Also Human

by Caroline Elton

  28 STEP 1 scores can discriminate against African-American applicants: Edmond, M., Deschenes, J., et al., ‘Racial Bias in Using USMLE Step 1 Scores to Grant Internal Medicine Residency Interviews,’ Acad Med, 76:12 (2001), pp. 1253–1256.

  29 The 2015 GMC’s commitment to ensuring fair training pathways, available online at: http://www.gmc-uk.org/education/29478.asp.

  30 The GMC commissioned literature review: Plymouth University Peninsula., ‘Understanding differential attainment across medical training pathways: A rapid review of the literature,’ GMC (2015) available online at: http://www.gmc-uk.org/about/research/28332.asp.

  31 The second GMC commissioned study: Woolf, K., et al., (2016). ‘Fair Training Pathways for All: Understanding Experiences of Progression,’ GMC (2016) available online at: http://www.gmc-uk.org/2016_04_28_FairPathwaysFinalReport.pdf_66939685.pdf.

  32 The American Medical Association’s official apology to African-American physicians: Aluko, Y., ‘American Medical Association Apologizes for Racism in Medicine,’ J Natl Med Assoc 100:10 (2008), pp. 1246–1247.

  33 Acceptance into the Alpha Omega Alpha Honor Society: Boatright, D., et al., ‘Racial Disparities in Medical Student Membership in the Alpha Omega Alpha Honor Society,’ JAMA Intern Med, 177:5 (2017), p.659.

  34 An invited commentary on the need for tracking allegedly race-neutral systems and advancement from: Cooke, M., ‘Implicit Bias in Academic Medicine,’ JAMA Intern Med, 177:5 (2017), p.657.

  35 In 2016 the GMC reported that over a quarter of all doctors gained their primary medical qualification outside of the UK or Europe. The report is available online at: http://www.gmc-uk.org/SOMEP_2016_Full_Report_Lo_Res.pdf_68139324.pdf

  36 ‘What happens in medical school is a wider reflection on society,’ wrote Professor Aneez Esmail in: Esmail, A., ‘Ethnicity and academic performance in the UK,’ BMJ, 342 (2011), 10.1136/bmj.d709.

  37 Global information from HEFCE on the differences in student outcomes available online at: http://www.hefce.ac.uk/pubs/rereports/Year/2015/diffout/.

  38 Over a ten-year period, the University of Texas Medical Branch introduced significant reforms: Lieberman, S., et al., ‘Comprehensive Changes in the Learning Environment: Subsequent Step 1 Scores of Academically At-Risk Students,’ Acad Med, 83: (10 suppl) (2008), S49-52.

  39 The Cooper Medical School of Rowan University matriculated its first class: Personal Communication. I was directed towards this new medical school by a colleague at the AAMC who is involved with increasing the diversity of applicants admitted to medical school. Further information about the institution available at: www.rowan.edu/coopermed.

  40 A 2017 article entitled ‘Breaking the Silence’: Acosta, D., and Ackerman-Barger, K., ‘Breaking the Silence: Time to Talk about race and racism,’ Acad Med 92:3 (2017), pp. 285–288.

  No Exit

  1 A 2013 survey carried out by a group of epidemiologists at Oxford University concluded that UK doctors rarely give up a medical career within twenty-five years of graduation: Goldacre, M. L., and Lamber, T. W., ‘Participation in medicine by graduates of medical schools in the United Kingdom up to 25 years post graduation: national cohort surveys,’ Acad Med 88:5 (2013), pp. 699–709.

  2 In the US the 2015 Graduation Questionnaire reported that only 0.2% of respondents did not intend to practice medicine. The 2015 report is available online at: https://www.aamc.org/download/440552/data/2015gqallschoolssummaryreport.pdf.

  3 UK teacher recruitment and retention information available online at: https://www.teachers.org.uk/edufacts/teacher-recruitment-and-retention.

  4 The Guardian 2015 article: Campbell, D., ‘Almost half of junior doctors reject NHS career after foundation training’ available online at: https://www.theguardian.com/society/2015/dec/04/almost-half-of-junior-doctors-left-nhs-after-foundation-training.

  5 The Wall Street Journal 2014 article entitled ‘Why doctors are sick of their profession,’ available online at: http://www.wsj.com/articles/the-u-s-s-ailing-medical-system-a-doctors-perspective-1409325361.

  6 The total NHS investment in each fully qualified hospital consultant is estimated to be over half a million pounds: ‘How much does it cost to train a doctor in the United Kingdom?’ BMA (2013) available online at: https://www.bma.org.uk//media/Files/…/pressbriefing_cost_of_training_doctors.docx.

  7 UKFPO Annual Reports 2010 and 2011, and F2 Careers Destination surveys for each year 2012–2016 inclusive are all available on the UKFPO website: www.foundationprogramme.nhs.uk.

  8 Figures of UK doctors who have permanently left the profession available online at: www.foundationprogramme.nhs.uk.

  9 The results from the BMA EU Survey of Doctors working in the UK are available at: https://www.bma.org.uk/collective-voice/policy-and-research/education-training-and-workforce/eu-doctors-survey.

  10 Doctors’ self-reported intention to leave practice reported in: Rittenhouse, D. R., et al., ‘No exit: an evaluation of measures of physician attrition,’ Health Serv Res 39:5 (2004), pp. 1571–1588.

  11 A 2004 study carried out by the British Medical Association found that the decision to leave medicine is often traumatic: Cooke, L., and Chitty, A., ‘Why do doctors leave the profession?’ BMA, Health Policy and Economic Research Unit (2004).

  12 A survey of emergency physicians in the US found that 64% reported feelings of guilt or inadequacy after unsuccessful pediatric resuscitation: Ahrens, W. R., and Hart, R. G., ‘Emergency physicians’ experience with pediatric death,’ Am J Emerg Med 15:7 (1997), pp. 642–3.

  13 A study of over 600 anaesthetists: Gazoni, M. F., et al., ‘The impact of perioperative catastrophes on anesthesiologists: results of a national survey,’ Anesth Analg 114:3 (2012), pp. 596–603.

  14 A study of the impact of perinatal death on obstetricians: Gold, J. K., et al., ‘How physicians cope with stillbirth or neonatal death: A national survey of obstetricians,’ Obstet Gynecol 112:1 (2008), pp. 29–34.

  15 The BMA small scale study of fourteen doctors: Cooke, L., and Chitty, A., ‘Why do doctors leave the profession?’ BMA, Health Policy and Economic Research Unit (2004).

  16 Michael Crichton described leaving medicine in his essay ‘Quitting medicine’ in: Crichton, M., Travels (New York: Vintage Books, 2004).

  17 Helen Rose Fuchs Ebaugh study: Ebaugh Fuchs, R. H., Becoming an Ex: The Process of Role Exit (Chicago & London: University Of Chicago Press, 1988).

  Natural Selection

  1 University of Oxford statistics available online at: https://www.ox.ac.uk/about/facts-and-figures/admissions-statistics.

  2 The Medical Schools Council ‘Guiding Principles for the Admission of Medical Students,’ (Revised, March 2010) available online at: https://www.medschools.ac.uk/media/1931/guiding-principles-for-the-admission-of-medical-students.pdf.

  3 In the UK, four-year graduate entry programmes comprise 10% of admissions: Garrud, P. (2011). ‘Who applies and who gets admitted to UK graduate entry medicine? – an analysis of UK admission statistics,’ BMC Med Educ 11:71 (2011),10.1186/1472–6920-11–71.

  4 Low attrition rate statistics in: Yates, J., ‘When did they leave, and why? A retrospective case study of attrition on the Nottingham undergraduate medical course,’ BMC Med Educ 12:43 (2012); Maher, B. M., et al., ‘Medical School Attrition – beyond the statistics. A Ten-year study,’ BMC Med Educ 13:13 (2013),10.1186/1472–6920-13–13.

  5 The AAMC reported in 2010 that approximately 3% of medical students do not complete their degrees. The report is available online at: https://www.aamc.org/download/165418/data/aibvol9_no11.pdf.pdf

  6 Most students accepted to medical school end up graduating. An alternative explanation is known in the trade as the ‘failure to fail’: Cleland, J., et al., ‘It is me or is it them? Factors that influence the passing of underperforming students,’ Med Educ 42:8 (2008), pp. 800–9.

  7 Yates’ analysis of five consecutive intakes at Nottingham University Medical School in: Yates, J., and James, D., ‘Predicting the “strugglers”: a c
ase-study of students at Nottingham University Medical School,’ BMJ 332:1009 (2006), 10.1136/bmj.38730.678310.63.

  8 The 2010 GMC study of doctors who were disciplined for professional misconduct: Yates, J., and James, D., ‘Risk factors at medical school for subsequent professional misconduct: multicenter retrospective case-control study,’ BMJ 340 (2010), 10.1136/bmj.c2040.

  9 Studies from the US, on doctors who were disciplined for professional misconduct by the State Licensing Board: Papadakis, M., et al., ‘Unprofessional behaviors in medical school is associated with subsequent disciplinary action by a state medical board,’ Acad Med 79:3 (2004), pp. 244–9; Papadakis, M., et al., ‘Disciplinary action by medical boards and prior behavior in medical school,’ N Engl J Med 353 (2005), pp. 2673–2682.

  10 Only a tiny proportion of doctors in the UK and USA end up being disciplined by the relevant regulator: Figures for the UK are available online at: https://www.gmc-uk.org/DC9491_07___Fitness_to_Practise_Annual_Statistics_Report_2015___Publis hed_Version.pdf_68148873.pdf.

  11 Figures for the US are available online at: https://www.fsmb.org/Media/Default/PDF/FSMB/Publications/us_medical_regulatory_trends_actions.pdf.

  12 Jennifer Cleland, a physician and educator at Aberdeen Medical School, has researched the ‘failure to fail’ within the medical school training: Cleland, J., et al., ‘It is me or is it them? Factors that influence the passing of underperforming students,’ Med Educ 42:8 (2008), pp. 800–9.

  13 Cleland questions the approach to remediating underperforming students in: Cleland, J., et al., ‘The remediation challenge: theoretical and methodological insights from a systematic review,’ Med Educ 47:3 (2013), pp. 242–51.

  14 In the US, MCAT scores have routinely been shown to predict results on the first set of national examinations (STEP1): Brenner, J. M., et al., ‘Formative Assessment in an Integrated Curriculum: Identifying At-Risk students for poor performance on USMLE Step 1 Using NBME Custom Exam Questions,’AAMC 92.11S. Proceedings of the 56th Annual Research in Medical Education Sessions (2017), S21-25.

  15 The ability of MCAT scores to predict later clinical performance as a doctor seems to be extremely weak: Sagull, A., et al., ‘Does the MCAT predict medical school and PGY-1 performance?’ Mil Med 180: 4 (2015), pp. 4–11.

  16 Chris McManus et al., discuss the ‘academic backbone’ in: McManus, C., et al., ‘The academic backbone: longitudinal continuities in educational achievement from secondary school and medical school to MCRP (UK) and the specialist register in UK medical students and doctors,’ BMC Med 11:242 (2013), 10.1186/1741–7015-11–242.

  17 A national survey of first year foundation doctors found that 31% attended a private school. For further information see the ‘Selecting for Excellence’ report, available online at: https://www.medschools.ac.uk/media/1203/selecting-for-excellence-final-report.pdf

  18 A similar social bias is seen in the US with approximately half of medical students coming from families with the top 20% of income. Figures available online at: https://www.aamc.org/download/102338/data/aibvol8no1.pdf.

  19 Since 2001, King’s College London has admitted students from low-achieving secondary schools onto the Extended Medical Degree Programme (EMDP): Garlick, P., ‘Widening participation in medicine,’ BMJ 336:1111 (2008), 10.1136/bmj.d918.

  20 In an article for the Psychologist, McManus et al., caution against lowering medical school entry grades: Woolf, K., McManus, C., et al., ‘The best choice?’ the Psychologist 28:9 (2015), pp. 730–734.

  21 A five-year study of over six thousand entrants to Medical School in the UK: Tiffin, A. P., et al., ‘Predictive validity of the UKCAT for medical school undergraduate performance: a national prospective cohort study,’ BMC Med 14:140 (2016), 10.1186/s12916-016–0682-7.

  22 An evaluation and case study of the Biomedical Admissions Test: McManus, I. C., et al., ‘Predictive validity of the Biomedical Admissions Test: An Evaluation and case study,’ Med Teach 33:1 (2011), pp. 53–7.

  23 In 2012 the medical profession was named and shamed in this review: ‘Fair Access to Professional Careers: A progress report by the Independent Reviewer on social mobility and child poverty,’ (2012) available online at: https://www.gov.uk/government/publications/fair-access-to-professional-careers-a-progress-report.

  24 A Scottish study found that GPs from less affluent backgrounds were more likely to work in deprived communities: Dowell, J., et al., ‘Widening access to medicine may improve general practitioner recruitment in deprived and rural communities: survey of GP origins and current place of work,’ BMC Med Educ 15: 165 (2015), 10.1186/s12909-015–0445-8.

  25 Students who study in a more diverse medical school end up having more positive attitudes towards patients from minority groups: Saha, S., et al., ‘Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in US Medical Schools,’ JAMA 300: 10 (2008), pp. 1135–1145.

  26 In 2014 the Medical Schools Council compiled a list of the key skills and attributes needed to study medicine, available online at: www.medschools.ac.uk.

  27 Studies have asked patients what they look for in their doctor, for example: Wen, S. L., et al., ‘What do people want from their health care? A qualitative study,’ J Participat Med 7: e10 (2015).

  28 Cleland led a major review identifying best practice in the selection of medical students: Cleland, J., et al., ‘Research Report: Identifying best practice in the selection of medical students,’ GMC (2013) available at https://www.gmc-uk.org/about/research/25036.asp.

  29 Guidance from the Medical Schools Council shows that the majority of UK medical schools no longer score personal statements: ‘Entry requirements for UK medical schools 2017 entry,’ Medical Schools Council (2017) available online at www.medschools.ac.uk/media/2357/msc-entry-requirements-for-uk-medical-schools.pdf.

  30 An exploratory study of which eleven-year olds would like to become a doctor: McManus, C., et al., ‘Doctor, builder, soldier, lawyer, teacher, dancer, shopkeeper, vet: exploratory study of which eleven-year olds would like to become a doctor,’ BMC Psychol 3:38 (2015), 10.1186/s40359-015–0094-z.

  31 The impact of unconscious bias has been found to be a significant factor in interviews for other professions: Howard, J. R., Everyday Bias: Identifying and Navigating Unconscious Judgements in Our Daily Lives (Lanham: Rowman & Littlefield, 2014).

  32 Icahn School of Medicine in New York are doing unconscious bias training for all interview panel members. (Personal communication with author).

  33 A study in a medical school in the Midwest found that all members had significant unconscious bias for white people: Capers, Quinn IV; Clinchot, D., et al., ‘Implicit Racial Bias in Medical School Admissions,’ Acad Med 92:3 (2017), pp. 365–369.

  34 In 2004, Professor Kevin Eva and his colleagues at McMaster University adopted the multiple mini interview format: Eva, W. K., et al., ‘An admissions OSCE: the multiple mini-interview,’ Med Educ 38:3 (2004), pp. 314–26.

  35 In the UK, MMIs were piloted by Dundee Medical School: Dowell, J., et al., ‘The multiple mini-interview in the UK context: 3 years of experience at Dundee,’ Med Teach 34:4 (2012), pp. 297–304.

  36 Kevin Eva followed up with the original MMI cohort in: Eva, W. K., et al., ‘Association between a Medical School Admission Process Using the Multiple Mini-interview and National Licensing Examination Scores,’ JAMA 308: 21 (2012), pp. 2233–2240.

  37 In 2011, the great and the good in the world of medical education produced a consensus statement on medical school selection: Prideaux, D., et al., ‘Assessment for selection for the health care professions and specialty training: consensus statement and recommendations from Ottawa 2010 Conference,’ Med Teach 33.3 (2011), pp. 215–23.

  38 Around the world, medical schools’ desire to apply rigorous standards of evidence to their admissions processes: Dowell, J., et al., ‘The multiple mini-interview in the UK context: 3 years of experience at Dundee,’ Med Teach 34:4 (2012), pp. 297–304.

  39 Chris McManus contributed
to the global consensus statement on best practice in selection in: Prideaux, D., et al., ‘Assessment for selection for the health care professions and specialty training: consensus statement and recommendations from Ottawa 2010 Conference,’ Med Teach 33:3 (2011), pp. 215–23.

  40 Donald Barr, writing in The Lancet: ‘The art of medicine: Science as superstition: selecting medical students,’ The Lancet 376 (2010), pp. 678–679.

  41 Unprofessional behavior (such as lying) has been shown to increase the risk of subsequent action once the student has qualified: Papadakis, M. A., et al., ‘Disciplinary action by medical bboards and prior behavior in medical school,’ N Engl J Med 353: 25 (2005), pp. 2673–2682.

  42 According to guidance from the GMC and the Medical Schools Council (2015), serious health issues will not jeopardize a career in medicine: ‘Supporting Students with Mental Health Conditions’ available online at: https://www.gmc-uk.org/Supporting_students_with_mental_health_conditions_0816.pdf_53047904.pdf.

  43 Some medical schools advocate using a screening questionnaire: Powis, A. D., ‘Selecting medical students: An unresolved challenge,’ Med Teach 37:3 (2014), pp. 252–60.

  44 Organisations that assess whether staff will cope with extremely demanding assignments have developed sophisticated questionnaires. (Personal communication regarding the work of Interhealth Worldwide – an international charity that provided medical, psychological, occupational and travel health to staff working in international development. The charity was founded in 1989 and sadly closed in 2017 due to financial challenges).

  Epilogue

  1 The video of the liver transplant operation is available online at: https://www.theguardian.com/society/video/2016/feb/08/living-donor-liver-transplant-from-son-to-father-video

  2 The mantra of ‘patient-centred care’ from The National Institute for Clinical Excellence (NICE) outlines what patient-centred care involves, available online at: https://www.nice.org.uk/guidance/cg161/chapter/patient-centred-care