Selecting medical students: an Australian case study

The recognition that medical practitioners require more than simply a high level of academic ability to function successfully in their profession, together with a sharp increase in the number of academically qualified applicants to medical courses, has led to new ways of selecting medical students. Consequently the selection of students into the high-stakes course of medicine has become an area of considerable interest and research activity. The issues involved in selection are now prominent in the medical and medical education literature published in the UK, the USA, Australia, New Zealand and Canada, and in some European countries. At the same time as the introduction of new selection procedures, and independently of it, due to advances in pedagogy the nature of the medical curriculum has also changed. Changes have been characterised by the use of problem-based learning, and an emphasis on self-directed learning, as well as an increase in interaction between the students in classes and between students and their teachers. The recognition that problemsolving, communication and interaction skills in the courses, in addition to the requisite intellectual capacity, would enhance performance as practitioners, has reinforced the need for students to be selected on a different set of attributes from those used previously. In Australia, changes in the way in which medical students are selected were initiated by the University of Newcastle in the early 1990s, with the introduction of some tests of cognitive skills and an interview. Over the following ten years, the other Australian undergraduate medical schools followed suit and a three-component selection process developed in an attempt to differentiate among the high calibre applicants to medical courses, by identifying additional important skills and attributes. The three components are the academic score, results on an aptitude test and results on a selection interview. Two of the nine undergraduate medical schools chose not to use a selection interview. The focus of this thesis is on evaluating the new selection processes and investigating the consequences of the admission of school-leaver applicants into undergraduate medical courses, where the Tertiary Entrance Rank (TER) is the academic criterion for determining suitability to undertake tertiary studies. Each undergraduate medical school has developed its own unique way to operationalise the selection of its students. However, the use of the Undergraduate Medicine and Health Sciences Admissions Test (UMAT), which developed out of the University of Newcastle’s test of cognitive skills, and the conduct of an interview for a select group of applicants are common to these practices. The implementation of the new selection processes has not been without its critics, mainly from within the medical profession. This thesis studies the issues which underlie the three components of selection (the TER, the UMAT and a selection interview) and uses as a case study the particular process used to select students into the six year undergraduate medical course at The University of Western Australia (UWA). The UWA selection process involves applicants passing a threshold score on each of the three components and then being ranked by a mechanism which combines the three scores with equal weight. This is a compensatory system in which applicants can compensate for a score near the threshold on one component by high scores on the other two components. This study showed that the resultant cohort is eclectic in its characteristics, with the full range of scores (above the threshold) in each component being represented. Both qualitative and quantitative methods of data collection were used to address the issues surrounding the way in which medical students are selected and the outcomes of such processes. First, semi-structured interviews were held with different groups of stakeholders, including the staff at secondary schools which prepare the students for tertiary entrance; academic and administrative staff at The University of Western Australia (UWA); academic and administrative staff at other Australian universities; and senior staff at the major teaching hospitals in Western Australia. Secondly, quantitative studies on UWA data addressed the predictive validity of the components of selection; inter-rater reliability and the internal consistency of the data sets from the selection interview; and the attrition rate in the course. Outcomes from the research showed that in general, the reactions from stakeholders have been positive. Importantly, academic levels amongst medical students and recent graduates do not appear to have been eroded by the new process, in which the academic threshold has been lowered. The UMAT is a contentious national test which has had its validity as a selection instrument questioned. A recent construct and content validity study on the UMAT (Mercer and Chiavaroli, 2006) has gone some way towards settling some of these issues, but the question of predictive validity has yet to be addressed adequately. The existence of commercially available preparation courses has been controversial because of the equity issues involved for those applicants who for some reason do not have access to such courses. The selection interview, one of the three components of selection, conducted by the Faculty of Medicine, Dentistry and Health Sciences at UWA, whilst attracting criticism from some for appearing stilted and overly prescriptive, was judged to be robust and rigorous by many of those directly involved in its implementation. Furthermore a high proportion of medical students were judged by their teachers to have good communication skills, which is a positive outcome for future members of the profession. A study to quantify reliability indices for the UWA selection interviews indicated high levels of inter-rater reliability and internal consistency of the ratings data produced. The predictive validity study conducted as part of this study showed the two major predictors of course outcomes at UWA to be the TER and female gender. The TER predicts outcomes in the knowledge-based units across the course and in some clinically-based units in the later years. However, the interview score (in particular the Communication Skills component) and scores on the first section of UMAT (Logical reasoning and problem solving) also predict outcomes in some of the clinically-based units. The results of these studies are encouraging to those who believe that the new selection process, whilst imperfect, has gone some way towards solving the problems attached to selection based solely on academic merit. The question now becomes how to improve further on the selection of medical students and to do so in an evidence-based way. The characteristics to be included in selection remain controversial. The rigorous assessment of such characteristics needs to be addressed in the longer term and will be an evolving issue, as the medical curriculum and the nature of the profession also continue to change.