SHOULD STUDENTS BE ADMITTED TO MEDICAL SCHOOL DIRECTLY FROM HIGH SCHOOL OR AS UNIVERSITY GRADUATES?
The decision as to whether students should be admitted to medical school directly from high school or as a university graduate will depend on a number of factors.
Across the world outside North America, where it is the norm, there has been a noteworthy shift from traditional high-school entrance to medical school towards graduate entry to study medicine. The philosophy behind this move is varied; some schools feel that the life experience that graduates bring will help them understand the issues that patients face better than school-leavers, who have little experience of life’s challenges or coping with them. Others feel that graduates, having already succeeded in their studies, will have developed good adult learning methods and be more resilient to the stress of study and working in emotionally charged situations. For some schools, the opportunity to bring into medicine excellent scientists who might take forward future research is an important consideration, and finally for some, the possibility of completing medical training in a reduced timeframe has influenced the introduction of graduate-entry programmes. One of the core purposes of undergraduate medical education is preparation for postgraduate training and continuing lifelong, self-directed learning in order to deliver good medical practice. In this chapter, we examine the question of graduate versus school-leaver entry to medicine and how this might affect that purpose.
Definitions
Cullen et al. (2007) found that there was confusion around the understanding of graduate entry. In this chapter three kinds of medical education programmes as means of entry to study medicine are distinguished: school-leaver entry programmes (SEP), graduate entry programmes (GEP) and mixed parallel-entry programmes (MEP).
In SEP, the basic requirement for entrants is the satisfactory completion of secondary education in high schools or equivalent. The length of the medical programme is usually 5 or 6 years. This type of medical education is the norm in many countries of the world. The case studies from Australia and Argentina present examples of SEP. Not infrequently, graduates may also be admitted to SEP from the beginning and study together with school-leaver entrants. These students are better understood as graduate entrants in SEP and will not be considered further here.
Case study 5.1 Catering for the school-leaver, Bond University, Gold Coast, Australia
Bond University, a private, not-for-profit organisation, offers one of only four undergraduate medical programmes in Australia. The MBBS course is ‘accelerated’ in that students enter in May and graduate 4.8 years later. Year 1 comprises two 12-week semesters, followed by 2 years of three 12-week trimesters before clinical rotations begin in January of Years 4 and 5. School-leavers make up about one-quarter of the annual intake, with at least one-third of the cohort having no prior experience in biology. Graduate entrants are often from other health professions, such as nursing, physiotherapy and pharmacy.
A revised curriculum began in May 2013. We describe our Year 1 (2 × 12-week semesters, May and September) as a guided, hybrid problem-based learning (PBL) approach, allowing us to accommodate the lowest common denominator (i.e. a school-leaver with no biology). Each week, cases have been specifically designed to address the basic sciences required for the more traditional PBL approach in Year 2, an organ systems course. The ‘guided’ aspect relates first to the generic/transferable skills to which students are exposed during a ‘middle’ PBL session, scheduled between the traditional tutorial one (case opening) and tutorial two (case closing). To the best of our ability, the activities students undertake in this ‘middle’ PBL (often in small groups with their facilitator in a large venue) are related in some way to the content covered in the week’s case in one or more of the programme themes (i.e., doctor as scientist, practitioner or professional and health advocate). The transferable skills include information literacy, critical thinking, group work, communication skills, technical and numeracy skills and self-management.
To give an example of how this worked for the first iteration:
• In Week 1, the ‘middle’ PBL is group work. It involved students in their newly formed groups, under the guidance of their trained facilitator, getting to know each other, drawing up their ground rules, exploring the various roles that they will be carrying out each week (e.g. chair, scribe, recorder, reflector, learning issue (LI) tracker) and clarifying any issues they may not have understood from the PBL guidebook they had been asked to read prior to the session and the training they had received during orientation.
• In Week 5 (Information Literacy 2), two colleagues from the university’s Teaching and Learning Office provided students with a critical reading for the week’s case on Day 1 (case opening) and then discussed with them the strategies they had used to read and summarise the information. These were explored further during the session. Additional exercises allowed students in their PBL groups the opportunity to try different strategies, including graphic organisers.
• In Week 8 (Critical Thinking 2), groups reviewed some of their earlier LIs, as command terms (i.e. Bloom’s taxonomy) were introduced as a means of better defining the breadth and depth expected. For the next cohort, this session has been scheduled earlier, as the feedback suggested that it helped learners to define better the expectations of self-directed learning required for the week.
A particularly useful additional role in PBL that has been introduced at Bond is the LI tracker. At the outset of the semester, via BlackBoard, students are provided with the learning outcomes (LOs) for the semester and the year. These form the blueprint for continuous assessment. Each week, under the guidance of the trained facilitator, the LI tracker maps the LIs generated by the group for the case, as well as those generated from other activities (e.g. clinical skills, placements), to the faculty LOs. At the end of each semester, these are checked by the group to ensure that all LOs have been addressed.
The second aspect of the ‘guided’ approach to PBL relates to the training and direction provided to facilitators, who are largely casual. Each week, they attend a briefing session, both for the new case and for the ‘middle’ PBL session. Each case has a facilitator guide, which follows the eight steps of PBL, for example:
• Step 1 – Identify unfamiliar terms.
• Step 2 – Identify the major phenomena.
• Step 3 – What are the major questions that arise from this trigger?
• And so on.
The notes provide guidance to the facilitators in terms of the expected depth and breadth, and identify links to past and future cases to assist learners with the concept of spiral learning.
The student feedback received for the first semester of the renewed curriculum was overwhelmingly positive. Although a few of the graduate students felt that they had already developed some of the generic skills addressed during the ‘middle’ PBL, most school-leavers appreciated the opportunity to apply new strategies to their learning, whether this be concept mapping or time management. Facilitators too felt that the guided approach was beneficial, particularly for students entering directly from school.
Having covered most of the first spiral in terms of generic skills, the ‘middle’ PBL in Semester 2 was more integrated into the case. Students needed to apply the skills that they began developing in Semester 1 to data released in the case, e.g. interpreting graphs, statistics. We believe that our guided, hybrid approach has provided a supportive learning environment in which students, particularly those entering directly from school, have been exposed to a range of transferable skills that will be developed further as they progress through their studies.
On the other hand, true GEPs are usually 4 or 5 years in length and students are required to have a tertiary or higher degree at the point of entry. GEPs were unanimously adopted in all medical schools in the USA after the Flexner Report (Flexner 1910). The case studies from Saudi Arabia and South Korea discuss the experience of GEPs.
The third model of medical student recruitment is where graduates are admitted as a different cohort from SEP entrants and learn at first in a shortened course before merger with SEP cohort at a later point in the course. These parallel programmes should be identified as mixed MEP in order to distinguish them from pure GEP. The case studies from St George’s, London, UK and Japan provide examples of MEPs.
A move from SEP to GEP
Following the movement to a more student-centred approach to learning, and a change from didactic lectures to self-directed, discussion-based indepth learning in medical education that started at McMaster University, Canada, in 1969 (Barrows and Tamblyn 1980), an intense debate emerged chiefly in Australia and the UK in the 1990s as to whether school-leavers are mature enough to benefit fully from an updated medical education for the 21st century (Charton and Sihota 2011; Geffen 1991; Horton 1998; Searle 2004; Sefton 1995). Transitions are known to be stressful for many individuals, and the transition period from high school to medical school has been shown to be particularly stressful. Additionally the medical course itself, with its intensive study and knowledge acquisition, together with its high-stakes assessments, has been shown to produce stress in medical students (Radcliffe and Lester 2003). Clinical attachments, often involving challenging and emotionally charged issues relating to patient care, have also been shown to provoke anxiety in medical students. Indeed, issues relating to a lack of maturity, discipline, life skills and direction amongst school-leavers have led some universities to introduce pre-entry or access courses to allow students time to adapt to university life (see the Argentina case study).
Conversely, rationales for graduate entry often promote the advantages to be gained from additional maturity and experience of study, almost regardless of the subject area, alongside notions of having a ‘second chance’ at achieving a vocation. In this section we review the uptake of GEP in a sample of countries from around the world.
Case study 5.2 Supporting transition to university study, Austral University, Argentina
In Argentina the medical degree lasts for 6 years and students apply to medical school after finishing their high school, when they are 17 or 18 years old. Entry at this age brings with it some challenges to effective university studies, as students often come to medical school without the educational and learning skills required for a career like medicine, can be immature and unsure of what they want, and are usually vulnerable due to the new and tough requirements for studying medicine. Moreover, strong generational identities and differences are an additional obstacle to entrance into medical school.
Our institution is young, only 18 years old. During this time we have had to make many changes to the admissions process and to the first year of the degree in order to facilitate student adaptation to university life. Our approach involves a short entrance course of two parts: first, a biological section to refresh some basic aspects of chemistry and biology, and to introduce students coming from schools with a social or liberal arts orientation to these subjects; second, a course called ‘Introduction to academic life’ that provides a brief introduction to logic, text analysis, and some effective study methods essential to facilitate the adaptation to the new studying paradigm. This entire course lasts 1 month.
Despite completing this course, half of the students admitted had poor academic performance in their first year. This led us to incorporate a seminar on study methodology and a change in the curriculum, placing subjects requiring description and recognition skills into the first year, and those that demand greater capacity for abstraction into the second year.
Over time we have recognised that many students need more time to adapt in the transition to university. In response to this, we have now introduced a new year-long programme, which involves the same orientation, and adds learning materials from the first year of the medical course. This allows us to make first year not so demanding, and helps potential students learn in a slow, yet progressively complex, way with a longer period of time for adaptation. During this extended programme, we expect our students to mature, and to discover and develop those skills they will definitely need during their first year of medical studies.
To be admitted to medical studies the students need to complete these two courses, and have an admission interview that focuses on motivational aspects, interests and personal characteristics that may support or delay these students’ entry into university life. Those students who are admitted after this schema, either long or short, are afterwards monitored closely to avoid drop-outs caused by difficulties adapting to medical school. Retention is still a concern due to career issues, as many potential students do not know what they want to do in their future professional life. However, by the end of the second year most students were able to improve their academic performance and the drop-out rates decreased.
Japan
Some medical schools with SEP implemented GEP in parallel as MEP. As is outlined in the case study from Japan, in 1975 Osaka University Faculty of Medicine, one of the leading traditional schools, introduced an MEP. Twenty graduates were accepted onto a 5-year course and joined the 6-year SEP for 80 school-leavers (Kiyohara et al. 2005; Nara et al. 2011). By 2011 MEP has been implemented in 36 of 80 Japanese medical schools. The total number of GEP students in Japan is 2.8 per cent of a total of around 9,000 medical students.
Case study 5.3 A 30-year history of graduate-entry medical education programmes in Japan
There are 80 Japanese medical schools: 42 national, eight prefectural (founded by local government), 29 private and one national Defense Medical College. High-school-leavers are eligible to enter medical school, and study a 6-year curriculum followed by the National Licensing Examination for Physicians on graduation, and 2-year obligatory postgraduate training. There were places for 8,932 new enrollees in 2011, in a country with a total population of 127.5 million.
The GEP started at Osaka University Medical School, a traditional national university, in 1975 with the purpose of creating a better merger of medicine and the natural sciences, and nurturing leading medical scientists, physician educators and good, mature clinicians. The GEP was partially changed in 2000 to MD-PhD course where the eligibility was having Master's degree or higher, and consent to proceed to Osaka Graduate School of Medicine after graduation. There were places for 20 GEP entrants (reduced to 10 from the year 2000) and 80 places for the SEP. Applications for the GEP were more than ten times over the available places each year. Graduate entrants were incorporated into the third-year class, with some electives only for graduates. Their mean age was 26 years old, and economic and family problems were big stressors for the graduate entrants.
Between 1975 and 2004, academia became the workplace for 32.8 per cent of GEP and 39.5 per cent of SEP graduates, 9.3 per cent of GEP and 6.2 per cent of SEP in departments of basic medicine. Full professors were 5.6 per cent of GEP and 2.2 per cent of SEP. Associate professors were 3.6 per cent of GEP and 2.8 per cent of SEP. Hospital directors were 6.1 per cent of GEP and 2.9 per cent of SEP. Private clinical practitioners were 15.7 per cent of GEP, and 7.9 per cent of SEP (Kiyohara et al. 2005).
In 2011, 36 Japanese medical schools offered GEP, 45 per cent of all 80 medical schools (Nara et al. 2011). The total number of GEP places available was 2.8 per cent of 9,000 medical school places in 2012. The number of places available in individual schools was on average five: 1–5 in 24 schools, 6–10 in seven schools, 11–15 in one school and 16–20 in three schools. The graduate entrants are incorporated into Year 1 of SEP in two schools, Year 2 in 29 schools, and Year 3 in four schools, with various amounts of elective introductory programmes (data supplied by Associate Professor Tetsuya Urano of Tokai University).
The purpose of GEP is not necessarily uniform: the development of mature learners, physician scientists and shortened tracks for rural community medicine are just some of the many reasons. The selection process also varies: independent selection for GEM; recommendation by deans; admission office selection.
In Japan enthusiasm for GEM is lacking and, in the absence of persuasive evidence, an exploration of its value continues.
Australia
In 1996–97, three Australian medical schools, Flinders University, University of Queensland and University of Sydney, started to implement GEP (Prideaux et al. 2000). It is noteworthy that they formed a consortium, collaborated effectively and shared information on curriculum planning, staff development, admission processes and used staff from partner institutions in the process of converting SEP to GEP (Prideaux et al. 2000). Elements of this planning have also been exported as some medical schools utilised the work of this consortium in developing their own GEPs (see Saudi Arabia and UK case studies). Currently, there are 14 GEPs in Australia and most of them are MEPs (Powis et al. 2004).
Case study 5.4 The experience of graduate entry into a medical programme – the case of College of Medicine, King Saud Ben Abdul-Aziz University for Health Sciences, Riyadh, Saudi Arabia
The College of Medicine (COM), King Saud bin Abdul-Aziz University for Health Sciences (KSAU-HS), was established by Royal Decree in January 2004. Initially, studying at COM began by enrolling only graduate students who had obtained their bachelor degrees from colleges of sciences, applied medical sciences, pharmacy and veterinary. Four years later, the COM accepted high-school graduates as another stream of students.
The curriculum of the University of Sydney was initially adopted, as it was designed to be a graduate-entry level, problem-based and community-oriented curriculum. This curriculum was then modified to meet the needs of the college and our community. The COM at KSAU-HS is a leader in enrolling graduate students locally and regionally. The annual intake of graduate students ranges between 25 and 30 students.
The evaluation of the student experience of enrolling for graduate entry was satisfactory for both students and decision makers at the COM. Subjectively, for some graduate students their life’s dream was to be a doctor, but for one reason or another it had not been possible at the time of their graduation from high school. The COM at KSAU-HS helped these students to achieve their dream. The COM found that most of these students showed a high level of interest, enthusiasm and maturity. Their previous degrees also enriched the discussion in the lectures, tutorials and in the clinical setting.
On an objective level, the COM successfully achieved international accreditation by the World Federation of Medical Education (WFME) in 2010. Moreover, at graduation from the COM, our students achieved the highest marks amongst graduates from all medical colleges in Saudi Arabia, in the national Saudi Licensing Examination (SLE), for 3 consecutive years. At present the intake of graduate students continues, and there are plans to expand it further. This may give another indication about the success of this approach.
The challenges associated with accepting graduate students are mainly due to the fact that some of them have already begun their professional life, taken the decision to change their career and resume the role of being a student. This decision can be associated with significant financial and social burdens on students, which can often subject them to significant stress. Graduate students should be supported and offered counselling services to help them to overcome these challenges.
At present the COM continues to accept high-school and graduate students. This approach is likely to continue, as it is in line with national trends in accepting high-school graduates and continues to offer a unique opportunity that is not available, nationally or regionally, for selected graduate students to continue their studies in medicine.
UK and Eire
In 2000, the move to GEP in Australia was followed by an MBBS graduate-entry programme at St George’s Medical School in the UK, in collaboration with Flinders University (McCrorie 2001). This MBBS programme is a 4-year curriculum and is implemented in parallel with the pre-existing 5-year SEP (see UK case study). Other medical schools adopted GEP and currently there are 15 GEPs in the UK offering approximately 10 per cent of admissions in the UK (Garrud 2011; Medical Schools Council 2014). In Eire, the University of Limerick started the first GEP in 2007, admitting 61 entrants (Finucane et al. 2008).
Case study 5.5 Graduate entry – the St George’s experience, London, UK
In 2000, St George’s started the first UK GEP, admitting students with degrees from any discipline. It was felt that medical schools were missing out on potentially good doctors, just because they didn’t have the right A-levels, or because they wanted to make a career change. This course provided them with the opportunity they needed.
In 1999, a team was put together, consisting of a senior experienced course director, a skilled administrator and six young educationally sound, enthusiastic clinicians from a generalist background. The broad principles and outline of the curriculum were created at a series of away days. Funding was secured from St George’s and Higher Education Funding Council for England (HEFCE)/General Medical Council approval for the course obtained. Appointments were made in areas where there was insufficient expertise or work overload in both academic and support staff. This was crucial for the acceptability of the programme.
The first 2 years of the programme involved PBL using the progressive-release format. To overcome the very short course design time before the first students arrived, PBL cases were purchased from Flinders University in Adelaide and adapted for UK use. Training on PBL facilitation and writing PBL cases was provided by Flinders staff. The course was divided into a series of modules and themes and teams were assembled to flesh out the course content and timetable. The PBL cases were allocated to specific modules and put in an appropriate order. All teaching was contextualised and time was created in the timetable for self-directed learning. There were no individual courses in any discipline, though there were curricula for each; the overall curriculum was therefore both horizontally and vertically integrated.
A key principle of the course was meaningful early patient experience, linked to the case of the week, mostly in general practice. The whole course was centrally controlled, each year having its own academic lead. The overall course was planned as a 4-year entity, although the detailed yearly course content was created on a step-by-step basis. Clinical attachments followed the module structure as far as possible, with students being given greater opportunity to plan their own learning. Assessments were theme-based, but run within modules, with formative assessments always preceding summative assessments. Assessments tested scientific and clinical reasoning, maturing into diagnostic reasoning, management and treatment in the later years, clinical and communications skills and professional behaviour, including medical ethics and evidence-based medicine.
Problems encountered mostly related to interaction with the 5-year school-leaver programme, which was running in parallel to the GEP. It proved burdensome to run two completely separate programmes, especially because of the confusion on clinical placements where two sets of students were present at the same time but for different periods and using different educational philosophies. The two courses were eventually combined into a single course with two entry points, one for school-leavers and one for graduates, with students coming together for the final 3 years. Inevitably some of the key educational innovations were lost during this exercise. A decision to move to graduate entry only would likely have been a better solution.
The first two years of the graduate entry programme have been sold to new medical schools in two other countries (Ireland and Portugal) and franchised to a third (Cyprus). All are running successfully. The success of the original GEP was shown by the students being required to sit the same final assessments, and being at least as successful as their school-leaver counterparts, winning prizes, merits and distinctions and publishing papers on a range of research topics undertaken while on the course. The drop-out rate was close to zero and, when this occurred, was related to personal issues and rarely to academic performance. Almost all graduates of the programme are in full employment and have gone on to achieve successful careers in a wide range of specialties.
Graduates, being more mature, are generally more self-directed and motivated than school-leavers. They find it easy to relate to patients and are academic high achievers. Students with non-science degrees perform at least as well in final examinations as those with science degrees. The mix of backgrounds makes for a much richer learning experience. Graduates of whatever discipline – art or science – make good medical students and successful doctors. But design a course specifically to match their skills, and avoid running a parallel course for school-leavers.
South Korea and Iran
In 2002, GEPs were introduced to ten of 41 medical schools in South Korea (see South Korea case study). It is interesting that, in South Korea, it was political pressure from the government that urged medical schools to implement GEP. At its height, 27 out of 41 medical schools converted SEP to GEP or MEP. After a change of government, there was a reversal of this policy and only five medical schools in South Korea will be left as GEPs in 2015.
Case study 5.6 External influence in medical education, South Korea
There are 41 medical colleges in South Korea. Since 2006, 15 colleges have admitted only college graduates (GEP: 4 + 4), 14 have admitted only high-school-leavers (SEP: 2 + 4) and 12 have admitted an equal number of both college graduates and high-school-leavers (dual-entry system).
The GEP was first introduced by the Korean government to ten colleges in 2002, with the intention of producing better doctors. However, the Korean government never defined what they meant by the term ‘better doctor’. In fact, the aim of introducing GEP was to ease the current university entrance examination fervour. The government’s original plan was to force every college to implement the GEP. However, many medical colleges refused to change their admissions system/criteria, due to the fact that GEPs only serve to lengthen the time needed to earn the medical degree and there is no evidence that the graduates of GEP perform better than those of SEPs. For the medical colleges that refused to accept the government’s request, the Ministry of Education threatened to cut their research funds. Consequently, 27 out of 41 medical schools converted into either a strict GEP or a lateral (dual)-entry system. However, there was also a very significant appeal from the Faculty of Natural Sciences and Engineering that they are losing their graduates to medical school. In addition, professional societies appealed that the process of change was not democratic. Finally, the former government (under the Lee Myung-Bak administration) decided to leave this decision to each medical school. Eventually, only five medical schools will be left as GEP medical schools in 2015. This is after the two public hearings in 2009 and 2010, held at the National Assembly of Korea.
Having GEPs has nothing to do with the quality of doctors. In Australia, where half of all medical schools have GEP, the aim of having GEP is to allow the late-decision-making students to be admitted to GEP schools. These students are definitely older and more mature, but age does not affect school performance. In Taiwan, the government forced five medical schools to convert to GEP in the 1980s. However, all five GEP schools closed down within 5 years except one, which continued as a dual-entry programme.
The experience of implementing GEP in Korea really was, and is, a costly war of attrition. It is not simple to change a standard entry programme (high-school-leaver system) to GEP. It is not a matter of just changing the name of the school. It is a very complex and complicated matter which needs very careful pre-planning, and requires ample time for changes to organisational culture as well.
The future of GEPs is not quite clear yet in Korea. So far, there has been no evidence that GEP schools are superior to SEP schools.
In 2008, 21 students were admitted in Tehran University of Medical Sciences in Iran. This move had three stated objectives: (1) strengthening the links between basic and clinical sciences; (2) selecting the students on the basis of a wider range of criteria instead of strictly academic ones; and, as graduate applicants are older and have previous academic experience, (3) providing a chance for applicants to make a more informed choice of medicine (Majdzadeh et al. 2009).
Comparing SEP and GEP: students and performance
As detailed in the case studies from Saudi Arabia and the UK, the increased maturity and improved learning skills of graduates are often seen as the benefits of GEP, while possible increased stressors of life stage and personal responsibilities can be a disadvantage. In addition the possibility for enabling access to a vocation to skilled and able people who have previously not had the opportunity, whether by timing or circumstance, is a powerful argument for GEP. In contrast, the additional costs incurred by students in terms of additional study, and by institutions in terms of adapting and running additional courses, are arguments against. Further, entry level has become a political issue in some countries, with GEP being introduced without the support of the medical schools (see Japan and South Korea case studies).
Ultimately, it may be argued that whichever entry level is adopted, solid research evidence of the benefits to be gained in terms of performance and outcomes is required. However, direct comparison of the success of different entry systems is complicated by a multitude of factors, including different curricula, teaching and assessment methods, and the context in which the research takes place. In their 2004 study Wilkinson et al. discovered that a change to graduate entry was often accompanied by a change in admission criteria and a change in curriculum, therefore it was not certain if the difference in student performance, if any, could be due to students having a prior degree, exclusion of less motivated students via admission process or to the changes in the curriculum. For meaningful direct comparisons of performance of the two groups it is important that the studies are undertaken of students on the same education programme.
Comparison of SEP and GEP performance should involve not only the academic aspects but also the perspectives of stakeholders; such as patients, student/family, society, academia, government and international world. Ideally, evidence would be available from controlled, large-scale longitudinal datasets, setting some staged endpoint such as pre-clinical, full-time clinical attachment, postgraduate board certification, workplace and lifelong performances as final outcomes, in a wider range of countries. However, such studies have still to be reported. This section will explore some of the key research findings that are available.
Demographic profiles of GEP candidates and entrants
Graduate entrants tend to be on average 7 or 8 years older than school-entry students (Harth et al. 1990; Rolfe et al. 2004). An analysis of the 2002–2003 data obtained from the Universities and Colleges Admission Service (UCAS) by the University of Nottingham Medical School in the UK found that applicants and successful entrants to their GEP were significantly more likely to be male and more socio-economically deprived and had a lower UCAS tariff point score when compared with applicants to the SEP (James et al. 2008). Additionally the researchers found that Caucasians were significantly fewer in number as entrants from this route. A second longitudinal study at Nottingham Medical School using 2003–2009 UCAS data of their GEP showed that applicants and entrants were older, marginally more likely to be female, and more likely to come from white and black UK communities rather than southern and Chinese Asian groups than their SEP counterparts. In this study again the secondary educational achievement of the GEP cohort was poorer in comparison with the SEP cohort (Garrud 2011).
In 2007 an analysis in Eire of 61 Irish/EU GEP students showed a slight male preponderance: over 90 per cent were still in their 20s, all had a first or upper second class honours degree, fewer than 20 per cent had a higher degree and 24 per cent were from a non-science background (Finucane et al. 2008).
Evidence relating the differences in levels of maturity and experience of stress between SEP and GEP students is ambivalent. A study by Hayes et al. (2004) found that graduate entrants on the course were significantly less anxious when compared to traditional undergraduates. However, in another report, mature-age entrants experienced greater stress throughout the medical course, but the stressors in the graduates appeared to be related to personal issues such as financial difficulties, loneliness and family problems (Harth et al. 1990). The academic advantage for GEPs was identified within the Saudi Arabia and UK case studies, with both suggesting that graduate entrants were more mature and self-directed and enriched the learning environment. Both also highlighted the challenges of studying later in life, with the UK case study highlighting that, while the drop-out rate for graduate entrants was close to zero, when it did occur it was for personal rather than academic reasons.
Motivation
Some evidence exists on the differing motivation of students entering SEP and GEP. Rolfe et al. (2004), in their study of 16 years of graduates at Newcastle University, Australia, found that, while the motivation for studying medicine was not substantially different between the two groups, the level of parental expectations was greater among school-leaver entrants, and the wish for professional independence and desire to prevent disease were found more frequently in graduate entrants. In Finland, a comparison of 25 students with prior degrees and 120 school-leaver classmates studying the same curriculum suggested that graduate students had stronger theoretical and practical commitment to their studies with a strong work-life orientation (Kronqvist et al. 2007). Wilkinson et al. (2004) showed that a prior degree predicted distinct goal orientation and cooperativeness, but postulated that entry to the course at an older age might be more important than having a prior degree in this regard. The case studies from Saudi Arabia and the UK both comment on the increased and more altruistic motivation of graduate students.
Overall student performance
In a controlled study at the University of Queensland (Harth et al. 1990), comparing 121 mature-age (7 years older) and 270 normal-age entrants of the same curriculum it was found that course grades were similar in both groups, but normal-age entrants tended to win more honours/prizes and postgraduate diplomas/degrees, including specialist qualifications. A cross-sectional mail-out survey to graduates from the first 16 graduating years (1983–98 inclusive) at Newcastle University, Australia revealed there were no differences in academic performance, awarding of research degrees, publication of scientific papers, holding career positions, choice of general practice or another specialty, practice location or employment sector between graduate and school leaver entrants (Rolfe et al. 2004). The authors concluded that there were no clear differences between the two groups based on the outcomes measured in this study.
Subject of previous degree
In some cases students entering medical studies, whether on SEP or GEP, do not have a scientific background, which may be considered to have some bearing on performance in medical school. Researchers at Newcastle University in the UK looked at the performance of graduate students who joined an SEP. They found that those students with a previous degree in arts and nursing were significantly more likely to receive a ‘not satisfactory’ assessment in the first year. The arts students made up the deficit by the end of the first year, but the reasons the nursing students struggled with the course were not clear and as a group they were more likely to get an unsatisfactory at the level of the final examination (De Clercq et al. 2001). Similarly, Craig et al. (2004) concluded that there was a small positive difference between the performance of science graduates and non-science graduates early in the programme, but that this tendency lessened with time. The case study from Argentina reports on the development of biology and chemistry teaching in their pre-entry programme as an introduction or refresher for students. The Australian case study discusses how a PBL approach is utilised to accommodate students with no biological background.
It is interesting to consider whether the type of programme, in addition to level of entry, may have an influence on student performance. In a more recent analysis at the University of Newcastle, UK, GEP students performed significantly better in the knowledge assessments than both 5-year programme students and graduate students on the 5-year programme (Price and Wright 2010). At the University of Birmingham, UK, where GEP entrants and SEP entrants are merged in the final 3 years (MEP), analysis of 19,263 student assessments revealed that MEP students showed better academic performance than mainstream students and obtained more ‘honours’ awards (Calvert et al. 2009).
Stage of education
It is also interesting to consider whether any differences identified between student performance on SEPs or GEPs are sustained over time. Leicester-Warwick Medical Schools, UK, which provide parallel courses for graduate entrants and school-leaver entrants, found that in Phase 1 (applied basic sciences, 2.5-years long for school-leavers, and accelerated to 1.5-years long for graduate students) no significant difference between the performance of the two groups was identified. However, in the midpoint intermediate clinical examination, school-leaver entrants performed significantly better than graduate entrants, but there was no significant difference in the final professional examination (Shehman et al. 2010). Research at the University of Nottingham comparing the full-time clinical summative assessment results of GEP and SEP students found them to be very similar in terms of their overall competence, with similarly high proportions completing their medical degree (Manning and Garrud 2009). However, the two groups showed different patterns of ability: in clinical Phase 1, GEP students did better in their assessments, but subsequently they performed less well in clinical Phases 2 and 3 than their SEP colleagues.
In contrast, a comparison of bioscience knowledge and the clinical skills assessments by Objective Structured Clinical Examination (OSCE) for GEP and SEP students at the University of Melbourne showed marginally better results for the GEP students during the early years, which were attributed to prior bioscience knowledge. However they also performed better in clinical skills that could not be attributed to prior learning (Dodds et al. 2010). Other studies from the University of Queensland (Groves et al. 2003) and the University of Melbourne (Reid et al. 2012) also indicated that GEP students performed better than SEP students in their early years, but the difference seemed to disappear by the final years.
Taken overall, these studies seem indicate some advantages of GEP, especially in the earlier stages of medical education, but these advantages seem to be lost in the later, more clinical parts of the course.
Career choice of the GEP graduates
A final area of interest relates to whether there are any differences in the final outcome of GEP and SEP students in terms of the career choices they make. Research at Osaka University Medical School on the career choice of 405 GEP students from 1975 to 2004 revealed that GEP students were less likely to work as academics in medical schools; however, they were more likely to work in departments of basic medical science. Full professors and hospital directors were more likely to come from GEP and a higher percentage of private clinical practitioners were from GEP (Kiyohara et al. 2005). The principal aims of GEP in Osaka University Medical School are the integration of medicine and science, nurture of leaders in medical science, medical education and clinical medicine, and they concluded their GEP to be successful. Flinders University in Australia offered a 1-year elective Parallel Rural Community Curriculum (PRCC) and Northern Territory Clinical School (NTCS) to the entire SEP Year 3 in addition to GEP students (Worley et al. 2008). They studied subsequent preference for a rural medical career in 150 eligible graduates. The results showed a higher percentage of PRCC and NTCS graduates choosing general practice, but no association between specialty choice, gender or rural background of the students. Interestingly, they found that for each 1-year increase in age at admission, there was a 15 per cent increase in the likelihood of choosing general practice.
Origins of initiative
One clear influence on the success of GEPs may concern the reasons why the programmes are being developed. The case studies from the Saudi Arabia and UK suggest that their programmes developed out of a demand from graduates to retrain and fulfil ambitions. In these case studies the motivation for and perceived success of GEPs are high. In contrast, the case studies from Japan and South Korea suggest that GEPs are less popular. In the South Korean case study in particular, changing political decisions appear to have reduced the enthusiasm for such programmes within medical schools.
Summary and suggestions for future studies
The findings outlined in the studies highlighted above are not uniform or extensive enough to conclude that graduate entrants are superior to school-leavers. Comparisons of SEP and GEP students in the same curriculum showed no consistent evidence of the advantages of GEP, although some advantages associated with age were indicated. However, in these studies numbers of GEP students were consistently lower than numbers of SEP students and in some of the reports the students did not study the same curriculum simultaneously.
The possibility of GEP programmes increasing the diversity of background of medical students was repeatedly emphasised. However, with the cost of higher education having increased dramatically in countries such as the UK, the cost of studying on a GEP programme will increase the debt burden for these students and there is no guarantee that any increase in the diversity of students, particularly around social class, will continue. What is needed is large-scale, well-designed longitudinal tracking of both SEPs and GEPs to finally answer the questions of academic performance, stress management and influence on career choice. Overall therefore, at the present time, the published literature does not demonstrate any clear advantage for schools to move from SEP to GEP.
• With the exception of North America, entry to study medicine has traditionally been on leaving high school.
• Changes to curricula and teaching methods that promote greater independent and active learning have raised questions about whether school-leavers have the appropriate maturity, life and study skills to benefit fully from a demanding learning experience.
• A variety of challenges have been identified to running graduate-entry programmes, both administratively and with regard to student knowledge and ability. Arguments have been raised as to whether the additional time and resources required are a worthwhile investment.
• Differences exist in relation to evidence of the relative performance of SEP and GEP students. However, most studies conclude that, where differences in levels of performance exist, these lessen over time.
• The case studies reveal a range of practical strategies that have been employed to minimise any disadvantages experienced by SEP and GEP, including pre-entry or access courses, and PBL.
• Graduate entry remains a contentious issue in some areas, particularly where it has been forcefully administered.
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