Can we improve on how we select medical students?

Getting the right policy for admission to medical school is a balancing act: be fair to society by choosing people with the potential to be good doctors; and be fair to the applicants—that diverse group of people who for many reasons want to set out on the long road to a medical career. Selection is not an exact science but we must use what evidence we have to ensure that we do our best by all concerned. There is widespread agreement that we should select future doctors on wider criteria than scores of academic success1,2, though in practice many medical schools have valued pre-admission academic scores at the expense of other considerations3. There are recognized drawbacks to the use of school exam performance even as a measure of intellectual competence. One study has shown that a major causal determinant of A level results is social class, independent of ability4, and some would-be medical students elect to focus on sciences for their school leaving exams because very high marks are more easily achieved in the physical sciences than in the humanities5. The conviction that only exam results give valid and reliable data has been trenchantly dismissed as a ‘seductive but fallacious’ belief in the precision of quantitative tests6. We are reminded that all selective instruments depend on subjective judgments and each must be accountable to the rules of reason, fairness and public scrutiny7. However, if we decide to consider non-cognitive criteria, a legitimate concern is that the many specialties of medicine need diverse skills and they must not be too narrow. We also want to be reassured, if we include noncognitive characteristics, that we can assess them reliably and that such evaluation can predict personal character over years of practice. While we need to maintain diversity of skills and personality, there are some characteristics which we demand in any doctor. Enough intellectual ability to do the job, plus honesty, integrity and conscientiousness, must be at the heart of good practice8. Helpfulness and willingness to cooperate come close behind8, while patients give high priority to interpersonal skills and empathy2. The personal welfare of the profession is another consideration9. Doctors are more vulnerable than comparable professional groups to alcoholism, drug abuse and suicide10,11. Burnout is well recognized, and has a high cost for the individual, for colleagues and for the quality of service that patients get12. One answer may be better support for psychologically vulnerable doctors12,13 (together with improved working conditions for all doctors), but perhaps we should try to evaluate ability to deal with stress right from the start.