Pool of potential medical students needs to be enlarged

EDITOR—McManus says that the only way to increase the pool of medical school applicants is to lower A level requirements or to increase the pool of A level chemistry candidates.1 We argue that a better pathway to recruiting successful medical students is to appeal to a much larger pool both of able school pupils and of mature, older graduates and health professionals. Selection from this enlarged pool should be based on overall academic ability, which predicts both the likelihood of staying the course and ultimate success more powerfully than having science A levels and assessment of the personal qualities required to be a good doctor.2^–4

The real challenges are of affirmative action (making medicine seem an attractive career to the many young people who have the appropriate potential but are not currently considering it) and of tailoring undergraduate curriculums to meet the needs of students with the necessary scientific reasoning abilities but without the science knowledge base. Specific elements of such a strategy would include:

• Dispelling myths to school pupils and their teachers that medicine is an option only for scientists and requires unreasonable levels of dedication and study

• Broadening the range of A levels accepted without lowering grade requirements

• Expanding graduate and professional entry and access to medicine programmes5

• Defining (parsimoniously) the science base that is relevant to medicine and helping students learn it through guided discovery in a clinical context.

Compensating factors do not compensate for poor A level performance

EDITOR—Although statistical analysis of students' progression and performance in general finds school attainment to be a significant determinant, doubt about the validity of this finding seems to be considerable. The finding is based on the widely held view that nearly all medical students who entered on the basis of A level qualifications scored 30 points.1-4 If this were true, then it would indeed be impossible to infer any statistical relation between performance in A levels and later outcomes of medical students. Crucially, a surprisingly large variation exists in the A level scores of medical students.

The only currently available dataset for the full population of medical students, used in our own work, 2 3 is from universities' statistical records. This contains precise and complete information on pre-university qualifications for all medical students completing a medical degree in the United Kingdom between 1991 and 1997.

Of the population of students in English medical schools, 94% of students entered with A/AS levels as their main entry qualifications in 1985. Over time, a small decline has occurred, to 90%, among the 1993 entrants (completing in 1999). Of these students, only 28% had a full 30 point score (AAA) in 1985. In 1993, this proportion was 33%. The percentage achieving a score of 26 to 29 (22 to 25) points decreased slightly, from 44% (24%) in 1985 to 42% (20%) in 1993. This variation in the A/AS scores enables us to look at the effect of varying entry qualifications on dropout behaviour of the students.

The dataset does not contain information on the criterion by which students with A level scores notably below 30 points were accepted on to a medical school degree programme. If, however, students showed some compensating factors that offset lower A level performance, then they would be expected to have the same probability of dropping out as a student with higher A level scores. We have observed a significant negative relation between a student's probability of dropping out and A level score once other observable personal and university characteristics were controlled for, which implies that any compensating factors do not compensate for poor A level performance. Therefore, appropriate support programmes must accompany any policies aimed at widening participation by lowering entry qualifications.

Applications have increased again for second year running

EDITOR—McManus may have been overly pessimistic in his assessment of the attractions of medicine as a career.1 Predicting trends based on limited data is dangerous, but the latest figures for applications to medical schools which had arrived with the universities and colleges admissions service by the deadline of 15 October 2002 show a 28.1% rise compared with the year before. This is the second year in which there has been an increase. The number of applications is 14 040 for a target of 7135 places, giving a ratio of 1.97 applicants for every place despite the higher number of places.

Arulampalam et al (previous letter) also display unwarranted pessimism. It is clear from their data that a higher percentage of individuals with lower A level scores drop out, but the number of dropouts even in this group is low and the data can be interpreted to show that most individuals with lower scores succeed. Should we prevent them from entering the profession, or should we be looking for better selection criteria that identify who is really suited to a career in medicine?

I endorse the view of the Katonas (overleaf), that broadening the range of applicants does not mean lowering standards and provides a potential pool of applicants, which might maintain the number of applications even if McManus's prognostications prove to be correct.

Medicine and myth need to be separated

EDITOR—That Britain needs more doctors is a myth that arises, in part, from the need of the professions to protect existing structures and institutions from change.1 Much of medical care can be broken down into discrete tasks that do not require the training and costs associated with doctors, or even nurses. We do not need more doctors; we need more clarity in thinking about processes and outcomes.

The current expansion of medical schools is a disaster; an expensive solution that will lock many bright and capable people into unchallenging jobs and deprive the wider economy of a considerable source of talent and enterprise.