In 2006, approximately 19,000 students made 75,000 applications for 8,000 medical school places in the UK.[1
] Applications are made centrally via the Universities and Colleges Admissions Service (UCAS).[2
] Candidates may apply for up to four separate medical schools each October, for admission in the following academic year. The application form requires candidates to list their current school examination results and their Head Teachers to provide predicted grades for final examinations. The majority of applicants to medical schools in the UK will be studying three or four subjects at General Certificate of Education Advanced level (GCE A-level) in their last year at school, although some follow alternative qualifications such as Scottish Highers or the International Baccalaureate. Although selection criteria vary between Institutions, and there are various moves to widen admission criteria.[3
], the majority of 5-year undergraduate medical courses still place great emphasis on A-levels or equivalent.[4
A-levels have been extensively studied. Good science grades are related to success on the undergraduate course [5
], a lower drop-out rate in the first year [10
], better medical degrees [5
] and possibly post-graduate career progression.[11
] Most medical schools therefore require a minimum of two A grades in science, and one B grade, or equivalent tariff points, in another subject.[4
] Many students offer a third science subject, some a fourth.
Competition for admission to medical school in the UK is intense and selection is becoming increasingly difficult.[12
] At Nottingham, the selection procedure includes academic and non-academic criteria which have been shown to predict success on the medical course. [5
] In 2000, we required applicants for the 5-year medical course to have an A grade in Chemistry and another science, and at least a B in any additional subject (excluding general studies). Non-academic criteria (comprising personal statements and references from the UCAS form, an online questionnaire of extracurricular activities, and interview performance) were scored.
Cowley has recently proposed that students who study a non-science subject would be better prepared for the medical course, and such subjects should be compulsory.[13
] He suggests that studying English Literature in particular would develop students' capacity to understand individual patients, to communicate skilfully, and to be better able to discuss complex ethical issues. However, these arguments are made without demonstrable evidence from medical school performance.
The context of this study – the University of Nottingham 5-year undergraduate course
The course comprises pre-clinical and clinical components. Topics for the first two years (Part I, pre-clinical) are grouped into four Themes: A (The Cell), B (The Person), C (The Community), and D (The Doctor). Of these, A and B are largely biochemical and physiological science-based whilst C and D are behavioural, social and clinical science-based. A wide variety of techniques are used to assess students' progress. Themes A and B are assessed extensively over the 2 years; examinations consist predominantly of blocks of true/false questions, short answers, short essays, and single word (or phrase) answers, with some course assessments. These can all be grouped as 'knowledge-based', and averaged as a proxy for 'pre-clinical knowledge'.
Theme C (Behavioural Sciences, Public Health and Disease Epidemiology, and 'Services, Clients & Community'), is assessed four times, with short answer and true/false questions, plus a prepared essay of 2000 words. Theme D (Communication Skills, and Early Clinical & Professional Behaviour) is assessed each semester by in-course appraisal. In addition there is an OSCE-format assessment of communication and early clinical skills in Semesters 2 and 4, and presentation skills assessment in semester 4. (OSCE = Objective Structured Clinical Examination; skills are assessed by role-play in various standardised situations). Although Theme C is examined by means of written assessments, the subject matter is less scientific than in Themes A and B, and therefore we have grouped the results with those of Theme D as a proxy for 'pre-clinical skills'.
Pre-clinical study in the first half of the third year (Part II) consists of a research project, including dissertation and viva, and several taught courses, all of which contribute to the marks for the award of BMedSci (Bachelor of Medical Science) at the end of the third year.
Clinical study is in three phases. Phase 1 (second half of the 3rd year) concentrates on general adult medicine and surgery. Phase 2 (4th year) contains specialties such as child health, obstetrics and gynaecology and psychiatry. Phase 3 (5th year) encompasses advanced medicine, surgery, musculo-developmental disorders and disability, and general practice. All these attachments have formal written examinations, which generally consist of objectively-marked questions (OMQs) of various types, and constitute a score for 'clinical knowledge'. In addition there are practical examinations in the form of OSCEs and/or OSLERs (Objective Structured Long Case Examination Record) to assess clinical and communication skills for the medical and surgical attachments, child health, obstetrics & gynaecology, and psychiatry. These generate a score for 'clinical skills'.
Students on the course are therefore subject to a wide variety of assessment types, but they can be grouped broadly into knowledge and skills in both the pre-clinical and clinical course. Part II (the research project) includes quite specific additional skills and therefore we have considered this separately.
As part of our ongoing evaluation of admission and selection procedures, we therefore investigated whether the choice of subjects at A-level influenced performance on the University of Nottingham medical course, for one entry-year cohort of students who progressed normally to graduation.