The role of general practitioners in medical school admission interview panels in the UK (2012–2014): a national survey

Background

In recent years, there has been a growing workforce deficit in general practice in the UK National Health Service (NHS). ¹ Although policymakers have emphasised the need to shift care into the community ² and provide a more comprehensive primary care service throughout the week, ³ concern has been expressed about how this will be achieved given the recent yearly reductions in applications to general practice specialty training. Indeed, current and projected shortfalls in general practitioner (GP) numbers have prompted a number of national reviews of the primary care workforce to be commissioned.^4,5

Although some researchers have been exploring opportunities to increase the role of allied health professionals such as physician associates ⁶ and pharmacists, ⁷ there has also been a focus on understanding the reasons why doctors are not choosing general practice as a career. ⁸ In the UK, doctors spend two years in foundation training after graduating from medical school and make their application to a specialty training programme in the first half of the second year of this training. Junior doctors will typically, therefore, have less than 18 months of clinical experience at the time of applying to specialty training. As a result, experiences during undergraduate medical training are likely to feature prominently in the choice of specialty training, leading to particular interest in the role of medical schools in influencing career decisions. ⁹

Medical schools are required to expose students to a variety of clinical settings representative of the environments in which they may go on to practise. In recent decades, the expansion of academic general practice as a discipline has helped to increase the profile of GPs in medical schools, and this has been cited as a reason why curriculum time in general practice has increased in recent decades. ¹⁰ General practice placements early on in the medical course have also been a major contributor to meeting the General Medical Council objective of having early patient contact in undergraduate medical courses. ¹¹ However, a recent survey of medical schools across the UK showed that time spent by medical students in general practice placements has actually fallen in the last decade and cited this as a potential factor explaining the reduction in interest in applications to GP training. ¹²

A particularly important area of medical school activity is the admissions procedure. Medicine remains one of the most oversubscribed university courses, so that medical schools’ admissions processes can considerably influence the aspirations of the future clinical workforce. It has been suggested that an improved focus on relevant traits during admissions may improve the likelihood of selecting students that will go on to choose a career in general practice ¹³ so that GP involvement in the process may help identify students with the relevant traits for that specialty. A review of UK medical school admissions in 2006 highlighted that interview panels were variable in size and composition. ¹⁴ There was no indication, however, of the background of those either leading the admissions process or participating as interview and assessment panel members. As the professional background of those involved in admissions procedures may influence the decisions they take, this study sought to explore the clinical specialty backgrounds of admissions leads and of interview and assessment panel members at UK medical schools, with a particular focus on the proportion who are practising GPs.

Methods

The authors developed a proforma and piloted it with a medical school Associate Dean, leading to refinements. The final version requested information from medical schools about the professional background and clinical specialty (if medically trained) of the admissions lead for undergraduate medicine courses (A100 and A101) and the make-up of interview or face-to-face assessment panels for these courses in the 2012/2013 and 2013/2014 academic years. This proforma was distributed by the Medical Schools Council to admissions leads at all UK medical schools, through the Medical Schools Council Assessment Alliance, a partnership to improve undergraduate assessment practice through collaboration between all 33 undergraduate medical schools in the UK. A reminder was sent out four weeks after the initial distribution. Responses from collegiate universities were collected individually and pooled to give a single institutional survey response. Institutions responded between June and July 2015. Results were anonymously collated and reported to the Medical Schools Council in a report in Autumn 2015.

Results

Eighteen out of 33 eligible medical schools (54.5%) responded to the survey.

Admissions leads

The professional background of medical admission leads across respondent school is shown in Table 1. Of note, 44% of admission leads were not clinical in background and only two individuals (11%) had backgrounds in general practice, one of whom was additionally accredited in another specialty.

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Table 1.

Admissions leads’ professional background.

Clinical background	Number of schools
Secondary care clinician	7
General practitioner	2
Non-clinical	8
No clear lead individual	1

Interview and assessment panel members

Three schools were unable to supply detailed numerical data but provided a textual response. One was unable to complete the form, as they do not collect the data requested, stating that ‘at least one third of selectors come from secondary care backgrounds’. They provided no indication of how many GPs were involved. The second reported that all panels contain ‘at least one medically-qualified member’ and did not distinguish between those from secondary and primary care backgrounds. The third reported that they ‘do not have strong data on precise categorisation’ but felt it was highly likely that each panel included at least one secondary care doctor and that around 10%–15% included GPs.

The 15 institutions that provided complete responses to the survey are included in Table 2. Of these, 11 institutions provided data for 2012/2013 and 2013/2014 admission rounds and 4 provided data on just one of these.

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Table 2.

Composition of medical school admissions interview and assessment panels.

Medical school	Total number of interview/assessment panels held	Number (%) of panels including a secondary care clinician	Number (%) of panels including a GP	Number (%) of panels including other medical doctors
A	56	40 (71.4)	9 (16.1)	11 (19.6)
B	64	36 (56.3)	45 (70.3)	27 (42.2)
C	17	17 (100)	7 (41.2)	0 (0)
D	35	35 (100)	21 (60.0)	33 (94.3)
E	88	41 (46.6)	13 (14.8)	18 (20.5)
F	30	30 (100)	15 (50.0)	3 (10.0)
G	10	10 (100)	6 (60.0)	0 (0)
H	91	79 (86.8)	8 (8.8)	4 (4.4)
I*	17	17 (100)	11 (64.7)	11 (64.7)
J	123	96 (78.0)	24 (19.5)	17 (13.8)
K	52	20 (38.5)	2 (3.8)	13 (25.0)
L	182	158 (86.8)	16 (8.8)	4 (2.2)
M	18	18 (100)	15 (83.3)	0 (0)
N*	68	68 (100)	68 (100)	5 (7.4)
O	25	18 (72.0)	1 (4.0)	2 (8.0)
Overall	876	683 (78.0)	261 (29.8)	148 (16.9)

GP: general practitioner. * Institutions recorded particularly high GP numbers.

GP representation ranged from 3.8% to 100% of individual schools’ panels; however, eight schools (about half the respondents able to offer numbers of participants) omitted GP representation in more than half of their interview panels. Of note, a number of responding institutions ran multiple mini interview assessment panels, allowing a larger number of assessors per panel and these institutions (marked *) recorded particularly high GP numbers.

Discussion

This survey demonstrates that amongst 18 respondent UK medical schools, involvement of GPs in the student admissions process is variable and limited. In only two schools were GPs the admissions lead, whilst GPs were unrepresented on over half of interview or assessment panels in about half of the respondent schools able to provide numbers of panel participants. It seems unlikely that respondents unable to provide numbers and non-responding schools have higher rates of GP participation than this.

The strengths of this study include the role of the Medical Schools Council in disseminating the survey in a timely and reliable way to admissions leads across the UK medical schools. Whilst the suboptimal response rate is a limitation, the fact that a number of responding schools were unable to provide robust data suggests that non-responding schools may be in a similar position. A further limitation is that the survey has not collected data about the non-interview elements of the admissions process including scoring application forms, although the interactive and cultural elements of admissions seem likely to be most closely related to interview and face-to-face assessments.

The Centre for Workforce Intelligence has highlighted that in order to meet future workforce requirements, significant increases in GP training posts will be needed, and in 2013, the Health Education England Mandate from the Department of Health set the target of 50% of medical students becoming GPs by 2015. ¹⁵ In light of the national policy agenda to increase the GP workforce, the observed variability and level of GP involvement in admissions may represent one important contributing factor that warrants review.

Interviews and face-to-face assessments are widely used in medical school admissions processes ¹⁴ and have been shown to be an important aspect of admissions decisions. ¹⁶ In our survey, only half of medical schools responded and of those, a number were unable to provide robust data. This suggests that whilst composition of admissions interviews may be monitored to assure equality issues and the presence of at least one clinical representative, there has been less consideration to the relative importance of specialty background. Although there has been research exploring current medical students ¹⁷ and members of the public ¹⁸ being involved in admissions interviewers, the clinical specialty background of interviewers has not been investigated to date.

In light of the clinical and personal values that draw GPs towards their career choice, they may be more likely to select students with traits that demonstrate an interest in human relationships, continuity and the social aspects of medicine. However, the precise extent to which this would impact on individual decisions is unlikely to be measurable. Previous research into medical school admissions reveals the presence of a ‘hidden curriculum’ at work in admissions policies, ¹⁹ by which applicants understand the behaviours needed to gain entry. Social learning theory suggests that applicant responses will invariably be influenced by consideration of expectations, rewards and punishments within a complex social system. ²⁰ Applicants may infer from a question a socially desirable response that would allow them to conform and gain a reward (admission to medical school). Conforming to the expectations of the medical school interview may thus be the first step to a longer and more sustained process of conforming to norms set by doctors in positions of authority. ²¹

In a 2010 survey of fourth year students at 20 US medical schools, it was demonstrated that whilst personal preferences contribute to choices to enter primary care as a career, the prevailing medical school culture also plays an important role. ²² A multiple case study across medical schools in Canada, France, Spain and the UK also stresses the influence of academic discourses on medical students’ ability to identify with family medicine as a career choice. ²³ Indeed, a systematic review to determine the factors that influence a medical student’s decision to choose primary care as a career demonstrated that role models, prestige and medical school environment were all considered significant. ²⁴ It may, therefore, be reasonable to hypothesise that a lack of GP representation at medical school interview admissions panels may be a proxy for the culture of some UK medical schools and a paucity of GP role models.

Conclusions

This national survey of UK medical schools demonstrates that the involvement of GPs in the admissions process is highly variable and overall, disproportionately smaller than secondary care disciplines. In the context of national policy that is striving for increases in GP numbers in the years ahead, improving this representation could prove to be an important signal of a medical school culture that is increasingly supportive of a future GP career.