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Year : 2021  |  Volume : 19  |  Issue : 3  |  Page : 194-196

Considering medical education research: Selection into medical school

1 Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
2 Department of Physiology, Christian Medical College, Vellore, Tamil Nadu, India
3 Public Health, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK

Date of Submission11-Mar-2021
Date of Decision14-Apr-2021
Date of Acceptance13-May-2021
Date of Web Publication05-Jul-2021

Correspondence Address:
Jennifer Cleland
Medical Education Research and Scholarship Unit, Lee Kong Chian School of Medicine, Nanyang Technological University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmi.cmi_28_21

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How to cite this article:
Cleland J, Oommen V, Poobalan A. Considering medical education research: Selection into medical school. Curr Med Issues 2021;19:194-6

How to cite this URL:
Cleland J, Oommen V, Poobalan A. Considering medical education research: Selection into medical school. Curr Med Issues [serial online] 2021 [cited 2022 May 18];19:194-6. Available from: https://www.cmijournal.org/text.asp?2021/19/3/194/320647

Medicine as a science and as a profession has made great progress in the last 150 years. The infection epidemic was mastered by the invention of antibiotics, cardiovascular disease became treatable, and our knowledge of cancer advances rapidly. However, at the same time, tens of thousands of people die worldwide every year as a result of medical errors. “To err is human, building a safer healthcare system,” an influential report from the Institute of Medicine, estimates that in the US alone, every year, at least 44,000 and perhaps even 98,000 patients die as a result of medical errors.[1] In short, more people die in a given year as a result of medical errors than from motor vehicle accidents, breast cancer, or acquired immunodeficiency syndrome.

These findings imply that an important cause of medical errors is how the physician is trained. Although the training of doctors started about 2000 years ago, times have changed and so did practice, society, healthcare systems, and patient expectations. There are also shifts in how we deliver education and in training linked to changing healthcare practices and systems (e.g. limits on hours of training in many countries). Moreover, our knowledge of what constitutes good clinical practice is constantly evolving.[2] Medical education must therefore prepare today's medical students and doctors in training to work in very different ways from those of the past.[3]

To meet these standards and expectations, medical education has to keep up with prevailing standards and look forward, both of which depend on medical education research. Just as the biomedical researcher seeks ways to improve treatments that help patients, the medical education researcher seeks ways to improve education such that the graduate is better prepared to help patients. Both have the same goals albeit use different means.

Meeting the goal of preparing the doctors of tomorrow optimally requires generating and using evidence from well-designed – and well-conducted – medical education research.[4] Medical education research is the birthplace of many innovations including the introduction of simulated patients; simulation, in general; the objective structured clinical examination; advanced knowledge testing such as the introduction of the longitudinal “progress test;” and small-group tutorial learning such as problem-based learning. All these innovations emerged from research into medical education and indicate how medical education research has transformed policy, curriculum, teaching, and learning.[5]

We look to selection into medical school, a major area of endeavor for health professional educators, as an example of the utility of medical education research. Often described as the first assessment of medical school, more than 20 years of research into medical school selection has identified three broad approaches to medical school selection: individually focused processes, competency-based frameworks, and social accountability/workforce planning.[6]

In individually focused processes, the capacity for academic success is typically the basis for selection and this is assessed via attainment on school-leaving examinations or national-level standardized tests, such as the USA's Medical College Admission Test. To broaden selection to encompass personal attributes (characteristics desirable in a doctor, such as empathy and communication skills) as well as academic achievement, many countries now use “competency-based” selection frameworks. These use a combination of methods at the point of selection to assess not only for academic ability but also for predetermined behaviors and attitudes that are thought to indicate success as a healthcare practitioner or student.

The third selection philosophy focuses on the interplay between individual competencies and meeting societal needs. This model of selection is holistic, considering applicants in respect not only of their individual capabilities but also taking into account student diversity, physician maldistribution, and community needs in the selection processes and goals. India has long struggled to attract and retain doctors and healthcare professionals to remote, rural, and deprived, and disadvantaged areas. Not-for-profit Indian medical schools, such as Christian Medical College (CMC), have focused on social accountability mission since long before the World Health Organization suggested that the accreditation criteria of medical schools should better reflect priority health needs.[7]

How to evaluate the success of medical school selection processes? A recent systematic review of the research literature shows clear messages about the comparative reliability, validity, and cost-effectiveness of various selection methods commonly used by medical schools [Table 1].[8] Note that CMC's approach would be considered a selection center. There remain relatively few reports of the use of, and outcomes from, this approach in the literature.
Table 1: Summary of the evidence and implications for different election methods

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The outcome measures used to evaluate medical school selection methods have been criticized for typically focusing on indicators of attainment and performance (e.g. retention, medical school achievements, and performance on licensure examinations). Many studies have compared medical schools in respect of graduate performance on postgraduate examinations and fellowships, to assess whether performance on selection is associated with later performance (studies of predictive validity).[8] These academic metrics are relatively “easy measures” and certainly of use. However, if individuals are good enough at passing examinations to get into medical school, they likely will remain good at passing examinations. Hence, what then are good outcomes against which to measure admissions process? There is clear evidence, admittedly from a small number of countries, that origin (e.g. rural upbringing) and intentions on graduation (e.g. intention to work rurally) are also related to later working patterns, suggesting that studies must take personal characteristics and preferences into account when trying to assess the relative contribution of individual factors and medical school influences on graduate patterns.[8],[9],[10]

Should we also look at our graduates' career outcomes, such as working in direct clinical care, working in underserved regions, and/or working in certain specialties? Using these broader criteria, the indicators of success may include retrospective data on where graduates worked or whether the nature of the populations they served was aligned to the mission of their medical school. These indicators of success may be assessed via cohort studies. These broader indicators of success are essential for schools, particularly schools with a social accountability mission, in respect of selecting applicants who are fit-for-purpose in terms of meeting the healthcare needs of less advantaged populations.[9]

Our final point is that the 2018 Ottowa Consensus Statement on Selection noted that the majority of selection research originates from a limited number of global regions. Research from countries including India is lacking in international journals.[10] This influential Statement concluded that medical education research generally and selection research specifically “cannot be isolated from the cultural and social structural context in which it takes place” and made a plea for research from “contexts whose voices are currently under-represented” (p. 8). The time is right for a program of medical education research from India. With this in mind, our intention is that this article opens a short series of Current Medical Issues papers which focus broadly on selection practices, processes, and outcomes and will be of interest to a broad audience.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Donaldson MS, Corrigan JM, Kohn LT. To Err is Human: Building a Safer Health System. National Academies Press; 01 April, 2000. Available from: https://pubmed.ncbi.nlm.nih.gov/25077248/. [Last accessed on 2021 Mar 15].  Back to cited text no. 1
Chin L, Satell G. How Physicians Can Keep Up with the Knowledge Explosion in Medicine. Harvard Business Review; 19 December, 2016. Available from: https://hbr.org/2016/12/how-physicians-can-keep-up-with-the-knowledge-explosion-in-medicine. [Last accessed on 2021 Apr20].  Back to cited text no. 2
Cooke M, Irby DM, O'Brien B. A Summary of Educating Physicians: A Call for Reform of Medical School and Residency. California: Jossey-Bass; 2010.  Back to cited text no. 3
Cleland JA, Durning SJ, Driessen E. Medical education research: Aligning design and research goals. Med J Aust 2018;208:473-5.  Back to cited text no. 4
Sarli CC, Dubinsky EK, Holmes KL. Beyond citation analysis: A model for assessment of research impact. Med Lib Assoc 2010;98:17–23.  Back to cited text no. 5
Roberts C, Khanna P, Rigby L, Bartlett E, Llewellyn A, Gustavs J, et al. Utility of selection methods for specialist medical training: A BEME (best evidence medical education) systematic review: BEME Guide no. 45. Med Teach 2018;40:3-19.  Back to cited text no. 6
Boelen C, Heck, J. World Health Organization. Division of Development of Human Resources for Health. Defining and Measuring the Social Accountability of Medical Schools 1995. Available from: https://apps.who.int/iris/handle/10665/59441. [Last accessed on 2021 May 10].  Back to cited text no. 7
Patterson F, Knight A, Dowell J, Nicholson S, Cousans F, Cleland JA. How effective are selection methods in medical education? A systematic review. Med Educ 2016;50:36-60.  Back to cited text no. 8
Cleland JA. The medical school admissions process and meeting the public's health care needs: Never the twain shall meet? Acad Med 2018;9:972-4.  Back to cited text no. 9
Patterson F, Roberts C, Hanson M, Hampe W, Ponnamperuma G, Eva KW, et al. Ottawa consensus statement: Selection and recruitment in the healthcare professions. Med Teach 2018;40:1091-101.  Back to cited text no. 10


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