Are we selecting the right medical students?

Medicine is not so much a job we do; it is who we are, defining us as individuals. Medical training is not just an academic exercise, rather it is a rite of passage into an all-consuming culture that not only defines our working lives, but in many cases shapes our social network, including friends and partners. Selecting the right medical students, therefore, is one of the most important and challenging tasks we can ever do. Getting it wrong is not only costly in financial terms, but can cause untold damage to the student, the doctor they become and to the patients they go on to treat. I have experience of both sides of applying to medical school: as a candidate myself; as chair of a medical school selection committee; and latterly as an anxious parent as I watch my daughter prepare for her application to medical school this autumn.

Medicine, without doubt is very stressful, yet many prospective students still see the profession through rose-tinted spectacles and fail to fully appreciate the workaday stresses of life in the National Health Service (NHS) as enumerated in the British Medical Association’s 2022 submission to the Parliamentary Health Committee. ¹ Based upon data from multiple NHS Staff surveys, it was revealed that 30% of doctors felt burnt out, and 27% reported symptoms of post-traumatic stress disorder, citing punishing workloads, stress, physical exhaustion, and the verbal and physical abuse of staff by patients. They further commented that the system has been run on goodwill for many years and the coronavirus disease 2019 pandemic merely exposed established fault lines that have long dogged the service.

Despite the current media focus on doctors’ pay and conditions, we mustn’t overlook the importance of retention within the workforce. When I entered the medical profession 40 years ago, ‘dropping out’, either as a student or junior doctor, was almost unheard of. Now, it barely raises an eyebrow and begs the question – are we recruiting the right people?^2,3 There are many reasons why doctors become dissatisfied with their career: some generational, older colleagues hankering for the ‘good old days’, such as ‘the firm’, the doctor’s mess and what was a relatively unchallenged, autocratic lifestyle. Younger colleagues who never knew those times become frustrated for other reasons: task-based work, often repetitive and intellectually unchallenging, a lack of continuity of care or sense of belonging within the workplace. ¹

At present, despite efforts in medical school applications to assess so-called ‘soft skills’, the emphasis is still very much on selecting the most academically able students and clearly, in some cases at least, we are getting it wrong. Although we may be loath to admit it, you do not need the brains of the proverbial rocket scientist to pursue a successful career in medicine; in a protocolised, tick box culture, being a doctor in the 21st century may be seen as intellectually unrewarding and perhaps the time has come to recalibrate the way we select our future colleagues? Moreover, selecting the ‘brightest and most academically able’ for a career where they will be overseen by non-medical managers, who may be less experienced, clinically naïve, less well trained, and in some cases, less intelligent, is a recipe for job dissatisfaction. Perhaps we should be selecting students better suited to the current culture in healthcare? Doctors need to be academically good enough, but that doesn’t necessarily mean A* grades. In the modern workplace, the academically most able are probably more likely to experience frustration and disillusionment. Such students are (almost by definition) perfectionists by nature and there is evidence to suggest that these individuals are particularly susceptible to moral stress, burnout and the mental health problems that ensue.^4,5

Other elements of the selection process are also in need of reform: personal statements may be heavily edited, or even ghost written, and work experience, now demanded by almost all medical schools, is of variable quality and relevance and often obtained randomly, as a result of parental connections favouring students from more privileged, and better-connected backgrounds. Medicine aptitude tests such as UCAT and BMAT are useful; however, students from good schools often receive coaching tailored to these tests, as well as for interviews.

Undergraduate medical training needs reform: medical schools should revise their first year of study with an introductory lecture-based course to help orientate students in preparation for a six-month work-based placement. This placement may or may not be clinical, but would need to be professionally relevant, in which skills such as resilience, team working, communication and decision making can be assessed in real time. It would also create a level playing field and overcome the current iniquities of work experience prior to selection. At the end of this year, successful students then go on to complete their training. Some will see for themselves that they are unsuitable and vote with their feet, others will be deemed unsuitable to proceed by the medical school. Importantly, students who progress will do so with their ‘eyes wide open’, knowing what they are letting themselves in for. A first-year preparatory lecture-based course could also be multidisciplinary, creating a better understanding of other healthcare professions and fostering mutual respect. Students deemed unsuitable, or who elect not to proceed further, should be counselled and given transferable credit and an honourable opportunity to switch to a more suitable course that should not be perceived as failure.

Of course, this is expensive both for students and universities. Government, however, has already suggested that traditional medical training be reduced to four years, thereby saving money; and, of course, every student or junior doctor dropping out comes at a considerable cost to the taxpayer. Payback, whereby student tuition fees and maintenance are offset by time spent subsequently working in the NHS, would not only improve retention among junior doctors, but it would also relieve the burden of student debt as it is clear that debt is now a big consideration for students when applying to university, particularly among those from more disadvantaged backgrounds, actively discouraging them from applying to medical school. Such a system has worked effectively for many years in countries such as Singapore and the UK military, where cadetships fund the clinical course in return for the student giving six years of subsequent service, thereby disincentivising abandoning a career in medicine prematurely.

Our students are our most precious asset and choosing them carefully is vital for them as individuals as well as for the future of the medical profession. Investment at an early stage would be more than offset by the savings made in reducing dropout rates later on. Future doctors will only thrive if they are the best fit for the healthcare culture. If we continue to select on the basis of academic excellence and continue to choose the ‘brightest and the best’, current workplace culture will have to change if we are to address the retention problem. Alternatively, if the current trend toward over management and the demeaning of doctors continues, then we need to seriously look at the qualities our students will need to survive in this intellectually restricted environment and academic excellence alone may well not be one of them.