A single admissions test to select the best medical students

All human societies across the some 300,000 years of Homo sapiens existence have needed healers – from hunter-gatherer tribes to the first agricultural societies to our modern world today.

The medicine men of ancient Egypt gave way to Indian Ayurveda and the Chinese sinseh; Hippocrates and the Greeks; Ibn Sina in the Islamic Golden Age; the shamans, witch doctors and medicine men of various indigenous tribes worldwide; and the Malay archipelago’s bomoh, pawang and dukun.

These different names eventually converged on the modern “doctor”, which comes from the Latin word meaning “learned person”.

What remained the same though, was the trust, power, and even mystical status, enjoyed by healers throughout history, due to their ability to cure sickness and keep death at bay.

Today’s process of selecting medical students is merely the latest version of a profound spiritual, cultural, and even religious process of selecting healers.

Although Malaysians naturally desire the best doctors, there are some natural hurdles.

One, we can’t agree on what “best doctor” means – is it someone with excellent communication skills, high intelligence or sincere empathy?

Two, even if we agree and then have the best as doctors, what about having the best teachers, scientists or policymakers?

Three, any admissions process must match ambition to ability and availability of spots, inevitably breaking hearts in the process.

We have to change two deeply-held beliefs in Malaysia.

Firstly, it is wrong to believe you’re successful only if you’re a doctor.

There are many professions that are equally noble, respected, trusted, financially stable and with great career prospects; I know because I’ve had four fulfilling careers outside medicine.

Secondly, medicine is very tough and unglamorous.

You have to deeply accept that actual human beings will completely and utterly rely on you to solve their problems.

If you cannot even manage yourself, then you must seriously consider another vocation or you will become part of the problem.

Transparency and neutrality

The selection of medical students will always be imperfect, so we must not believe we’ll ever have it down to a perfect process.

The following proposed basket-of-solutions is uncontroversial and can be implemented inside the current affirmative action (or quota) system for university admissions. Although we will not debate the quota system itself, we will consider social mobility, meritocracy and justice as useful themes.

In reality, selecting the best doctors is a grand problem of talent allocation on a societal level, and it is always imperfect. Therefore, a transparent and neutral process is crucial.

The process must also consider an increasingly cleverer population (more straight A students), more demanding millennials (with a higher sense of entitlement) and that the public interest is as important as individual ambitions.

The selection process will always be accused of unfairness by those who are rejected, so we must say a few words about this terrible emotion.

While the government should do everything it can for the happiness of its citizens, we must draw the line where individual happiness harms the collective health and safety of 32 million fellow citizens.

While we don’t need (and shouldn’t aspire to have) the very best of society to become doctors, we do need (and should aspire to) select very competent medical students, because they will eventually become our healers.

A single admissions test

Firstly, to improve the selection of medical students in Malaysia, we must have a Medical School Admissions Test (MSAT), similar to the US Medical College Admissions Test (MCAT).

It can be administered by the Malaysian Examinations Syndicate, partnering the Malaysian Medical Council (MMC).

Anyone wanting to study in any medical school anywhere in the world must pass the MSAT, i.e. it’s a license to study medicine.

It should test for cognitive ability, empathy and psychological resilience, and communication skills, using currently-available electronic psychometric tools.

The MSAT will harmonise two sets of entry standards: those of the MMC and of individual medical schools.

MMC currently prescribes minimum academic standards for 22 recognised pre-university qualifications, from Matriculation to STPM, and even as obscure as the Ontario Secondary School Grade 12 Diploma (is that truly necessary? How many take these every year?).

These 22 exams are wildly different, and it’s difficult to regularly track their standards and grade inflation.

Additionally, each of the 378 recognised medical schools from 36 countries have different admissions criteria, some of which are lower than our already-very-low MMC criteria (e.g. minimum 5 Bs in SPM at a time when students score 17 A1s).

So in summary, we have many written standards to enter medical school, but they are too many, too uncoordinated, and never enforced.

There are other advantages to the MSAT beyond the harmonious high standards.

It should test for non-cognitive aspects, however imperfectly, which no pre-university exam does.

We can use a grading curve to control the number of annual students, combining the local/foreign, public/private and scholarship/self-funded routes. We can even add a little buffer to account for drop-outs and future career changes.

The MSAT is only one data point in deciding who gets into medical school though.

After harmonising standards with MSAT, we need a fair, transparent and neutral administrative selection process for all local medical schools.

I propose an algorithm adapted by Emeritus Prof Dr David Powis in 1998, when he was then undergraduate education assistant dean at the University of Newcastle, Australia.

It utilises four data points: an appropriate academic threshold (e.g. minimum STPM scores), the MSAT, an information-gathering interview and the socioeconomic status of the applicant.

The relative weights of the data points can be decided by individual schools.

The selection event should be a purely administrative task, based on a composite score from the four data points. In other words, we remove any bias in the process by making it purely administrative.

A pre-determined selection algorithm can be designed and publicly communicated by each medical school.

This allows each medical school to have their own character and culture, which is important to create healthy competition between schools.

Improving the process

There will never be a perfect way to select medical students.

Although society may want the best students to become doctors, the definition of “best student” is infinitely debatable.

Even if we can agree on the definition, society must consider that we also want the best to become teachers, lawyers and business people.

No matter how fair and transparent the entire process is, hearts will be broken as ambitions are dashed and hopes are crushed by large numbers of students applying for finite numbers of places.

Medicine is not for the faint-hearted. The selection process today is broken, so we must improve it through the Admissions Test and then using it as one of four data points in deciding who gets to become a medical student.

Dr Khor Swee Kheng has postgraduate degrees in internal medicine and public health, and has worked in five health sectors across three continents. He is currently reading Public Policy at the University of Oxford. The views expressed here are entirely his own.

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