Selection for medical education: a review of the literature

Prepared for the Access to Medicine Project at King’s College London

Dylan Wiliam, Monica Millar & Hannah Bartholomew

King’s College London, February 2004

Background

Access to health care in the United Kingdom is not equitable, partly because some
areas (especially inner cities) have high concentrations of disadvantaged and
vulnerable people, and partly because the health services find some of the barriers
to best practice difficult to overcome. Some vulnerable groups are difficult to reach
and differences in language, sex, class, ethnicity and culture between patients and
their doctors have been shown to affect the doctor-patient relationship and can thus
have important adverse clinical consequences (Flores, 2000). Thus widening access
to the medical profession to make it representative of the population it serves can
contribute in the long term towards the provision of more culturally competent
health services. There is, for example, evidence that medical students from more
socio-economically deprived backgrounds are more likely to work in socio-
economically disadvantaged areas (Magnus & Mick, 2000).

The Council of Heads of Medical schools (CHMS) has committed to a statement of

principles, which includes the following;

The purpose of a medical education is to graduate individuals well-fitted to meet

the present and future needs of society for medical care [...] The social, cultural
and ethnic backgrounds of medical graduates should reflect broadly the diversity
of those they are called upon to serve (Council of Heads of Medical Schools,
1998).

The Government’s emphasis on widening participation in higher education (Higher

Education Funding Council for England, 1998; Higher Education Funding Council
for England, 1999; Woodrow, 1998) increased the pressure on all universities to
examine their admissions procedures, and amendments to the Race Relations Act
now make this a legal requirement. With 6000 extra medical school places opening
between 2002 and 2005, selection procedures for medical education will be under
particularly intense examination (Crail, 1999).

This report is based on a study undertaken in the Department of Education and

Professional Studies in the School of Social Science and Public Policy at King’s
College, University of London (KCL). The aim of the study was to explore methods of
selecting and supporting students following medical school programmes in the
industrialised world, in order to support the work of the Access to Medicine
programme at King’s College London, and other initiatives designed to increase
participation in medical education by those who are currently under-represented.

Method of review

In order to ensure that the review was as wide-ranging as possible, we did not limit
our search of the literature related to medical education by date or country. Due to
time constraints, only sources that were available in English were reviewed, and in
a few cases, the review was limited by the availability of copies of the journals or
books in the UK. We began by compiling a list of journals publishing articles

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identified as important to this review, and began a manual search through these,
identifying relevant articles. We also searched online databases, including ‘Web of
Science’, MEDLINE and ERIC for all years that were available. The most productive
search was generated by requiring the key words for the citations to contain one of
the key words ‘selection’, ‘admissions’ or ‘recruitment ‘ and either ‘medical
students’ or ‘medical education’. The results were scanned for relevance to our
theme of undergraduate medical student selection and the nature of the research
evidence contained (in this context, it is worth noting that many of the articles on
medical student selection are discussions or commentaries rather than original
empirical research). We also obtained copies of the prospectus material of all UK
medical schools (as of November 2001) and collected relevant materials from their
web-sites, including details of admission criteria, admissions process, published
student support services and widening participation initiatives.

By following up references in research reports and key review articles, and

reviewing all articles citing original papers, and reviewing papers which cited these,
we identified a total of 871 references which are included in the EndNote™ library
that accompanies this report. As the references were read, a system of key-words
was built up, and entered into the keyword field of the database. A final list of the
159 keywords used in the database is included as an appendix to this report.

In order to keep an overview of the field, given the proliferation of key words, we
also developed a series of key themes running through the resources we had
identified as relevant to the study. The final list of the key themes is:

Choice of Higher Education by different groups in the UK

Identity
Intellectual and moral development
Interviews
Learning and teaching medicine (undergraduate and professional education)
Medical school attrition/persistence/stress
Mentoring and counselling medical students
Personality
Personal statements
Race and higher education in the UK
Recruitment and retention programs in medical schools
Selective admissions
Selection criteria and admissions testing
Study habits, styles and strategies
Widening participation in Higher Education

However, despite the large number of references generated, and despite the time
that has been spent in collating this report, we are aware that this is, at best, a work
in progress. We hope that others will find the bibliographic database that
accompanies this report a useful resource, and that they will add, both to the
database and to this report.

Existing methods of selection for medical education

For most of the last century, admission to medical education in developed and
developing countries has been based on measures of cognitive ability and academic
achievement. Such measures have repeatedly been shown to be some of the most
significant predictors of performance in medical school (Campos-Outcalt et al, 1994;
Gottheil & Miller Michael, 1957; Gough, 1967; Gough & Hall, 1975; Rolfe et al,
1995; Swanson & Mitchell, 1989; Walton, 1987; McManus, 198; Mitchell et al, 1994,

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Vancouver et al, 1990) and of later clinical competence (Tamblyn et al, 1998). Less
obviously, these predictions have been found to hold across cultural groups (Lynch
& Woode, 1990; Sedlacek & Prieto, 1990; Vancouver et al, 1990).

At most medical schools in the UK, details from the official application form
(submitted through the Universities and Colleges Admissions Service, or UCAS),
including a personal statement and the reference written by the school, together
with other demographic information, are used in the first stage of the selection
process. Applicants who clear this initial screening process are interviewed in order
to provide information about motivation, awareness of ethical issues related to
medicine, and personality.

The stated minimum criteria for admission to medical schools in the UK rose in the
1970s (McManus, 1982) but have remained steady in recent years. Different
medical schools in the UK have always differed in their admissions (GMC, 1977), but
a typical University (Nottingham, for example) will require Chemistry (as required
by the GMC), one other science subject and any other mainstream academic subject
at A-level. All UK medical schools now require a minimum of ABB at A-level or its
equivalent (and typically AAB outside London, although Sheffield is pioneering a
selective admissions process including lower academic achievement criteria for
some of its medical students; see Angel & Johnson, 2000). However, due to the
intense competition for places, in practice most students entering medical school
obtain three grade As at A-level, and since 25% of students taking A-levels get a
grade A, many medical schools also take GCSE grades into account. Students with
three As at A-level may thus be ‘let down’ by less than perfect GCSE results.

Students who do reach the threshold of three grade As at A-level are typically
invited for interview at the medical school. Concerns about the cost, the reliability
and the validity of interviews had led some institutions to abandon selection
interviews in the 1970s, although concerns about drop-out rates resulted in their re-
introduction during the 1990s (Crail, 1999) and almost all applicants to medical
school are now interviewed.

Critiques of traditional selection methods

The reliance on achievement and ability (often grouped together as ‘cognitive’

factors in the literature) in selecting for medical education has recently come under
attack for a variety of reasons, all of which can be regarded as aspects of validity.

While some authors, such as David Powis, have argued forcefully for selection on
the basis that factors other than academic achievement and cognitive ability (Powis
et al, 1992), others regard the attempt to select on individual characteristics as
futile (McManus, 1997; Ryten, 1988). Certainly the existing research basis is at best
equivocal (Tutton, 1996; Morris, 1999) and it is clear that much more work is
needed to determine what factors are associated with success in medical education,
and subsequent medical practice.

The use of an invalid tool as a selection instrument is worse than using no tool at all, for an invalid tool
will, by definition, unbalance the cohort of entrants in some dimension. This will affect the nature of
the student body and, ultimately the graduate body, possibly to its detriment. It will also affect research
into the efficacy of the selection process, since the tool will have eliminated candidates with (or
without) certain qualities. Indeed, there may be other desirable qualities associated with those that are
the overt goal of the tool, which will also be eliminated without ever being identified. (Powis, 1994 pp.
453).

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The first source of concern is that the correlation of cognitive factors with success in
medical education and subsequent practice in medical education is low (although,
because of the large numbers involved statistically significant). Typical values for
correlations of scores such as A-level with final performance in medical education
are in the range 0.3 to 0.5 (McManus et al, 2003). Even taking the most optimistic
value, this indicates that at most 25% of the variance in students’ final scores in
medical education is attributable to their achievement and ability on entry. Put
another way, given two applicants for a single place at medical school, with no other
information, one has a 50% chance of selecting the ‘best’ applicant (in the sense of
the one who will go on to get the best results at medical school). By taking the one
with the better A-level performance, we improve our chances of getting the better
student to 65%. This is a significant improvement, but it is not a large improvement.

Correlations with subsequent performance in post are even lower. A recent

synthesis of the available research evidence suggests that the correlation of A-levels
and job performance is as low as 0.25, suggesting that only 6% of the variability in
job performance is attributable to academic achievement on entering medical
education (Ferguson et al, 2002). Now of course, these findings do not mean that
prior achievement is unimportant. One of the reasons these correlations are so low
is the restriction of the range of applicants—we are selecting from a very narrow
stratum of the general population—but nevertheless, these findings indicate the
limits of cognitive and academic predictors of success.

The second reason for concern with over-reliance on A-level grades is that they are
‘impure’ measures, in that they measure some things that are related to the
individual such as ability and perseverance, but others that are not, such as quality
of teaching. Many talented students in state schools, sixth-form and further
education (FE) colleges do not gain the A-level grades necessary to be considered
for medical education because their schools do not have teachers with experience of
teaching at this level, or sufficient resources for students to gain the highest grades
at A-level. Furthermore, the presence of high-attaining students in a school is known
to increase the achievement of other students in the school, so that students in
schools and colleges where there are few high-attaining students are at a
disadvantage (Bursten, 1992; Sammons, 1999; Smith & Naylor, 1999). Another
complexity relevant to medical education is that students from minority ethnic
communities are more likely to choose A-level combinations that effectively preclude
undergraduate admission to medical school (Coffield, 1999; Coffield & Vignoles,
1997; Rasekoala, 1997a; Rasekoala, 1997b; National Committee of Inquiry into
Higher Education, 1997).

For example, African-Caribbean students are more likely to study arts and
humanities programmes and are under-represented in science, engineering and
technology programmes and some professional programmes. Moreover, the
narrowing down of options begins well before students choose their A-levels. One
study (Mason, 2000) found that choices of options supposedly made by 14-year-old
students and their parents “were typically structured by staff assessments of ability
(not all of them based on formal testing), motivation, and behaviour. They had the
effect of determining at what level students would be entered for 16+ public
examinations and in what subjects.”

It is therefore hardly surprising that the intake of medical schools around the
country is rarely representative of local populations (Bedi & Gilthorpe, 2000a;
2000b). It is also worth noting here that while there are systematic differences
between ethnic groups, the variation within each group is far greater, and social
class and sex are stronger determinants of academic success than ethnicity
(Gillborn & Gipps, 1996; Rasekoala, 1997a; 1997b; Sammons, 1995; Demack et al,

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2000), although the effects of these characteristics are difficult to disentangle (Ball
et al, 2001; Demack et al, 2000; Gillborn & Mirza, 2000; Tomlinson, 1987).

The third reason for concern is that effective clinical competence requires much
more than just good knowledge. To be effective, doctors need good interpersonal
skills, and thus it seems that aspects of personality such as interests, values,
motivation, interpersonal skills and concern with other people’s problems need also
to be taken into account. As the eighth recommendation of the World Federation for
Medical Education made in 1994 states:

Medical schools should design admission criteria that address both academic and non-intellectual
characteristics, such as social commitment and minority status. Attitudinal assessment techniques
should be studied in every medical school for validity in identifying the necessary non-cognitive
qualities in would be applicants.

The same report, however, also required that, “The principles of selection should be
clear, equitable and valid” which is much more difficult to establish with non-
cognitive factors than with (say) A-level results. Carl Whitehouse reviewed recent
research on selection (Whitehouse, 1997) and concluded, as did the BMA in its
discussion paper (Board of Medical Education, 1998), that current medical school
selection procedures are often arbitrary. In particular, it has been suggested that
admissions process used by medical schools in the UK are biased against students
from minority ethnic communities (McManus, 1998a; 1998b), although this has been
contested by others (see, for example, Bland, 1999). Part of the problem is that
current methods seek to select from within the current applicant pool (i.e. selection)
rather than seeking to diversify that pool (i.e. recruitment). If the students who
choose to apply to medical school are not representative of the population as a
whole, then it is very difficult to ‘re-balance’ the sample through selection methods.
As Powis (1994) noted “It is self selection out that is of value, not attempts to select
in.”

A fourth difficulty with interpreting the research on predictors of success in medical

education is that almost all studies examine the progress of students in the existing
systems of medical education. These systems have been designed to cater for
students who are successful at school, and who arrive at university with more or
less well-developed study skills. That students without this amount of preparation do
less well tells us only about the existing systems of medical education, not what
might be possible with different forms of medical education.

Measures of personality in selection for medical education

The most common recommendations for enhancing recruitment to medical

education include the selection of students on the basis of non-cognitive factors
such as beliefs, attitudes and other aspects related to personality.

Traditionally personality, understood either as ‘the structures, dynamics, and

processes inside a person that explain why he or she behaves in a particular way
(Mount & Barrick, 1995), or as the functional equivalent of a person’s ‘reputation’,
has been seen as a variable with low validity for predicting job performance. The
last decade has seen the emergence of an increasingly influential framework for
structuring and understanding personality traits. Earlier work on the use of
personality measures for selection treated personality as a stable trait, if not innate
(or even inherited) then at least fixed relatively early in life. Early factor analytic
studies such as those by Eysenck identified as many as 16 different traits, but
subsequent factor analyses of self- and peer-report measures of personality traits

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have consistently found convergent evidence for the presence of five broad factors
(O'Hehir, 1998; Wiggins, 1996), although the exact form and definition of these
factors differs between authors. There is considerable evidence that the ‘Five
Factor’ model is broadly congruent with the personality models of Cattell, Comrey
and Eysenck (Noller et al, 1987), Murray (Deary & Mathews, 1993) and Wiggins
(McCrae & Costa, 1989b).

The Five Factor Model (FFM) is a descriptive taxonomy that provides surface
characteristics of recurrent behavioural patterns that are readily observed. Most
taxonomic systems of cognitive and non-cognitive attributes are hierarchical:
clustering similar behaviours into narrow traits, then clustering these into higher
order traits, and eventually into a limited number of dimensional types. It is widely
agreed that the first factor in the five-factor model of personality is Eysenck’s
Extraversion (E), and individuals who score highly on this factor are active,
assertive, energetic, enthusiastic, outgoing and talkative. There is also widespread
agreement about the second factor, Neuroticism (N), with high-scoring individuals
being anxious, self-pitying, tense, touchy, unstable and worrying. The third factor is
generally interpreted as Agreeableness (A) focusing on whether individuals are
appreciative, forgiving, generous, kind, sympathetic and trusting. The fourth factor
is most frequently called Conscientiousness (C), for which the associated traits are
efficiency, being well-organised, planful, reliable, responsible and thorough. The
fifth factor is the most difficult to identify. It has been interpreted as Intellect or
Intellectance but is most commonly known as Openness to Experience (O)
accounting for the extent to which individuals are artistic, curious, imaginative,
insightful and original.

The utility of the five-factor model (FFM) for personnel selection is still a matter of
great debate. There are difficulties in the use of the FFM because authors vary in
their interpretation of factors (Newman, 1996). McCrae and John argue that the
‘Five Factor model is comprehensive and is applicable across observers and cultures
(McCrae & John, 1992), but it is unlikely to be the definitive integrative model of
personality, because the science of personality traits is young and continues to
evolve.

The use of any factor, cognitive or non-cognitive, as a criterion of admission to a

programme of professional education requires these factors to have a logical
association with end-product professional performance and that the factor should
demonstrate relative stability within individuals in the time interval separating
application and professional practice. The FFM is a version of trait theory and a
fundamental tenet of psychological trait theory is that there is relatively little
likelihood of radically altering a personality structure of (medical) students during
their training (Rothman et al, 1973).

From the FFM perspective, O’Hehir (1998) concludes that the cumulative evidence
indicates that conscientiousness and neuroticism are valid predictors for all
occupational groups and all job -related criteria studied. High scores on E are
associated with success where interpersonal skills are required. Therefore,
conscientious, emotionally stable, and extraverted individuals should perform better
in the working environment. There is consistent evidence that individuals who are
open to experience and, to a lesser extent, agreeable, may be people who are most
likely to benefit from training programmes.

Recent analyses of correlations of the FFM, obtained from child, adolescent, and
adult samples, suggest the presence of two higher-order factors. These constructs
furnish the links between a theoretical FFM and various theoretical systems of
traditional and contemporary personology (O'Hehir, 1998), ‘which, under a variety

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of interpretations, have dealt with one or the other – or both – of these high-level
factors’ (Digman, 1997). The first factor involves the common aspects of
Agreeableness (vs. Hostility), Conscientiousness (vs. Heedlessness), and Emotional
Stability (vs. Neuroticism). The second factor contains Extraversion and Intellect.
The factors are termed Factor Alpha and Factor Beta respectively. Digman (Digman,
1997) suggests that Factor Alpha may represent socialisation and Factor Beta may
represent personal growth (versus personal constriction).

A recent study of the predictive validity of personal statements and the role of the
five factor model (FFM) of personality in relation to the first year of medical
training, proved negative (Ferguson, 2002), except for conscientiousness which was
positively related to success in the first year. Previous academic performance was
the only other predictor of success in the first year, but conscientiousness
demonstrated incremental validity over previous academic performance. Previous
academic performance has generally been found to be a more or less valid predictor
of pre-clinical performance but the predictive validity of pre-medical grades has
been shown to decrease during the period of clinical training. During this latter
period of clinical training other factors such as personality and motivation become
increasingly important. Whilst the FFM domains A and C and Factor Alpha (A, C and
N) were the predominant associates of pre-clinical training success (above and
beyond pre-medical grades) there was a notable lack of association between the
predictors and the criterion of clinical training success in O’Hehir’s study of the
FFM and the Alpha and Beta Personality Models in Medical selection and training at
Nottingham (O'Hehir, 1998). In other words, taking into account personality
provided no improvement in prediction over the use of previous academic
performance. This is consistent with the findings of McManus and Richards, who
analysed a sample of approximately 12.5% of all the applicants to British medical
schools in October 1981 (McManus & Richards, 1984). They found that there were
few differences in personality, career preference or attitudes between those
accepted and those rejected—the only major difference was in performance at A-
level.

While the relationship between personality and clinical performance is weak,

changes in personality variables have been claimed using different assessment
instruments during medical education. Parlow and Rothman (Parlow & Rothman,
1974) compared medical students with those in other disciplines. They found that
they scored higher on ‘Nurturance’ than the other students and this discrepancy
increased over the course of their education. However they scored lower than the
other non-medical students on measures of flexibility and their ability to tolerate
uncertainty.

The most widely-used personality inventory is the Myers-Briggs Type Inventory

(MBTI), which is used globally in counselling, education, personnel, management
and business, largely because it is so widely available, and can be self-scored
(Kendall, 1998). It was originally based on Jung’s theory that individuals differ in the
way they prefer to use their minds, but its application has been developed,
validating and refining questions extensively across groups so that in practice it may
no longer reflect wholly the theory on which it was originally based.

Correlations have been found between Extroversion (E) and a preference on the
Myers-Briggs Type Inventory (MBTI) for Extraversion (obviously, perhaps) and
Intuition. Similarly, those scoring high on Openness (O) in the FFM with the MBTI
Sensing/Intuition have been found. An inverse relationship has been found between
the MBTI Thinking/Feeling scale and Agreeableness (A). Conscientiousness (C) has
been shown to correspond with the Judging/Perceiving orientation in the MBTI
(McCrae & Costa, 1989a; Newman, 1996)

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Gill Clack administered the MBTI questionnaire to 351 students entering Years 1, 2,
and 3 of the medical course at King’s at the start of the 1996/97 academic year
(Clack & Head, 1997). Slightly over half the students expressed a preference for
‘extraversion’ over ‘introversion’’; they were almost equally divided between the two
perceiving preferences of ‘sensing’ and ‘intuition’ and nearly two-thirds preferred
‘thinking/deciding’ to ‘feeling/deciding’ and to lead their lives in a structured,
planned and organised way. A majority of female students preferred ‘extraversion’
compared to the majority of males preference for ‘introversion’ (the difference was
significant: p<0.01). More males preferred the ‘intuitive’ mode of perceiving
whereas the females reported a slight preference toward ‘sensing’; the majority of
both males and females preferred the ‘thinking’ mode of decision making, and here
the female medical students were opposite to the general population in which two-
thirds of females prefer the ‘feeling deciding’ decision mode. The majority of both
males and females preferred a judging orientation. The results of this study were
similar to other personality explorations among groups of medical students. There
was a wide range of preferences, predicting a diversity of preferred learning styles.
However, given the lack of evidence about the extent to which the MBTI is well-
founded theoretically, or even stable from one testing occasion to another, the
likelihood that it has any utility in medical selection (or indeed in any other area of
personnel selection) remains doubtful (Pittenger, 1993).

Learning styles, strategies and skills

Closely related to the research on personality, and sometimes overlapping with it

significantly, is a body of research on preferences for particular ways of learning.
Although there is no agreed definition of the distinction between learning styles,
strategies and skills, the following usages, taken from Adey, Fairbrother and Wiliam
(Adey et al, 1999), appear to be the most common:

A Learning Style is a deep-rooted preference an individual has for a particular type

of learning. One can think of this as being similar to the way one folds ones arms.
Each person has a preferred way to do it even though they are quite capable of
folding their arms the other way. However, in order to fold one’s arms ‘the wrong
way’ one has to think much harder about what one is doing, and it never feels quite
as ‘natural’. In the same way some people are imagers (they prefer to learn from
pictures and diagrams), whilst others are verbalisers (they prefer to learn from
words) although imagers can learn from words and verbalisers can learn from
images.

At the other extreme, Learning Skills are almost like ‘tricks’ which are specific,
designed to do one job and can be taught. One example of a learning skill is a
mnemonic to help remember a series of facts, such as “Richard of York Gave Battle
in Vain” in order to help remember the seven colours of the rainbow are red,
orange, yellow, green, blue, indigo and violet. Other examples of learning skills are
continuous repetition to remember text and high lighting or underlining important
pieces of text.

Somewhere in between these two extremes, the term Learning Strategy is used
for groups of skills, which a learner uses together for a particular purpose.
Examples include setting objectives, selecting and formulating questions, and
comparing characteristics.

There is no sharp dividing line between learning styles, strategies and skills. They
form a continuum from the generally deeply embedded (and possibly innate) styles
at one end to the teachable subject-specific skills at the other.

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Over the last fifty or so years, a large number of typologies and taxonomies of
learning styles have been produced (see Adey et al for a review), but some of the
distinctions are only weakly grounded in empirical data. In focusing on
psychological principles, Riding and Rayner (1998) concluded that robust evidence
supports only two distinctions. The first is that between a wholist style, descriptive
of learners who prefer to get an idea of the ‘big picture’ before engaging in the
details and an analytic style, where learners prefer to start work with details. The
second important distinction is between verbalisers, who like to think in terms of
words, and imagers, who prefer to think in diagrams and pictures.

Kolb’s Learning Styles Inventory (LSI) also classifies individuals along two
dimensions. The first is concerned with whether an individual is more comfortable
with concrete or abstract ideas (Feeling-Thinking). The second dimension relates to
the extent to which an individual would rather think and reflect on something or get
involved (Watching-Doing). Since these two continua are independent of each other,
this gives rise to a four-fold classification of learning styles:

watching + feeling ‘divergers’

watching + thinking ‘assimilators’
doing + feeling ‘accomodators’
doing + thinking ‘convergers’

Davies, Rutledge and Davies (1997) administered Kolb’s LSI to 200 students
entering Eastern Virginia Medical School in 1991 and 1992. They found that 21%
were divergers, 33% were assimilators, 22% were accomodators and 24% were
convergers. Accomodators performed better in interviews, but worst in physiology
examinations, whilst convergers were best in physiology, and worst at interviews.

Hofboll et al, (1982) explored the relationship between interview performance and
personality (as measured by the Californian Psychological Inventory) and
subsequent clinical and academic performance. They found positive associations
between ratings of interview performance and the CPI categories ‘Dominance’,
‘Self-acceptance’, ‘Well-being’, ‘Tolerance’, ‘Responsibility’ and ‘Achievement via
conformance’. Academic and teaching staff ratings were positively associated with
‘Achievement by independence’, Achievement by conformance’, ‘Self-acceptance’
and ‘Dominance’. However there were no significant correlations between the CPI
variables and clinical performance.

Therefore, whilst there is strong evidence that these learning styles are relatively
stable, it is by no means clear that these findings have any implications for
education in general, and for selection in medical education in particular. First, the
associations with outcomes are so weak that the issue of learning style may not be
worth bothering with. Second, even if they are significant, individualising learning
to take into account the preferred learning style of each student in a cohort of
medical undergraduates is unlikely to be practicable, and may not even be advisable
—Perry (1968) found that sometimes the discomfort of struggling with learning
attuned to a style different from one’s preference enhanced learning. The only clear
message from the literature on learning styles is that it is advisable for teachers to
ensure that they vary the presentation of work to take into account the range of
learning styles that may exist in the class.

Racism in medicine and medical education

In attempting to make the medical profession more representative of the population

it serves, it is necessary to expand both the ethnic and the socio-economic diversity

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of the population of medical students, and these two aspects interact in complex
ways. For example, applications from blacks, Indians and whites come
disproportionately from the higher socio-economic groups, but are distributed
evenly across the socio-economic range from students from Bangladeshi, Chinese or
Pakistani communities (Bedi & Gilthorpe, 2000). Students from black communities
had a similar social class profile to white students, whilst more students from
professional than intermediate backgrounds were observed for the Indian and
Bangladeshi communities (a 95% odds ratio extends from 1.32 to 1.80, with a mean
at 1.54). As well as these differences between groups, it is also necessary to be
aware that the differences within these groups is usually at least as great:

The dilemma which lies in the study of inequalities and differences of treatment among Britain's
minority ethnic groups is that such measurements, by definition, use some set categories in terms of
which data can be collected. However sensitively we seek to be toward people's self-definitions, any
category system runs the risk of failing to capture the richness and complexity of people’s identity
choices. There is then a danger that we may reproduce the very divisions we seek to problematize.
(Mason, 2000)

The debate about racial discrimination in medical school admission in the UK is

difficult to understand without an appreciation of the history of ethnic minority
applicants to medicine. Ethnic minorities have always been over-represented in
medicine when compared to the proportion in the general population (Modood &
Acland, 1998). However the racial mix of the applicants to medical schools is almost
exclusively made up of applicants who classify themselves as Indians. Applicants
who classify themselves as Bangladeshi, Pakistani and Afro-Caribbean are under-
represented when compared to the proportion in the general population (Esmail et
al, 1995). Esmail also showed that whilst there was no discrimination between
groups for candidates with the highest academic achievement, there appeared to be
a selection bias in favour of white candidates among applicants with lower A-level
scores (for applicants to medical school in the UK in 1990).

In the past, a typical response has been to ‘blame the victim’ (or at least their
parents), with underachievement being regarded as a function of family and
community integration, even though there was clear evidence of structural factors
producing disadvantage (Tomlinson, 2000). For example, in the 1980s, the ILEA was
unable to provide sufficient school places for children in Tower Hamlets and 95% of
the resulting ‘out of school children’ were of Bangladeshi origin (Tomlinson, 1992).

Manifestations of racism in the field of medicine in the NHS, the medical profession
and other areas of the UK health system have recently been described in a King’s
Fund publication Racism in medicine: an agenda for change (Coker, 2001). The
authors claim the impossibility of the NHS meeting its core values and ambitions, if
it does not eradicate racism. Racism, the report suggests may be manifested in
beliefs, and in behaviours including hostility, passive neglect, exclusion, isolation,
injustice, harassment or violent attacks.

This seems close to the definition of ‘institutional racism’ proposed by Macpherson

(1999) in the report of the inquiry into the murder of Stephen Lawrence as “the
collective failure of an organisation to provide an appropriate and professional
service to people because of their colour, culture or ethnic origin. It can be seen or
detected in processes, attitudes or behaviour which amount to discrimination,
through unwitting prejudice, ignorance, thoughtlessness and racist stereotyping,
which disadvantage minority ethnic people” (Jones, 1999).

Diversification of the medical student body, in terms of cultural background, age

and class, may in itself strengthen the profession’s ability to respond to change but

10 27/12/24 11:51 AM
the very strong culture and traditions of medicine itself, and the social structure of
medical schools (Bloom, 1989; Towle, 1998) are likely to make change difficult and
slow.

Under-represented minorities and medical education

From the foregoing discussion, it is clear that selecting students for medical
education is fraught with difficulties, and that there is no clear way forward even if
all we want to do is to improve selection from amongst those who are already well-
represented in medical education. It is hardly surprising therefore, that the existing
research base offers even fewer clear suggestions about how to diversify the
population of students attending medical schools, and qualifying as doctors.

In the United States in the 1970s, many medical students explored the use of
affirmative action programmes—typically admitting students from under-
represented minorities with lower scores than white students would need. As might
be expected, the outcomes in medical education have been mixed (Cohen, 1997;
Petersdorf, 1992; Petersdorf et al, 1990), but much has been learned about enrolling
black students in the competitive environment of selective colleges (Bowen & Bok,
1998). In particular, it is clear that findings related to segregated systems (as
existed for many years in the United States) do not generalise in any simple way to
de-segregated systems. Despite much evidence that African-American students are
increasingly developing their academic competitiveness for medical school
application, and that the MCAT is predictive for both blacks and whites of success in
medical school (Mitchell et al, 1994; Mitchell, 1990), it appears that traditional
predictors are not so robust for minority students (Sedlacek & Prieto, 1990). As well
as the necessary academic ability, students from underrepresented minorities need
an ability to deal with racism (which in turn presupposes that an individual has a
strong sense of his racial identity), and also need to know the ‘rules of the game’.
“Handling racism seems related to contextual intelligence, and this type of ability
seems even less likely than experiential intelligence, to be reflected in standardised
tests” (Sedlacek & Prieto, 1990).

Cariaga-Lo et al. studied the cognitive and non-cognitive effects of academic

difficulty and attrition in a medical school in North Carolina (Cariaga-Lo et al, 1997).
They modelled the probability of failure at any time point during the four years of
medical school and found that the risk of failure was significantly greater for non-
white students and for non norm-favouring /self-realised students. In general terms,
risk of failure was higher for women at this medical school. As might be expected,
the risk of failure was inversely proportional to the student’s score on the Medical
College Admissions Test (MCAT) and science GPA. However, when demographic and
psychological variables (the California Psychological Inventory or CPI) were taken
into account, the risk of failure narrowed between the high and the low scoring
students. This suggests that academic achievement is only part of the issue, and
that personal characteristics play a strong part in determining success and failure in
medical students, especially those from under-represented minorities.

What the research from the United States does show clearly is that one of the most
important predictors of persistence in medical education is the degree to which
students become integrated into the institutions at which they study, and not
surprisingly, this becomes more important the longer the programme and the more
residential it is (Tinto, 1998). What is less obvious is that the there are two aspects
of integration, which interact in complex ways. Social integration refers to the
extent to which students feel they ‘belong’ to the institution, and there is little doubt
that student persistence is greater at institutions that make students feel they are

11 27/12/24 11:51 AM
treated as valued members of the institution (Cabrera et al, 1999), although many
students who experience a low sense of belonging, do not drop out and it may be
that proximal affiliations (a sense of belonging to small social networks) is more
important in student persistence (Hurtado & Carter 1997).

Cabrera et al. acknowledge that differences in academic preparedness and patterns

of financing minority students, along with changes in high school completion rates
and expectation, have contributed to increased enrolment and persistence for
minority students. Yet, exposure to prejudice and discrimination in the classroom
and on campus, has gained attention as the main factor accounting for differences in
withdrawal behaviour between minorities and non-minorities:

Racism and discrimination are unique psychological and socio-cultural stressors, which heighten the
feeling of not belonging at an institution with spill-over effect on a students academic performance”
(Cabrera et al, 1999).

In their study of 1,454 students (1,139 whites, 315 African Americans) in 1992,
Cabrera et al. found that minorities and non-minorities adjust to college in a similar
manner, but exposure to campus climate of prejudice and intolerance lessens
commitment to the institution, for both blacks and whites. Along with all
researchers in the field of attrition from college, Cabrera concludes that adjustment
to college represents a complex process that links student motivations, attitudes,
and abilities with institutional features. He believes that encouragement and
support from significant others, can negate the deleterious effects of perceived
prejudice and discrimination.

Support from the institution can also mitigate some of the deleterious effects of
perceived prejudice and discrimination. However, by itself, social integration is not
enough. It is also important for students to be academically integrated into their
studies, for example by discussing programme content with other students outside
scheduled tuition periods. While disentangling the effects of social and academic
integration is difficult it does appear as if academic integration is at least as
important as, if not more important than, social integration, although it is important
to note that some studies have found that the relationship between academic and
social integration is different for students from different ethnic groups, and for
males and females (Allen, 1992; Cabrera et al, 1999; Hurtado & Carter, 1997;
Stage, 1989).

Allen found that academic achievement was highest, in African-American college

students in students with: high educational aspirations, who were certain that their
college choice was correct, and who reported positive relationships with faculty
(Allen, 1992). Black students on predominantly white campuses did not fare as well
as white students in persistence rates, academic achievement, postgraduate study,
or overall psychological adjustment. This author believes his results do not show
phenomena shrouded in mystery. He remarks, they are “.... the result of the same
historical, political, economic and psychological patterns that have perpetuated
Black subjugation and oppression since Blacks arrived (on these shores) in 1619”.

For example, a study by Strayhorn and Frierson (1989) looked at the 640 students
enrolling at the University of North Carolina medical school and found that black
students experienced considerable stress from their minority status and racial
concerns that were obviously not issues for white students. As Cabrera et al. (1999)
note, “Racism and discrimination are unique psychological and socio-cultural
stressors, which heighten the feeling of not belonging at an institution with spill-
over effect on a student’s academic performance”.

12 27/12/24 11:51 AM
It is also important to note that some of these differences cannot be attributed to
pre-existing differences in the students themselves. A study at the University of
Chicago medical school in the 1980s compared 184 medical students from different
racial backgrounds in terms of psychosocial assets and mental health during the
first year of the programme (Pyskoty et al, 1990). At the beginning of the
programme black and Hispanic students reported greater social support and more
advantageous mental health than white students which they attributed to pre-
entrance programs and more supportive ethnic cultural backgrounds. Even though
minority students incurred greater debts than white students, they did not report
greater stress, although over the course of the programme, white students reduced
the extent to which they attributed their academic outcomes to external factors,
while this increased for minority students. In other words, the process of medical
education itself made minority students feel less in control of their success, while
white students felt more so. It is also important to note that programmes to support
social integration are time consuming for students—there is a real issue of equity if
minority students have to attend extra classes or sessions in order to ‘level the
playing field’ taking up time that could be used for study or leisure.

Other stress factors, however, appear to impact equally on black and white students
when differences in science knowledge and other predictors of success are
controlled. Although there have been a large number of studies of stress in medical
education, based in the main on questionnaires (see, for example, Firth-Cozens,
1989; Firth-Cozens, 2001; Gaensbauer & Mizner, 1980; Guthrie et al, 1995; Mitchell
et al, 1983; Post et al, 1995; Wolf, 1989; Wolf & Kissling, 1984; Wolf et al, 1998;
Wolf et al, 1991; Pyskoty et al, 1990; Richman & Flaherty, 1985; Richman &
Flaherty, 1990) the result of these studies are inconsistent, suggesting that the
issues are still relatively under-theorised.

Few studies have explored differences amongst medical students from different
ethnic or socio-economic backgrounds in the UK, in terms of student progress.
McManus presented an analysis of retrospective data for two cohorts of London
medical students entering medical school in 1981 and 1985 (McManus et al, 1996).
He showed differences between white and non-white students, but he did not take
into account social class or socio-economic status. An investigation at Manchester
University medical school (Dillner, 1995) found that there were systematic
differences in progress between white and non-white students which, though small,
may well have accounted for the fact that all ten students who failed the final exam
were Asian. This raises important questions about the possibility of racial bias, the
conduct of the clinical examinations and the future monitoring and performance of
students (Esmail & Dewart, 1998).

Conclusion

As noted above, few firm conclusions can be drawn from the existing research
evidence. There is simply insufficient good evidence to provide clear guidance about
what kinds of measures are likely to be the most effective in diversifying the pool of
applicants to medical education, and eventually the medical profession. In short, the
research doesn’t tell us what to do. However, the research does indicate more and
less fruitful directions, and to the extent that the research says anything, it suggests
that the Access to Medicine programme at King’s has got it just about right.

First, as is acknowledged in the Access to Medicine programme, diversifying the

medical profession cannot be achieved simply by changing selection into medical
education. Many suitable applicants never even think of medicine as a realistic
possibility, or make decisions in their choices of options at 14 that make entry to a

13 27/12/24 11:51 AM
medical degree much more difficult. The first stage must therefore be not selection,
but recruitment—changing the pool of well-qualified students applying to medical
education in the first place.

Second, selection methods need to strike a fine balance between requiring the skills
and aptitudes needed to complete medical education on the one hand, and yet also
try to make selection as independent as possible of the quality of teaching
applicants have received. As the research on affirmative action in the United States
shows, aptitude is not enough if programmes assume a particular level of
knowledge, experience or maturity. But it is also important to bear in mind that in
the US medical education is undertaken at graduate level. Selecting 18-year-olds for
medicine is a much more difficult task than selecting 21-year-olds.

Third, selection methods have to be designed in tandem with the programmes they
are to be used with. For example, because we want our doctors to have strong
ethical values, some people have argued that ethical considerations should be part
of our selection criteria, but this follows only if ethical values cannot be changed
during medical education. Even if it were shown that ethical values do not change
during the course of medical education, this would not warrant the inclusion of
ethical criteria for selection unless it could also be shown that even with revised
curricula, and more attention given, ethical values could not be changed. In short,
selection criteria should be based only on those attributes that are impossible,
impracticable, or too time-consuming to change. As one professional basketball
coach said when he was asked about what he looked for in drafting professional
players, “You can’t teach height”.

Fourth, and most importantly, ways have to be found to minimise the extra burdens
on students from under-represented minorities. These students will often, through
no fault of their own, be less well-prepared for undergraduate study, and will,
because of the racism they will encounter, have to work harder and display higher
levels of maturity than their white peers. In responding to this, it is important to see
the whole project of diversifying the medical profession not as one of ‘being nice to
disadvantaged students’ but as one of seeing students from under-represented
minorities as key resources that can help us improve the cultural competence of the
medical profession. In the short term, Access to Medicine must change the
programme offered to all undergraduate students. In the longer term, Access to
Medicine must become at least invisible, and ideally unnecessary—not a ‘special
route’ into the profession for students who somehow need special help to get in, but
rather a way of looking at the whole of medical education.

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Appendix

The keywords used in the keywords field in the EndNote™ library that accompanies
this report are as follows:

academic criteria for health service preclinical medicine

selection higher education premed research
academic performance higher education choices experience
academic support higher education privilege
admissions process transition to problem based learning
adolescence house job allocation problem solving
affirmative action humanism profession
approaches to study identity profession medical
assessment information technology professional responsibility
assessment professional and evidence based psychological adjustment
assessment psychological learning qualitative research
athleticism institution student racism
attitudes commitment to recruitment and outreach
attrition institutional policy remediation
clinical academics interview remediation preselection
clinical competence job satisfaction retention
clinical governance leadership review process of
cognitive conflict learning environment role models
cognitive flexibility learning strategies school grades
communication skills learning style school mix
counseling service licensing examinations school reference
curriculum locus of control science education
decision making marginalisation science education
development intellectual medical care curriculum
development moral medical careers selection
development personal medical education selection monitoring
development professional medical educators self assessment
disadvantage cultural medical school self efficacy
disadvantage educational medical students self esteem
disadvantage medical workforce self knowledge
socioeconomic memory sex
discrimination mental health sexual orientation
diversification of medical mentoring social awareness
students metacognition social capital
doctor patient metalearning social class
relationship motivation social contract
education policy multicultural awareness socialisation
emotional intelligence overseas students sociology of education
empathy parental education sociology of illness
employment after higher parental income status of physics
education patient centredness stereotyping
employment financial person institution stress
rewards compatibility students perceptions
ethical behaviour personal interests supported self study
ethics formal teaching of personal relationships teaching
ethnicity personal statement test bias
ethnography personal support test of knowledge
family support institutional test of moral reasoning
financial support personal tutor test of performance
formative assessment personality test of understanding
professional portfolio assessment test of verbal reasoning
funding policy positive action test preparation
general practice post modernism test reliability
graduate entry powerlessness test validity
health inequalities pre entry programme tiredness

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training posts
underserved communities
values
widening participation
work experience
writing skills
written assessment

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