subjects and the grades required. Does an applicant really need three A grades at A level to succeed at medical school?

Use written psychometric tests

Use purpose designed tests to identify essential and desirable cognitive and non-cognitive skills—for example, logical reasoning, problem solving, and critical reasoning. Some tests are commercially available, some may need to be constructed. Tests could be administered in secondary schools under the supervision of teachers, or they could be administered during a visit to the medical school. Psychometric test data could be supplemented by data from the school principal’s report on qualities such as common sense and personal reliability.

Invite applicants with the appropriate profile for interview

Applicants with the appropriate profile of academic and other attributes should be interviewed. Interviews should be conducted by trained staff following a predetermined and constant procedure to assess additional personal qualities and attitudes—for example, verbal communication and interaction skills and motivation to be a doctor. In addition, the interview could be used to investigate the potential compatibility of the candidate with the curriculum at a given medical school. For example, how well does the candidate work in small groups? Does he or she prefer didactic teaching to self directed learning? Evidence should be sought from candidates to support their statements.

The interview should be used only to gather information in the predetermined areas: it should not be used as the selection event. If the interview is the selection event the interviewers would be diverted from their objective of gathering information by considerations such as whether they would like to see the candidate at their medical school.

Select on the basis of a combined score

The selection event should be an administrative task. Decisions whether to select are based on a compilation of the collected data in proportions determined by the admissions committee. The committee would rank the qualities in terms of their importance to student progress or ultimate professional excellence and then construct a selection algorithm. For example, it might decide that the personal qualities assessed at interview are the most important followed by those determined by the written psychometric tests. Furthermore, it might have found that above a certain minimum standard the academic achievements of applicants have no positive predictive value for performance as a doctor.

Given that the interview scores are discrete (discontinuous) scores—for example, an outstanding candidate scores 1 and a poor candidate 5—and the written test scores are on a continuum, candidates can be ranked according to their scores and offered a place according to their rank on the list. For example, all candidates whose academic achievements exceed the threshold and who scored 1 at interview are ranked on their test score from top score down to a predetermined minimum acceptable mark. Ranking continues with candidates who scored 2 at interview.

Conclusion

The fundamental principle is that students are selected according to a profile of qualities considered by the admissions committee to be important in a medical student and in a future doctor. Information relating to achievements and demographic variables that are not explicitly stated in the profile are ignored in the selection decision.

Further reading

Powis DA. Selecting medical students. Med Educ 1994;28:443-69.

Powis DA, McManus IC, Cleave-Hogg D. Selection of medical students: philosophic, political, social and education bases. Teaching and Learning in Medicine 1992;4:25-34.

Powis DA, Rolfe I. Selection and performance of medical students at Newcastle, New South Wales. Education for Health 1998;11(1):15-23.

Notes

Editorial by Abbasi and Paper p 1111

References

1. McManus IC. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ. 1998;317:0000–0000. [PMC free article] [PubMed]

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