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Logo of bmjThis ArticleThe BMJ
BMJ. 2007 November 24; 335(7629): 1073.
PMCID: PMC2094142

Should all medical students be graduates first? NO

Most people enter medical college straight from school. Ed Peile argues that changing to a single system of graduate entry medical schools would provide the diverse multiskilled workforce needed for the future, but Charles George thinks that there is insufficient evidence to make this a criterion of entry

Traditionally, admission to a UK medical school has been directly after leaving school or one year later. In a survey carried out for the Council of Heads of Medical Schools (CHMS) in 1998,1 only 15.6% were mature (21 and over), and the proportion of these 2955 students who were graduates was not given. Since the late 1990s, the numbers of students entering existing medical schools have expanded and four more schools have been created in England. The demography of people applying for a place has changed, and in the period 2003-2005 22.4% of entrants were mature.2

I argue that we do not need to modify the current system by restricting entry to graduates. My main argument is that it would be discriminatory to school leavers and to mature non-graduates to limit medical training to people who already have a degree in the absence of any convincing evidence of benefit. It would also cost more to the taxpayer for students to do both a first degree and a postgraduate medical degree.

Mature students and graduates

My experience of mature medical students and graduates at entry derives from more than 25 years as a clinical academic at the University of Southampton. There, from the first entry of students in 1971, we encouraged applications from “mature” people, taking up to 15%.3 Without exception, they were committed to becoming doctors, and had to be in view of the financial and other sacrifices they had to make. Their “wastage rates” were low, with almost all completing the course. In addition, they brought the diversity sought by Professor Peile and the medical schools to the student body—one of the guiding principles advanced by CHMS.4 But it was chiefly their experience of “life in the real world” that benefited the university and subsequently their patients. Importantly, these attributes applied equally to graduate entrants and those without degrees. Consequently, in my view, it would be wrong to discriminate between these two categories of mature students and to do so would limit the diversity sought by CHMS.

The view of school leavers

After publication of the first edition of Tomorrow's Doctors,5 the education committee of the General Medical Council made informal visits to medical schools in the late 1990s.6 The visitors talked with and listened to several hundred medical students and preregistration house officers (foundation year one doctors). These articulate young people pointed out that it is illegal to discriminate on the grounds of age and that by 18 they could buy alcohol, smoke, drive a car, enlist in the armed services, and vote. They thought that graduate only entry schemes would discriminate against school leavers and non-graduate mature students in the absence of convincing evidence for such schemes.

School leavers are intelligent, multitalented, committed, and come with excellent study skills and there is no evidence that graduate entrants make better doctors. The evidence here derives mainly from cohort studies performed at individual medical schools. Examples include Nottingham, United Kingdom, where James and Chilvers followed the students entering between 1970 and 1995.7 Graduate entrants were more successful in the first three years of the course, with more obtaining a first class Bachelor of Medical Science degree. However, graduate entrants in the period 1986-1990 were less successful in the final BMBS (Bachelor of Medicine, Bachelor of Surgery) examinations. These results suggest that the graduate entrants were less competent as clinicians than their school leaver counterparts. Although the numbers are not large, these findings are consistent with a study of interns in New South Wales.8 However, a study from New South Wales found no significant differences between school leavers and graduate entrants in terms of academic performance (measured by the award of honours) or in career positions obtained after qualifying.9

Academic medicine

Worldwide, there are concerns about recruitment into academic medicine, and intuitively recruiting science graduates into medicine ought to be beneficial. However, the Newcastle experience failed to produce evidence in favour of this idea. It contrasts with the well documented benefits of an intercalated BSc,10 11 which was extremely important to my career as a clinical academic. Each year, about 30 of the most able students can proceed to an MB PhD programme, which contrasts with more than 1000 in the United States, where such programmes have been running successfully for several decades.12

While selection for a career in medicine is problematic, CHMS (now the Medical Schools Council) and the universities have tried hard to make entrants more representative of all sections of society. Although the selection of school leavers relies heavily on academic performance at A level, follow-up of those entering the former Westminster Medical School between 1975 and 1982 showed that A level grades had long term predictive validity for both undergraduate and postgraduate careers.13

In conclusion, although graduate entrants increase the diversity of our future doctors, there is insufficient evidence to make this a universal criterion for entry. Finally, we should not forget that graduate and mature entrants are subject to additional stresses, such as balancing commitments and lack of leisure time. They also face extra financial pressures,9 when in 2006 the median debt of all people qualifying in medicine was £22 500 (€33 000; $46 000).


Competing interests: None declared.


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