Studying-Medicine-Fair-Process-For

Studying Medicine – A Fair Process for Graduate/ Mature Applicants in the UK:

Reflecting back on National Health Service (NHS) Principles

* M Mr Shahid Muhammad B.Sc. (Hons) BMS Tox, LIBMS Biomedical Scientist Practitioner and Chief in Research for the Renal Patient Support Group (RPSG)

Address 15 Stoke Hill Stoke Bishop Bristol BS9 1JN England UK Email [email protected]

* C Corresponding Author

Studying Medicine – Fair Process for Graduate/ Mature Applicants in the UK;

Reflecting back on National Health Service (NHS) Principles

Abstract

Background: Medicine is a popular choice of study in Higher Education. Evidence suggests that there are more applicants applying to study than institutions can accept. In the UK, the application process for medical school is disorganised and perplexing as a result of there being a single admissions gateway, the

University and College Admissions Service (UCAS) for graduate and undergraduate applicants.

Aim: It is proposed that there should be a separate selection and admission process for graduate applicants to Medicine

Introduction: Since its launch in 1948, the NHS has grown to become the world’s largest publicly funded health service. The National Health Service (NHS) stands for patients their needs. Future medics need to have empathy and a strong background of experience in a variety of health and social practices.

Discussion: Medical school applicants should understand how the NHS functions and the admissions process should recognise this imperative in all types of applicants. It is apparent that the current process favours school-leaver applicants.

Conclusion: Two application processes are required which justify entry criteria separately and with integrity. This paper proposes that there should be a separate application process for the mature applicant reflecting back on NHS core principles.

Keywords: Medicine, Medical Programmes, Application, Entry, University and College Admission

Service (UCAS), Widening Access, National Health Service (NHS)

Introduction

Of foremost importance is the observation that the study of Medicine is in great demand, and this has increased competition across all types of applicant. Evidence suggests that there are more applicants applying to study Medicine than institutions can accept, despite the introduction of ‘extra’ requirements such as aptitude tests (Parry et al. 2006). A study has been conducted to inform the process used by

English schools for candidate applications (Parry, Mathers, Stevens, Parsons, Lilford, Spurgeon, &

Thomas 2006). Of particular importance, especially when reflecting back on patient care is the following:

“Different approaches to admissions should be developed and tested”

(Parry, Mathers, Stevens, Parsons, Lilford, Spurgeon, & Thomas 2006)

Some medical schools select a proportion of applicants via interview, remaining applicants being identified on a chance-weighted process for assessing academic attainment (Bore et al. 2005; Lumsden et al. 2005). The present application and admission process would be more accurate if it were geared around selecting which school-leaver applicants would make better doctors. Use of the same entry criteria for graduate/mature as for school leavers leads to discrimination. The current single application scheme (the University and College Admission Service or UCAS), exacerbates the problem. Graduate/ mature applicants though they meet the traditional entry criteria and have excellent potential are frequently disappointed (Bore, Lyall, Dempsey, & Powis 2005;Lumsden, Bore, Millar, Jack, & Powis

2005).

The objective for medical admissions is to select applicants who will achieve and comprise of good doctors regardless of their academic or career background (Lumsden, Bore, Millar, Jack, & Powis 2005).

Entry to study Medicine in the UK is based on academic endeavor, the process often being less than transparent (Lumsden, Bore, Millar, Jack, & Powis 2005). Despite changes in the stringency of candidate selection criteria, numbers of applications to study Medicine remain overwhelming. Ultimately the admissions and selection process should exclude all applicants who will devalue the profession. It is interesting to note the following statement:

“High academic achievement in school-leaving examinations has been shown to predict success in empathy”

(Lumsden, Bore, Millar, Jack, & Powis 2005)

Graduate applicants may demonstrate a variety of relevant attributes which are not tested by examination

(Lumsden, Bore, Millar, Jack, & Powis 2005). Prejudice may be introduced into applicant selection because within the present system institutions could ‘comparing’ two cohorts of applicants solely on their

GCE A-level grades. A graduate/ mature candidate may therefore productively have advanced his/her career in relevant areas to find this is not recognized as a valid medical admissions criterion.

Aim: It is proposed that there should be a separate selection and admission process for graduate applicants to Medicine

The National Health Service (NHS)

Behind this proposal is the recognition of the core values and mission of the UK National Health Service

(NHS) and the consequential requirements of today's clinical practices and the doctors which serve them.

Since its launch in 1948, the NHS has grown to become the world’s largest publicly funded health service. It is also one of the most efficient, egalitarian and comprehensive. The NHS was born out of a long-held ideal that good healthcare should be available to all, regardless of personal wealth and circumstances. NHS care offers everything from screening and routine treatments to transplantation surgery, accident and emergency treatment and end-of-life care (NHS - http://www.nhs.uk).

NHS Core Principles

Launched by the then minister of health, Aneurin Bevan in 1948, the NHS was founded on three core principles:

1. That it meet the needs of everyone

2. That it be free at the point of delivery

3. That it be based on clinical need

The NHS mission is two-fold:

‘We believe that the patients' needs and experiences are the first and uppermost consideration and the best outcomes result when patients, their carers and relatives and staff are active in decision taking’.

(The NHS - http://www.nhs.uk)

‘We believe in the continuous improvement in everything we do and that staff's dealing with patients, their families and each other should be conducted with courtesy, professionalism, integrity, openness and respect’.

(The NHS - http://www.nhs.uk)

In March 2011, the Department of Health published the first NHS Constitution, which covers the principles of the NHS and the rights of its patients. Patient rights embrace how to access health services, the quality care patients receive, the information, treatments and programmes available to them, patient confidentiality, and the right to complain. The NHS Constitution is written in consultation with health professionals and patients. This should be apparent to all medical applicants who should be expected to have a working understanding of what patient care really means. At the same time, quintessentially, medical schools' admissions officers need to reflect on these principles in maintaining standards.

Studying Medicine Frameworks & Guidelines

Medicine is an intensive career pathway and clinicians now need to be able introduce an understanding of basic science into practice and appreciate patient involvement in research (Thompson and Evans 2009).

The Tooke Report (2008) outlines proposals for the governance of medical training. The Medical

Schools Council (MSC) which governs medical education (MSC - http://www.medschools.ac.uk/) embraces its recommendations. The Royal College of Physicians (RCPH - http://www.rcplondon.ac.uk/) expects future doctors to demonstrate increased professional responsibility. This can be assessed neither in graduate/mature nor school -leaver applicants for

Medicine as a 'paper exercise'. The full range of roles and attributes a doctor require better

5 comprehension by school-leaver applicants whose understanding of collaboration and research are unlikely to be well-developed. Research experiences gained through internships are just as important as academic standing. Clinical and scientific research and collaboration are important criteria since they are continuously measured and should a graduate candidate for example possess such capabilities, these should highlight their competency and integrity to study Medicine.

What does the present application process involve and how should this relate to the NHS?

All candidates for places to read Medicine apply through one system via UCAS and this is the British admission service for students applying to university and college generally, including post-16 education

(UCAS - http://www.ucas.ac.uk/). The UCAS process is used by both school-leavers and graduate/ mature applicants. Applicants who want to apply to study Medicine have to demonstrate good discipline, rigor, perseverance, motivation and determination, together with the potential for patience, compassion and empathy towards patients and a variety of supplementary personal quality indicators. Applicants must also demonstrate that they understand the various medical career pathways and that they also require respectively (Anderson et al. 2011;Arnold et al. 1987). (See also (McHarg et al. 2007;Searle and

McHarg 2003).

The current policy applies a range of general criteria including academic achievements (i.e. cognitive measures) coupled with experience through internships or voluntary work. For the secondary education applicant, the expectation is to achieve exceptional GCE A-level grades (Albanese et al. 2003;Arnold et al. 1984;Lumb and Vail 1997;Weisman et al. 1972).

If a graduate/ mature applicant is offered an interview he/she receives a mini-objective structured clinical examination (or OSCE) including general questioning along the lines: ‘Why do you want to study medicine’? ‘What characteristics do you think make a good doctor’? How would you contribute in medicine and not forgetting, (probably the most important), ‘What do you think a doctors role should be’? Medical institutions are now stressing the number of hours doctors face as part of their general admission declaration, but many applicants (both school-leavers and graduate/ mature applicants) wanting to study Medicine acknowledge this (Powis et al. 2004; Benbassat and Baumal 2007). Further clarity and transparency are thus required

6 on entry criteria and the selection process in order to preclude selection bias and prejudice (Powis,

Hamilton, & Gordon 2004).

Present Issues and Complications

Traditionally, in both the USA and Canada, Medicine is read as a postgraduate degree. In the UK,

Graduate Entry Programmes (GEPs) are still in their infancy. In comparing the general 5-6 year curriculum over the 4 year GEP a strong emphasis emerges in GEPs on inter-professional working and research ethos.

The current application process is not transparent enough and actually seems to ignore the graduate/ mature candidate as having any of the requisite qualities at all. The ‘right’ candidate will value NHS principles, professional conduct, integrity/honesty and have good research aptitude and a scientific approach to clinical dilemmas. An excellent candidate will be able to explain how current practices can be improved through collaborations and patient involvement; these now being absolutely crucial in the health practice context. All applicants should be able to envisage and articulate their planned medical career. Tests might be implemented to give a more accurate picture of whether the graduate will be a good doctor other than by assessing academic achievements at GCE A-level. Admission tests for graduate/ mature applicants are currently deficient because medical admissions panels may overlook the minority of candidates in this group who would make very good doctors.

The UCAS system does not give mature applicants the opportunity to express their attributes in full, especially where proficiencies are demonstrated as actual competency indicators. This is one of the many reasons why potentially bright aspiring graduate/ mature applicants find it challenging to get themselves

‘recognized’ (Niven et al. 2013).

It is important and a challenge to devise a system which recognizes the existence of graduate/ mature applicants who value the impact of collaborations in Medicine and how best to achieve excellence in patient care. Open-minded Medical admissions panels should be on the look out for such applicants.

Admissions criteria should reflect a balance in the assessment of academic effort, experience and consistency. The current process (including admission tests) of applicants directly ‘compares’ the school- leaver and graduate/ mature candidates, creating inconsistencies in the admission and selection strategy.

Using GCE A-level grades to select school-leaver candidates is an excellent way to predict potential competency and rigor. Post-16 students should be complemented for demonstrating rigor ‘early’, but they may still have a premature understanding of the NHS. The graduate/ mature candidate on the other hand may have demonstrated both academic ability (in science or another discipline) as well as originality and sophistication. The Medical Schools Council (MSC) should develop policy to separate the two populations of applicants, noting the following:

“The humane physician can be characterized by four distinct qualities: technical competence, humanistic attitude, knowledge of humanistic concepts, and humanistic behavior”

(Arnold, Povar, & Howell 1987)

“In the 1980s, applicants with an education in the humanities were thought to be a good way of developing more compassionate physicians” (Neilson 2003)

Two application processes are required which robustly and separately justify strong entry criteria. In effect, the present application and selection criteria thus needs to reflect back to what the NHS principles and actual selection processes should be based on these core values.

Mature Applicants & Selection

The graduate/mature applicant has achieved a good Honours degree preferably in a scientific programme such as Biomedical Sciences, Pharmacy, Pharmacology, Biochemistry) (Dall'alba 2002;Kieser et al. 2009;Searle & McHarg 2003). Most medical schools now expect graduate/mature applicant to hold a postgraduate qualification, demonstrating an understanding of an aspect of medical practice.

The present application system prevents ‘unfair’ assessment of the graduate/ mature candidate’s attributes. At present, a particular confounding issue is using a ‘collaborative’ application process, which does not asses the mature/ graduate applicant fairly. In comparing graduate/ mature applicants institutions may consider students with arts or humanities backgrounds, the criteria differing from one institution to the next. However science backgrounds are becoming a prerequisite in the majority.

Mature/ graduate applicants who come from ‘lesser’ research / scientific-driven programmes on non-

8 science academic backgrounds will face issues in the future as more entities of practice will involve

Evidence-Based Medicine (EBM), critical appraisals and translational clinical science within their everyday work. Health practices are changing and new ones continually emerging. In this environment bright graduate/ mature applicants who demonstrate autonomy, relevant practical competencies will have considerable potential and will be able to relate their experience and knowledge closely to working in the NHS (Powis, Hamilton, & Gordon 2004).

In modern medicine, Medical school applicants must understand translational work and ‘humanistic’ comprehension from all of a healthcare professional’s viewpoints. Medical schools should be attracted by a candidate who has attained diverse understanding and familiarity, potentially being able to contribute across all health sectors, and demonstrating aptitude and flair in a fast-moving healthcare environment.

Where there is potential for graduates to make good clinicians, these contenders should be given an opportunity to express further talent, particularly where the candidate’s background suits dual roles, i.e. clinical and academic. A selection protocol is unfair if it disadvantages cohorts of applicants (e.g. particular graduates), by admitting candidates on the basis of criteria not directly relevant to whether or not the applicant will be a good doctor.

Appraisal of Medical candidate’s academic performance by grade point averages (GPAs) is dependable but one-dimensional. Graduate entrants are attracted to medicine because of a desire for fulfillment to care for the sick but also to bring clarity, variety and control (Rolfe et al. 1995; Rolfe et al. 2004).

Benbassat & Baumal (2007) have stated:

“Admission criteria are expected to be fair, transparent, evidence-based and legally defensible” and “… the use of the vast majority of non-cognitive admission criteria is not evidence-based and that, these criteria should not be a component of the selection process for medical schools”

There needs to a clear pathway for graduate/ mature applicants and admissions should be using clearer criteria to differentiate between school-leavers and mature applicants, with separate processes (Albanese et al. 2003; Kanter 2009; Prideaux and McCrorie 2004; Wilkinson et al. 2004). Table 1 highlights how medical admission panels can ‘set up’ their Entry Criteria and Selection Process of applicants more decisively.

Discussion

Attaining academic requirements are of obvious significance for the graduate/ mature applicant, but admissions criteria need to bring these together in order to identify indicators for professional clinical quality (Benbassat & Baumal 2007). A more rational and an efficient approach should be put in place for the selection of graduate/ mature applicants (Powis, Hamilton, & Gordon 2004). In the present investigation for the ‘right applicant’, other values need to be clearly demonstrated, with competence being paramount (Neilson 2003). An excellent graduate/ mature applicant may have demonstrated excellent clinical proficiency on the ward, a contribution to community health, and show professional finesse in diverse settings. The General Medical Council (GMC) (http://www.gmc-uk.org/) has highlighted best practice in a variety of health environments.

The present application procedure should be a concern (aptitude test or not); the application and selection processes are confusing. The present ‘system’ does not allow thorough consideration of graduate/ mature candidates relating to the needs of tomorrow’s doctors:

“What we really require from our admissions process is a student who loves science and has “a heart that never hardens a temper that never tires, and a touch that never hurts” (Neilson 2003)

Graduate applicants should anticipate a separate application process, respectively.

“Nationwide collaboration could provide opportunities for research to establish more efficient and effective ways of selecting tomorrow’s doctors” (Powis, Hamilton, & Gordon 2004)

What Medicine urgently requires is a candidate who bears fluency in medical/ clinical research, shows empathy, and is a clinician-scientist aspirant. If an applicant is also a long-term patient (who actually realizes translational efforts momentous to their own care), this is also a great advantage.

In a recent study asking the question, what does Medicine signify to students in undergraduate medical education?

None of the participants mentioned scientific or medical/ clinical research (Dall'alba 2002;Kieser,

Dall'alba, & Livingstone 2009). School-leaver applicants are accepted into Medicine based on potential competencies and for these particular applicants, competency can only be realized over time. Indeed the need to address ways in which medical knowledge and medical care are viewed needs to be continually

10 reassessed as part of the medical education process (Dall'alba 2002;Kieser, Dall'alba, & Livingstone

2009). Of importance is recognizing the wider roles of the doctor. Ultimately care for a patient is both on and off the ward ('off ward' implies through research and on-going professional development). In this respect to potential of the graduate/ mature applicant (e.g. research-clinicians, academics, and governance inducers) has been recognised:

“Medical schools no longer matriculate sufficient numbers of students who are deeply interested in science and beyond neglect, one could also hypothesize that modern admissions committees actually resist applicants who have aptitude for scientific achievement”

(Neilson 2003)

Conclusion

There needs to be a balance in the assessment of, and respect for, the attributes of the graduate/mature applicant to medical institutions. Part of the change required would be for institutions to reflect deeper on the core principles of the NHS and the attributes of graduate/ mature medical applicants 'in the round'. Additional merits to be included as potential selection criteria would be the research and publications output and contribution to clinical care and/ or interventions.

A separate entry application process is required for the graduate/ mature Medical school candidates for a number of reasons. There are six advantages in the implementation of the proposed process 1) it will better select ‘tomorrow’s’ doctors in accordance with MSC and GMC objectives; 2) graduate/mature applicants will be better ‘recognized’ for their distinctive attributes, 3) the application process will be less arbitrary, 4) selection bias will be reduced, 5) it will set a more established balance between graduate/mature and school-leaver applicants and 6) potential competency vs. actual competency will also be better distinguished.

If there is a graduate/ mature candidate who possesses a very unique insight in medical practices, then this individual (or individuals) should be considered seriously. Doctors ‘today’ need to know their patients' voices are important and that they influence decision-making processes. In essence, two

11 populations of applicants exist. Selection and admission of both groups of applicants should be maintained with balance, fairness and justice.

Instigating a separate application process and re-evaluating the credentials and criteria for the graduate/ mature aspirant doctor should be at the top of medical schools' educational agenda. At present there is potential selection bias and discrimination when comparing the two groups. Having a separate application process would provide medical admission panels with the knowledge of how a mature/ graduate applicant’s background reflects back to the values and mission of the NHS.

Recommendation

For graduate/ mature applicants, the application process should include submission of a curriculum vitae and personal statement and be separate to the UCAS approach, involving selection criteria demonstrating competencies relating to Medicine and reflecting on NHS core principles. This provides a parallel channel enabling assessment on a 'level playing field'.

TABLE 1 – PROPOSED ENTRY CRITERIA AND SELECTION OF MEDICAL

APPLICANTS

Candidate/ Qualification/ Additional Criteria Route Applicant School Leaver  Possessing good A-levels Entry onto a 6 year programme Applicant (1)  General Internships/ or Placements Competing solely against  Aptitude Test (Sole test; not applicable to school leaver applicants graduates)

 Possessing good A-levels Entry onto a 5 year programme School Leaver Applicant (2)  Specifically demonstrating academic/ research ability  Placements and clinical internships Competing solely against school leaver applicants  Community contribution  Aptitude Test (Sole test; not applicable to graduates) Graduate/ Mature  Degree 1st, 2:1 or 2.2 class, any relevant Allows entry onto a 5/ 6 year Applicant (1) subject programme  Clinical, academic/ research internships  Associated with professional/charitable Competing solely against organizations graduate/ mature scientist candidates  Aptitude Test (separate test for graduates only)  Similar to the existing system (but admission for the 2.2 (Hons.) graduate at present is dismissed) Graduate/ Mature  Degree 1st, 2:1 or 2.2 class in the sciences Allows entry onto a 4 year Applicant (2)  Masters of Science/ or Masters of Research programme  Clinical, academic/ research internships Competing solely with M.Sc.  Associated with professional/charitable applicants and potentially organizations PhD students  CV includes one or more publications  No Aptitude Test Graduate/ Mature  Degree 1st, 2:1 or 2.2 class in the sciences Allows access to 4 year Applicant (3)  Masters of Science/ or Masters of Research programme  Clinical, academic/ research internships Automatic access into  Community contribution Medicine will be on the  Associated with professional/charitable basis of research publication organizations record  Extensive clinical and scientific publication record  No Aptitude Test

References

 Albanese, M.A., Snow, M.H., Skochelak, S.E., Huggett, K.N., & Farrell, P.M. 2003. Assessing

personal qualities in medical school admissions. Acad.Med., 78, (3) 313-321

 Anderson, W.G., Winters, K., Arnold, R.M., Puntillo, K.A., White, D.B., & Auerbach, A.D.

2011. Studying physician-patient communication in the acute care setting: the hospitalist rapport

study. Patient.Educ.Couns., 82, (2) 275-279

 Arnold, D.M., Coe, R.M., & Pepper, M. 1984. Structure and function of medical school

admissions committees. J Med.Educ., 59, (2) 131-132

 Arnold, R.M., Povar, G.J., & Howell, J.D. 1987. The humanities, humanistic behavior, and the

humane physician: a cautionary note. Ann.Intern.Med., 106, (2) 313-318

 Benbassat, J. & Baumal, R. 2007. Uncertainties in the selection of applicants for medical school.

Adv Health Sci.Educ.Theory.Pract., 12, (4) 509-521

 Bore, M.R., Lyall, D.G., Dempsey, S.E., & Powis, D.A. 2005. Assessment of personal qualities in

selection of medical radiation science students. J Nucl.Med.Technol., 33, (3) 180-185

 Dall'alba, G. 2002. Understanding medical practice: different outcomes of a pre-medical

program. Adv Health Sci.Educ.Theory.Pract., 7, (3) 163-177

 Kanter, S.L. 2009. The future of academic medicine: what can Academic Medicine do about it?

Acad.Med., 84, (4) 405-406

 Kieser, J.A., Dall'alba, G., & Livingstone, V. 2009. Impact of curriculum on understanding of

professional practice: a longitudinal study of students commencing dental education. Adv Health

Sci.Educ.Theory.Pract., 14, (3) 303-314

 Lumb, A.B. & Vail, A. 1997. Applicants to medical school: the value of predicted school leaving

grades. Med.Educ., 31, (5) 307-311

 Lumsden, M.A., Bore, M., Millar, K., Jack, R., & Powis, D. 2005. Assessment of personal

qualities in relation to admission to medical school. Med.Educ., 39, (3) 258-265

 McHarg, J., Mattick, K., & Knight, L.V. 2007. Why people apply to medical school: implications

for widening participation activities. Med.Educ., 41, (8) 815-821

 Neilson, E.G. 2003. The role of medical school admissions committees in the decline of

physician-scientists. J Clin.Invest, 111, (6) 765-767

 Niven, V., Cabot, L.B., & Gallagher, J.E. 2013. Widening participation - a comparison of the

characteristics of successful UK applicants to the five-year and four-year dental programmes in

2007 and 2008. Br.Dent.J, 214, (3) 117-122

 Parry, J., Mathers, J., Stevens, A., Parsons, A., Lilford, R., Spurgeon, P., & Thomas, H. 2006.

Admissions processes for five year medical courses at English schools: review. BMJ, 332, (7548)

1005-1009

 Powis, D., Hamilton, J., & Gordon, J. 2004. Are graduate entry programmes the answer to

recruiting and selecting tomorrow's doctors? Med.Educ., 38, (11) 1147-1153

 Prideaux, D. & McCrorie, P. 2004. Models for the development of graduate entry medical

courses: two case studies. Med.Educ., 38, (11) 1169-1175

 Rolfe, I.E., Pearson, S., Powis, D.A., & Smith, A.J. 1995. Time for a review of admission to

medical school? Lancet, 346, (8986) 1329-1333 available from: PM:7475772

 Rolfe, I.E., Ringland, C., & Pearson, S.A. 2004. Graduate entry to medical school? Testing some

assumptions. Med.Educ., 38, (7) 778-786

 Searle, J. & McHarg, J. 2003. Selection for medical school: just pick the right students and the

rest is easy! Med.Educ., 37, (5) 458-463

 Thompson, D.G. & Evans, T.W. 2009. Coordinating academic training for physicians. Clin.Med.,

9, (1) 7-8

 Weisman, R.A., Weinberg, P.C., & Winstel, J.W. 1972. On achieving greater uniformity in

admissions committee decisions. J Med.Educ., 47, (8) 593-602

 Wilkinson, T.J., Wells, J.E., & Bushnell, J.A. 2004. Are differences between graduates and

undergraduates in a medical course due to age or prior degree? Med.Educ., 38, (11) 1141-1146

Websites

 The General Medical Council (GMC); http://www.gmc-uk.org/

 The Medical Schools Council (MSC); http://www.medschools.ac.uk/

 The NHS; http://www.nhs.uk/

 The Russell Group (RG); http://www.russellgroup.ac.uk/

 The Royal College of Physicians (RCP); http://www.rcplondon.ac.uk/

 The Tooke Report; http://www.mmcinquiry.org.uk/

 The Universities and Colleges Admissions Service (UCAS); http://www.ucas.ac.uk/