Seven Myths Regarding Selection of Medical Students

Many beliefs are strongly held about undergraduate medical student selection but without any “visible means of support”. 

Myth 1: GCE A/L examination is an outdated method for student selection

Myth 2: GCE A/L examination is not a valid and reliable selection method  

Myth 3: In the past there have been students who were selected with very low A/L grades who went onto become excellent doctors and therefore the same criteria should continued to be applied

Myth 4: Academic capacity is not an important factor to become a good doctor

Myth 5: Entry criteria must be lowered since there are several deficiencies within the Sri Lankan educational system

Myth 6: Sri Lankan government medical schools admit students with very low entry qualifications

Myth 7: Free choice and desire should take priority over selection criteria

Myth 1: GCE A/L examination is an outdated method for student selection

In almost all the leading medical schools worldwide, performance during the GCE A/L or equivalent examinations is the main criteria for student selection.  This is a basic minimum, and the minimum standard for one of the most rigorous undergraduate programs is high – it is almost universally straight ‘As’, highest GPA scores or their equivalent.

Other methods such as letters of recommendation and interviews are now proven to be of questionable reliability and poor predictive validity. Cognitive or aptitude assessments and methods such as Multiple Mini Interviews (MMI), when they are used, are additional criteria and do not compensate for poor academic performance. Even in aptitude tests such as MCAT, the biology sub component has shown the best predictive validity. In the Sri Lankan context, the Advanced Levels (Biology stream) have been the yardstick for entry to medical schools. It is noteworthy that there are positive developments within the current Sri Lankan A/L system such as inclusion of mandatory English, IT and project work.

The rampant levels of corruption in the country further confirm that we lack the safeguards and maturity to prevent interference and manipulation of the entry process. As things stand, the Sri Lankan A Levels is probably the safest tool for student selection and the least susceptible to manipulation.

 Myth 2: GCE A/L examination is not a valid and reliable selection method 

Large-scale research worldwide has proven that Advanced level performance is the best predictor of future academic performance, undergraduate, postgraduate and CPD. As shown by extensive research conducted in the UK and supported by many research studies worldwide, our performance during high school education, undergraduate and postgraduate are mainly determined by our core-intellectual capacity, which is essentially like a “core-academic backbone”. GCE A/L and similar examinations can measure this capacity reasonably accurately.

The following similarities explain why GCE A/L is a valid tool to predict future academic performance.

1. Substantive content—GCE. A/Ls provide students with a broad array of facts, ideas, and theories relevant to future medical students. Content areas such as human biology, molecular biology, cell biology and genetics continue with expanding complexity throughout high school, undergraduate and postgraduate education.

2. Achieving high grades at the GCE A/level requires, not only intellectual ability, but also motivation, perseverance, dedication, commitment and personality traits that are also beneficial at medical school and for lifelong learning.

Myth 3: In the past there have been students who were selected with 3 Simple passes who went onto become excellent doctors and therefore the same criteria should continue to be applied.

The intellectual ability of a student who scored an S in the past will not be of the same quality as a student who gains an S in present times. This is to be expected as grade inflation over time is a common phenomenon. If medical education (as world over) is to select the most able students in a given generation, an S (or three Ss) is not sufficient, when selecting the best among the present generation of students; i.e. it is similar to the fact that what you could do with Rs. 100, fifteen years ago, cannot be done with Rs. 100 now. The value of a simple pass has gone further down due to the fact that the pass mark is now lowered to 35%.

The decision regarding students’ selection should depend on the baseline performance applicable to that population. The current baseline performance of those who are selected to follow medicine is very high particularly due to grade inflation.  For example, in 2016, over 580 students obtained 3 “A”s in GCE A/L Biology stream. With such grade inflation, the rational and logical measure should be to make the bar higher. For example, UK is now considering A+ or A++ as minimum criteria.

But we try to do the exact opposite!

Myth 4: Academic capacity is not an important factor to become a good doctor

Few questions that are commonly asked;

-Is it possible to train a totally unqualified person to pretend to perform some routine tasks of a doctor?

-Is it possible to train an unqualified person to perform a selective invasive medical or surgical procedure?

-Can there be doctors with poor professionalism and ethics from among those selected based on high academic achievements?

The answer to all these questions is; yes, it is possible. However, all these are isolated possibilities and individual examples. A proper and an established system always takes priority and generalisability over individual variations.

Research has shown that content knowledge is the single most important determining factor for competency of a doctor. To achieve that, the starting material, the student, has to be pluripotent, have adequate intellectual capacity and the potential to acquire skills and knowledge.

Time and again, I recollect being asked the question “So and so from NCMC is now a top consultant. What do you have to say about it”? I once analysed the A/L aggregates of NCMC top performers, only to find that most of them missed entry into a state medical faculty by just 10-15 marks.

Does that justify establishment of NCMC? The answer is no. Larger social justice must always prevail over individual justice. There must have been hundreds of other students within that mark range who could not afford to pay. If the government during that time took the correct decision to open two new medical faculties in Kelaniya and Sri Jayewardenepura (which they did anyway five years later), rather than trying to mess up with an established system and ending up in disastrous consequences, all of these students would have become proud graduates of state medical faculties.

We never learn from mistakes!

Myth 5: Entry criteria must be lowered since there are several deficiencies with the Sri Lankan educational system

No educational system or high school examination is flawless and Sri Lanka is not an exception. Sri Lanka’s education system is criticized for inadequate facilities, lack of good teachers and educational resources that are unevenly dispersed. Sri Lanka’s education spending stood at 2.1 percent of GDP in 2015 (World Bank). This is below the spending levels in other South Asian lower-middle-income countries.

But who is responsible for that?

Where is the real issue?

In 2013, 40,253 students sat for the GCE A/L in the Biology Stream; 20,215 students gained 3S passes (i.e. simple passes) or more (50% pass rate). Of these, over 7,000 students (one in three who passed) were selected to state universities. 2,300 students gained 3Bs and above. Approximately 50% of those who gained 3Bs and above were selected for medicine in state universities.

Now, lets compare this with the Arts stream,

In 2013, 70, 000 students passed the examination and only 7,000 got selected to the state universities (Only 10%).

This shows that the system of entry into medical education in Sri Lanka has maintained a fair and equitable system amidst chaos and inequity. 

Trying to use loopholes within a system rather than correcting them and improving the system (in this case 3S passes as entry criteria), will only lead to destabilization of the system and chaos.

With current grade inflation, three simple passes as the entry criteria effectively makes ability to pay the sole criterion for medical education, leading to worsening of the disparities and a huge social injustice.

The existence of tuition culture and coaching (shadow education system) is a frequent argument brought up to discredit the A/L system. Shadow education systems are not ubiquitous for A/Ls. They are available for every conceivable assessment anywhere in the world. Shadow education systems, by their very nature can only adjust according to changes of formal education and assessment system. It is never a substitute for the formal education system.  What we need to do is make improvements in the formal education and assessment system to achieve the desired outcomes.

If coaching is an issue, that is the very reason that the bar for entry should be made higher, for it is possible to get 3 simple passes or credits by coaching only, but not the higher grades. Furthermore, coaching is a more serious concern when it comes other admission methods such as interviews, letters of recommendations and self-appraisals.  The reasons are obvious.

Disparities are there and they will continue to be there. That is the very reason why the common A/L pathway, where there is the potential for a deserving student to overcome all the barriers through sheer dedication and commitment should be safeguarded. The existence of disparities is not a justification for a separate pathway only for those who can pay. It will only worsen the situation. 

Myth 6: Sri Lankan government medical schools admit students with very low entry qualifications

Much of the debate in favour of private medical education in this country has been on the basis of the perceived unfairness to those who failed to enter medical school despite having obtained better grades than counterparts entering on district based merit.

The district merit admissions (55% of the total intake), is an affirmative action based on the principle of equity.  It assumes that for a variety of social, economic and historical reasons some are at a greater disadvantage than others, and strives to compensate them for their disadvantage. Equity recognizes this uneven playing field and aims to take extra measures by giving those who are in need more than others who are not.

There are confounding factors in this assumption; variations amongst schools in a district, mass tuition classes attended by students from other regions and migration of high performing students to good schools in the cities to name a few. However, anomaly due to this subset is partially compensated by the national merit quota (40% of the total intake).

Even within the underprivileged districts, those who are getting these low grades are a very small minority of outliers out of a total of over 1,300 students selected for Medicine. For example in 2014, 30 students from Nuwaraeliya had 3Bs and above, and 32 students were selected for medicine, i.e. only two students who had grades less than 3Bs were selected for Medicine.

The grades of those who had the minimum Z-scores for medicine selection too is on the rise.

2010    C C S          

2011   C S  B         

2012   C C  C         

2013   C C  B         

2014   C B  B

2015   B B  B

There is no doubt that the district quota system needs to be revised. However, this cannot be achieved by lowering the entry criteria. Stipulating realistic entry criteria such as 3B or equivalent would correct the anomalies.

Myth 7: Free choice and desire should take priority over selection criteria

The key words here are, equity and merit and needs of the health system.

Health system requirements of the country and collective national responsibility take precedence over individual freedom and desire. Free choice and desire should never be allowed to camouflage hidden agendas of using nepotism, power and financial clout as means of accessing medical education.

Furthermore, we have a moral responsibility towards correctly guiding students who are lured into private medical schools by intense marketing, and driven by parental dreams and compulsion. They have little realization about the declining prospects of employment and career 10 years down the line. It will be too late by the time reality sinks in. We do not want to be the facilitators nor the beneficiaries of a multi-billion rupee medical degree awarding industry that will result in a surplus of unemployable medical graduates in the future. 

These are the key reasons that medical education has to be regulated in every sense, from entry standards, numbers, and course structure. That’s why we have an established system for selection, training and certifying.

Therefore it is imperative that our established system for selecting students into medical education should be safeguarded. Systems may not be perfect. However, destroying what we have been doing correctly by exploiting loopholes is not the answer.

We, as Sri Lankans, used to take pride in two things, our cricket and our health system achievements. As it is, the status of Sri Lankan cricket is the best example how political influences, individual agendas and corruption can totally destroy even the best systems. The same should never be allowed to happen in medical education.