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SELECTION of students to medical school should be more than an interview process or score-based merit system — it should begin years earlier, says one of Australia’s leading medical educators.
Emeritus Professor John Hamilton, who was dean of medicine at the Faculty of Health and Medicine at the University of Newcastle from 1984 to 1997, said debate about the role of the interview in the admission process was secondary to “growing our own wood”. In the late 1970s, Newcastle was the first university in Australia to introduce an interview as part of its selection process for medicine.
Professor Hamilton was responding to research published in the MJA which found that after the interview was removed from the selection process at the University of Queensland’s medical program at the end of 2008, there was a marked increase in the proportion of males granted admission. (1)
The study included 4051 students admitted to the program between 2004 and 2012. It found that between 2004 and 2008 before the removal of the interview 51.4% of enrolled students were male compared with 57.7% of students enrolled between 2009 and 2012 with no interview.
However, the change in the gender ratio was limited to the domestic direct graduate entry students, with the male proportion of that group rising from 50.9% to 64.0%.
The study authors noted that over the same period, male students consistently performed better than females on the double-weighted section III (reasoning in biological and physical sciences) of the Graduate Medical School Admissions Test (GAMSAT).
Professor Hamilton told MJA InSight that he believed there were “bigger issues at stake” than the possible gender bias of the current admissions process.
“Selection is only one of the steps in producing a medical workforce”, Professor Hamilton said.
“Student choice and orientation that leads to application in the first place is likely the most powerful [factor].
“The issue of what brings a student forward to apply for medicine in the first place actually starts way back in school, and in the home.”
Professor Hamilton said that in one of his previous roles determining admissions processes and curricula for medicine at Durham University in the UK he made a conscious decision to go back into the schools and lower socioeconomic areas to find potential medical students.
“When you’re selecting students, you’re creating an educational community. It’s a better educational community when there is a balance, not just of gender, but of different backgrounds”, he said.
“[In Durham] we went back into the schools and developed problem-based learning in the science subjects, including some practical experience in local hospitals.
“We were growing our own wood, so to speak.”
Professor Tarun Sen Gupta, professor of health professional education and director of medical education at James Cook University’s School of Medicine and Dentistry, in Queensland, agreed that focusing on the interview as a selection tool was missing the bigger picture.
“The question is not whether a specific tool (like an interview) is any good, or whether it is associated with any biases, but more around the purpose to which it is put”, he told MJA InSight.
“I would suggest we ask ‘what is the best tool for our defined purpose or outcome?’ not ‘can an interview (or any other modality) be made to work in our setting?’
“The important outcome is what graduates do with their degree — what communities do they serve, how do they serve the community — not their [grade point average] or other performance on assessments.
“The case could be made that underserved communities should be overrepresented in the cohort admitted, at least until imbalances are corrected.”
Professor Judith Searle, CEO of the Medical Deans of Australia and New Zealand, said medical schools walked a fine line “between merit-based selection versus society’s needs for the future”.
“We have to continue to ask ‘is this what the public want of us?’ ” she told MJA InSight.
“In terms of gender balance, I think the public have a reasonable expectation that about 50% of medical students will be women, otherwise it is not representative of the community. And they would want to ask why not, if that balance wasn’t there.
“We have a responsibility to the public. We are using their money to train the future health workforce and it is important that we provide the public with some evidence of the quality of product that they are getting.”
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Prof Searle’s first quoted sentence is correct, it’s a fine line between community desires and producing the best clinician on merit. It depends on how you engage with the lay community. If you ask the question, “do you prefer to see a doctor who speaks your primary language, or is male/female” you will usually get a “yes” response. On the other hand if you say “do you prefer to see the cleverest doctor” you’ll also get a Yes response. The trouble with treating “community expectation” is that it’s not a single mass response, so it’s important not to lose the very cleverest from a medical career just because they are the wrong sex or ethnicity.
I am now retired. If I had b een interviewing myself in the years after an ordinary Leaving Certificate (HSC) result I would not have passed myself. Yet I obtained 3 senior surgical degrees and was, for a time, senior surgeon at a leading teaching hospital. Of course we did not have interviews in those days and the only need to get into medicine was to graduate from high school!.
I have been privileged to teach the next generation of doctors for the last 7 years. There have been many inspiring young men and women who will make great doctors. I have however noted some worrying trends. The proportion of younger students with less real world experience has introduced an increase in the number of students seeking to pass the course rather than become doctors. Medical school, while needing a good academic base, is at its core also a source of apprenticeship style training in the art as well as the science of medicine. The process is about becoming a doctor not just getting a medical degree. In my opinion therefore medical school must incorporate diversity as well as academic ability in its selection for the course.
Agree with many of the earlier comments. the role of interviews should be to rule out problem personalities. Selecting specific attributes through interview may well act to counter student diversity- quite the opposite of the lofty aim. eg in some interviews, the strong weight placed on communication skills and leadership as criteria for selection does not offer our future community the broad range of personality types and interests that we expect in those engaged in practice of medicine. Many of us seek clinical competence and professionalism above other attributes. My metropolitan medical school year (students selected purely on marks), produced an internationally renowned researcher in autoimmune diseases (who as a student didnt excel in communication with patients), remote-area practitioners (including leaders in the field), advocates for marginalised populations (including refugees, etc); leader in sexual health; hospital administrators, heads of departments, Deans, internationally successful movie producer, as well as ‘run of the mill’ specialists and general practitioners. We need to move past some ideologies and support merit-based systems which need not be solely based on exam scores, but take account of factors such as motivation, past work experience, previous degrees, etc, without socially engineering the student cohort based on factors such as ethnicity or gender.
Yep, people who say they don’t care about their doctor’s communication skills are usually the kind of people who, by virtue of their status and economic position, have been listened with respect all their lives. They forgot that some members of our community need a different kind of doctor who will allow them to build rapport and trust with the medical profession.
If interviews are to be used they should be only to rule out obviously pathological personality disorders. We need obsessives, pedantics, free thinkers, warm and cuddly types, people with great pattern recognition, people with superb hand eye coordination, people who can multitask, people who aer happy to work at night, great communicators and so on. We need doctors in psychiatry, radiology, emergency medicne, intensive care, anaesthetics, orthopaedics and so on. The range of physical, mental and personality attributes for each specialty is different, sometimes vastly different. The problem with the current interview process is we tend to concentrate on a few attributes that then tend to select a lot of very similar people. I want my neurosurgeon to be an adequate communicator but very skilled with his hands, I don’t want the reverse. I want a radiologist who can pick the suble abnormality, a warm understanding type is of no help if the tumour is missed. Taking top scores at least will get a more random range – we just need to avoid dangerous pathological types.
Re poll, please redo poll, and add should rural backgorund students be worthy of polling?
If the question is one of responsibility to the public, the question is not of gender, nor Gamsat, nor Umat, nor interview, it is of responsibility to supply doctors to where doctors are needed-rural Australia, so forget all of the your selection criteria, select the students who are proven to work in rural areas, rural background students and train them in rural medical schools.
When visiting a top medical school in Germany ,I was greeted by the Dean of medicine with the following words “We do not select students on the basis of how many times they have read the telephone book as you do”.What he maent was that if the VCE notes ( Victoria) were read many times this would ensure a high result enabling you to enter medicine .This is unlikely to result in the most capable student entering medicine .
Talk about presuming what you are trying to prove. Does anyone seriously think that there is a gender bias in the double-weighted sectoin III? If so, how?
If you select people who are outgoing and gregarious, then you actually select against diversity. Speaking as someone in a talking field, I think having people who are quiet and technical is essential. We still need pathologists and etc.
The current problem is that about the smartest and brightest students being selected, it’s the ones with the wealthy parents who buy the marks at private schools necessary to enter medicine and/or the ambitious parents who have them tutored from the age of 5 in order to achieve the same marks at a lower cost in selective public schools. Some of the same parents have even learnt how to game the interviews. By the way, how are defining ‘smart’ and ‘bright’. Is it still getting high marks at the end of school?
Perhaps we should consider the Dutch model. The minimum high school mark necessary to complete the medical course is determined. It’s not actually very high. Then every one who wants to do medicine is put in a barrel and names drawn out. The results are genuine diversity, statistically determined across incomes and geography. The system is widely publicised so that even the more disadvantaged know they are in there with a chance.
Does that system produce good doctors? What is a good doctor? The Dutch doctors in my own specialty certainly punch above their weight. Probably a good epidemiologist has different attributes to a good surgeon or a good general practitioner. It is different to our system where selecting good doctors depend on their marks at the end of high school or the socio-demographic profile of their parents.
Greater diversity ? Of course. Goes without saying. I still, being long retired from GP, find Newcastle-trained registrars in general practice more interesting, interested, humane and, importantly, socially and communally aware than others. That is what’s wanted in all doctors who actually talk to real people seriously.
Equally, I still find many doctors trained elsewhere too prone to think themselves superior to the general public and more concerned with profit than care.
1 criteria – the smartest and brightest students should be selected. Pure and simple, as it was. Trust in the HSC system needs to be re-created. The students I now teach take a great social history, but lack the knowledge and confidence to be a good doctor.