A few years ago, I was invited to act as an external mentor at a medical school in the United Kingdom. The medical school in question was under pressure from a new dean to change its admissions process. As my first day at the school progressed, I struggled to remain neutral while listening to comments about “our kind of student” and justifications for keeping an admissions process that was woefully outmoded. I could not understand why the school was reluctant to give up a process that was at least 20 years behind current knowledge. I naively thought that, once I presented an overview of the evidence base, they would see the error of their ways and change their admissions process dramatically. Then all would be well with the world.
Of course, that was not quite how things worked out. Yes, they adjusted their admissions process, but, from the outside looking in, these adjustments did not affect the “kind of student” they selected.
This experience, and others I have had over the last few years, have demonstrated to me that, while medical schools typically use a student’s prior achievement as the first hurdle in their selection process, this practice is fundamentally a means to manage the large numbers of applications schools receive and to whittle down those applications to manageable numbers for later stages of the selection process. These later stages, usually culminating in some sort of interview, enable medical schools to select “their kind of student.” Schools then assess how good their selection process is using metrics such as assessment performance, retention rates during medical school, the number of students graduating, and the success of their alumni on later indicators of academic ability and clinical competence, such as Royal College of Physicians or specialty board examinations.
These metrics are important, but if individuals are good enough at passing exams to get into medical school, they likely will remain good at passing exams. Is it time then to shift our views on what constitutes good outcomes against which to measure our admissions process? Should we look not at our students’ academic achievements but at their career outcomes, such as working in direct clinical care, working in underserved regions, and/or working in certain specialties?
This shift may be challenging given that we do not seem to be very good at selecting applicants who are fit-for-purpose in terms of meeting the health care needs of the public. Globally, doctors are poorly distributed to meet population health needs in terms of discipline and location. Urban posts are generally preferred to rural ones. Some specialties are oversubscribed, while others struggle to recruit. Growing numbers of doctors are also leaving clinical practice. In the United Kingdom, approximately 50% of our medical school graduates—those selected to medical school via a highly competitive process—are choosing to step out of the training pipeline at the first opportunity, while keeping their options open (i.e., with full registration and eligibility to apply for higher training). These graduates opt to take a break from training, often working overseas for a period of time. Of course, many do return to resume training and working in the United Kingdom, but not all do, leading to empty posts now and a potential shortage of doctors in the future. This example may be extreme, but we do see doctors quitting direct patient care during or after residency training in other contexts as well.
Why is this? Medical education is a complex social system where, intentionally or not, medical schools focus on reproducing cultural, historical, and social norms. The medical school admissions process relies on traditions and taken-for-granted assumptions, which are often (but not always) unarticulated and unacknowledged values, attitudes, and beliefs. These are, in turn, grounded in the culture, history, and location of the medical schools and the universities in which they are situated.1 Although there is some variation by school in terms of the weighting of increasing diversity and/or selecting applicants for personal attributes, for example, the overarching driver in selection is typically maintaining the highest standards of academic excellence. In this system, medical schools will prioritize applicants who have demonstrated (via prior academic attainment) that they can successfully progress through assessments and then graduate, thus maintaining the school’s reputation as a prestigious institution within a competitive, global education marketplace. In short, medical schools are trapped on a carousel where institutional and systemic factors are shaping admissions policies and practices, limiting the opportunities for a shift toward using more meaningful, workforce-related outcomes.2
Simple solutions have been suggested to address these complex social, cultural, and political drivers. For example, one simple workforce solution to the maldistribution of the physician workforce is to increase the number of students admitted to medical school. If the number of medical students increases, the argument goes, health care needs will be met. However, increasing the number of students will have little impact on meeting the health care needs of the public if medical schools continue to select the same types of students. Selecting more of the same students will merely increase competition for the urban, high-status positions that are already popular. In his recent work, Gorman3 provides an excellent overview as to why “flooding a medical labour market will not by itself improve the match of doctors to need.”
Perhaps, then, one of the first steps in aligning admissions policies and practices with meeting the health care needs of the public is to acknowledge that simple, linear solutions cannot be readily identified (and those that have been, like increasing the number of students admitted to medical school, are unlikely to work). Rather, we must step back and think very differently about medical school admissions.
My first suggestion toward this end is to broaden our thinking about who decides on medical school admissions processes and selection outcomes. Typically, local admissions teams and/or national special interest groups, which often consist only of medical educators, have this responsibility. Stopping the current selection carousel may require bringing into the process the perspectives of other key stakeholders, including government officials, regulators, local communities, parents, applicants, patients, and high schools, to name a few. These stakeholders are likely to have different perspectives on the admissions process and its outcomes. For example, government officials want to ensure that the supply of doctors coming out of medical school can meet local demand. Local communities want doctors who will deliver care in their region after graduation. Regulators want medical schools to select not just applicants who will graduate but also those who will become good doctors (however that is measured). Parents, high schools, and medical school applicants themselves will have yet another stance on the purpose and outcomes of admissions processes.
Each group believes that their stance on medical school admissions is the right one, and there is relatively little dialogue between groups. Indeed, most often communication between groups takes the form of directives from the group with the most power (in the case of the government, for example, they may issue mandates to medical schools to increase the number of students admitted from particular societal groups). However, true change will depend on collaboration and dialogue between stakeholder groups to consider multiple interpretations of the same admissions phenomenon and how best to select applicants who will go on to meet the health care needs of the population. One model for this type of dialogue could be that of patient and public involvement in research, which aims to help researchers ensure that the design of their research is relevant, participant friendly, and ethically sound.
Second, fundamental systems changes need to happen if we are to align input (medical students) with output (producing doctors to meet the public’s health care needs). Instead of assessing medical schools by how many of their graduates go on to obtain prestigious postgraduate examination scores, for example, we should judge them by how many of their students go on to work in underserved areas and/or disciplines. Schools that produce doctors who work in areas of need (e.g., family medicine, psychiatry) should be rewarded, not penalized, when the grades of their matriculants drop, for example, as this change may have been necessary to achieve their desired outcomes.
Third, shifting to different outcome measures potentially has huge implications for selection research. The main focus of admissions research currently is the psychometric qualities of selection tools—studies typically examine the relationship between students’ performance on examinations at selection with their performance later on.4 If the outcomes of interest for medical schools shift toward graduates’ practice location and specialty, the development and evaluation of new selection processes and tools will be needed.
Medical schools must understand that their dual role is to select applicants who will both graduate with a medical degree and go on to provide care across the full range of health care contexts to diverse populations. To achieve this goal, we must challenge engrained attitudes about the “kind of student” we want and actively consider whether a medical school admissions process is privileging applicants whose backgrounds and pathways in life are similar to those who are leading the selection process. Using currently available research, jointly working across stakeholder groups to develop this evidence base further, engaging in change, and thinking differently are essential for the viability of our health care workforce in rapidly evolving health care contexts. We must engage more reflectively and collaboratively in debates about how to align medical school admissions and meeting the health care needs of the public.
1. Cleland JA, Nicholson S, Kelly N, Moffat M. Taking context seriously: Explaining widening access policy enactments in UK medical schools. Med Educ. 2015;49:2535.
2. Whitehead CR, Hodges BD, Austin Z. Captive on a carousel: Discourses of “new” in medical education 1910–2010. Adv Health Sci Educ Theory Pract. 2013;18:755768.
3. Gorman D. Matching the production of doctors with national needs. Med Educ. 2018;52:103113.
4. Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland J. How effective are selection methods in medical education? A systematic review. Med Educ. 2016;50:3660.