An important question for health care practice is ‘who becomes a doctor’ or more specifically ‘who chooses and who is chosen to enter medical school’.  Medical schools can support only so many students due to the size of facilities and, particularly, access to clinical learning spaces such as hospitals, clinics and general practices. Some countries have strict limits on the numbers of who students receive government funding for training, though such financial support does not usually cover all expenses.  Becoming a doctor is an increasingly expensive endeavour and this has repercussions for access to medical school.  

I now realise how fortunate I was to be educated during the 1970s in England.  University education was ‘free’ for most people in that it was covered by taxation.  Additionally, as well as tuition fees students received grants that were means-tested, so that those from lower socioeconomic communities received more money for living expenses than those from wealthier families.  My family was working class and I received about three-quarters of a full grant, with my parents expected to make up the rest, which they did.  Therefore, my choice of degree was not affected by cost but rather by ability and career aspiration.  This is not to say that elitism did not play a part in access to certain universities.  I was advised by my school in Manchester not to apply to certain London medical schools as they were unlikely to consider girls from northern English backgrounds.  In time I graduated as a doctor without any debt, and I am sure that has had a major influence on my life. 

These days the cost of a medical degree (which can involve from five to seven years at university) is high.  In many countries this had had the effect of reducing the diversity of the student population.  Not only are many socioeconomically individuals put off by the prospective high debts, but they are less likely to consider that becoming a doctor is possible from their backgrounds.  Young people at schools where a high proportion of the student body goes to university and there is a large number of past pupils in medicine have more role models to emulate.  Moreover, a high proportion of medical students have one or more medical parents. 

Does this matter?  

People can only be chosen to enter medical school if they apply.  What criteria are then assessed to reduce the pool of applicants to the chosen few?  Perhaps the question would be better worded as what criteria should be assessed which then leads to asking: what attributes are necessary to become a doctor?  I use attributes rather than knowledge and skills as most of these are taught, though not always learned, at medical school.  So, we are considering how to choose an individual who has the potential to become a doctor in several years’ time;  and, more specifically, a good doctor.  

There are many lists of the qualities or core values or attributes needed to study medicine and become a good doctor.   One example has been published by the Medical Schools Council of the United Kingdom^[1], which has been endorsed by all British medical schools. It is not surprising it includes academic ability and a genuine interest in the medical profession, as well as effective communication and problem solving.  But there are items that are more difficult to assess such as insight into own strengths and weaknesses, dealing with uncertainty, honesty and empathy.   

Academic ability is gauged by test results and medical schools look for students with the highest marks in school-leaving examinations or prior university degrees. For some medical schools, test results are the only parameter considered.  This is logistically an easier option and less resource intensive than a more detailed scrutiny of candidates.  Other medical schools consider that academic ability is necessary but not sufficient and conduct interviews or have away days to observe potential students undertake tasks.  There are a lot of studies looking at how various methods of recruiting students discriminate and predict future performance. Future performance here tends to mean success in medical school examinations rather than longer term professional impact. We know that students who do well in examinations before medical school also do well, on the whole, at medical school assessments, which is not unexpected.   Some countries also have national entry examinations for medical school.  These assessments cost money, not only to sit the tests but also for courses to help prepare for them, adding to the financial burden for many candidates.

When I applied to medical school during my final year at secondary school I chose five universities to list on the form. The choice was based on location more than anything else as I had little knowledge of how each school might differ in terms of the program offered.  I presumed they would be similar, and the prospectuses seemed to suggest this.  There were obviously no websites to look at in 1974.   Of these five, the two London schools had formal interviews, Newcastle and Edinburgh had open days to showcase their courses, and I didn’t hear anything from Birmingham (maybe because it wasn’t top of my list).  Interviews were a panel of dignitaries.  My memory suggests that the London panels were all male. And yes, I was asked why I wanted to become a doctor.  Rumours abounded that it would be easier to get an offer if you were male and played rugby.  I can’t remember much else about the process though the interviews lasted about 20 minutes. 

Victoria Wood, the late great British comedian, did a sketch in the 1980s in which she was a nervous school kid being interviewed for medical school.  It’s funny and toe-curling and similar to my experience.  A great answer to the question: do you think the National Health Service is crumbling or doing very well? She answered: ‘I think part of it is crumbling and part of it is doing well.  You have to look at both sides really.’  And, in response to the standard question about qualities – what qualities do you think you’ll bring to the medical profession? Are you particularly warm or compassionate? – ‘I’m quite tidy’.^[2]

By the 1990s educators were questioning the objectivity of the interview process and those medical schools that continued to include them experimented with different formats.  There were standardised questions that were asked of all candidates.  Some panels included a medical student.  Some even recruited local community members (the patient voice) as interviewers. Research papers were published about ways to make the process fairer and reliable. The important consideration was still whether traditional interview formats predicted future performance in medical school.  Were individuals being admitted who failed to become doctors or who had behaviour unfitting for the profession?  Some people were turned down by one school but were successful to gain entry to another.   But no-one could know whether those who never got into medical school would have been as good doctors as those who did – if they they had had the opportunity.

In 2001 a Canadian medical school introduced another interview structure: the multiple mini-interview (MMI).  This consists of a number of ‘stations’ each of which has a separate task with structured marking scale, focussing on critical and analytic thinking, communication and interpersonal skills, current events and ethical decision making.  All candidates rotate through all the stations, which typically last about eight minutes each with two minutes for preparation; there may be eight to ten stations.  The task is based on a scenario and the applicant engages in a discussion with the examiner who may be role-playing a patient or colleague, for example.  One station (very pertinent for 2023) might ask the examinee to role play a first year doctor (intern) while the examiner role plays a patient who is asking about the pros and cons of having a Covid-19 vaccine and the differences between the ones available.  This situation requires the candidate to have up-to-date information about the vaccines, their efficacy and side effects, be able to communicate these to the patient in easily understandable language, and have excellent interpersonal skills to be able to elicit and respond to the patient’s reluctance and concerns.  There are usually no right or wrong ‘answers’ for the stations – it is the applicant’s skills, their knowledge and its application, and ability to present a reasonable argument that are scrutinised.

The MMI process has been evaluated by many researchers over the last two decades. It is not confined to the selection for medical school but is also used for other health professional training such as psychology and pharmacy.  The scores on a MMI have been shown to predict performance of students in assessments at university particularly in relation to communication skills and patient-facing interactions.  However, the major issue for this selection approach is the cost in terms of examiner and administration time.  There is a wide variation in the number of students starting medical schools, but many have 200 to 500 entering year 1. If at a minimum two people go through an MMI for each one offered a place and the MMI has 8 stations with a total time of 90 minutes, that is 600 hours of examiner time for 400 applicants. This doesn’t include administration and other logistics. Given the time and expense it is no wonder that some schools choose to use school leaving or university degree marks as the sole criterion for entry. 

In the UK and Australia medical students may start medical school straight after high/secondary school (at around age 18) but some schools require a first university degree (graduate entry schools) so that students are older (at least 21) and thought to have more life experience.  Graduate entry is the norm for all medical schools in Canada and the US.   Educators have compared the two approaches in terms of academic performance and progression though the findings are inconclusive. 

What is known though is that becoming a doctor is expensive and there is concern that the selection and fee structures favour individuals from higher socio-economic groups.  This means that the medical profession does not reflect the society in which the doctors practise.  There are several initiatives underway to help diversify the medical student population. In the UK these are referred to as ‘widening participation’ and ‘widening access’, with the aim of increasing the proportion of students from socially and educationally disadvantaged groups and from Black and Black British backgrounds, as well as individuals with disabilities.  Successful entrants from other ethnic minorities are over-represented at medical school compared to the general UK population, while there are fewer entrants to medical school from lower socioeconomic groups compared to other higher education programmes.  These figures are important as many studies have shown that medical students’ backgrounds influence their future practice and that those from poorer families are more likely to practise in underserved communities once trained. But all students need to have an awareness of the social determinants of health – those non-medical factors that influence health such as employment status, income, housing, social isolation and years of education.   

One thing that has changed to better reflect society, however, is the proportion of females admitted to medical school compared to males.  The figure has risen steadily over the last 30 years in English-speaking countries.  In the US women outnumbered men at medical school for the first time in 2019^[3] while this occurred much earlier in the UK (around 1996).^[4]  When I was at medical school in the 70s-80s about 35% of my class was female, in 2016 this figure was 57%.^[5] There are many reasons for the increase including the merit-based changes to the selection process which reduced class and gender discrimination and the higher educational attainment of girls compared to boys.^[6]

I remember very little about my own two medical school interviews in London, which I managed to organise for consecutive days.  My mum sorted out a night’s accommodation at the YWCA, a cheap and central option for my second ever visit to the capital.  The train journey from Manchester was about two and a half hours.   I must have done ok because I received an offer of a place at my preferred school and six months later I was on my way to becoming a doctor at University College London. 

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^[1] https://www.medschools.ac.uk/media/2368/msc-infosheet-good-doctor.pdf

^[2] https://archive.org/details/barmynewvictoria00wood/page/n167/mode/2up

^[3] https://www.washingtonpost.com/health/the-big-number-women-now-outnumber-men-in-medical-schools/2019/12/20/8b9eddea-2277-11ea-bed5-880264cc91a9_story.html

^[4] https://www.bmj.com/bmj/section-pdf/959692?path=/bmj/360/8138/Careers.full.pdf

^[5] https://www.medschools.ac.uk/media/2536/selection-alliance-2018-report.pdf

^[6] https://academic.oup.com/bmb/article/114/1/5/246075