의과대학 학생선발: 풀리지 않는 과제 (Medical Teacher, 2015)

의과대학 학생선발: 풀리지 않는 과제

Selecting medical students: An unresolved challenge*

DAVID POWIS

The University of Newcastle, Australia

거의 모든 국가에서 의과대학에는 학업적으로 우수한 지원자가 몰림에도 불구하고, 의과대학생 선발위원회가 부적절한 판단을 내렸음을 지적하는 기사나 논문이 종종 등장하여 논란을 불러일으키곤 한다. 가장 우수한 학생을 선발한다면 이들이 좋은 의사가 될 것이라는 가정이 틀린 것일까? 아마도 이제는 초점을 옮겨야 할 때가 왔을지도 모른다. 최고로 우수한 지원자들 사이에서 차이를 내 보려는 기존의 노력 대신, 비학업적 인적특성에 초점을 둬서 부적절한 학생이 입학하지 못하도록 하려는 노력이 필요하다. 의과대학 학생선발의 문제를 분석하고 해결책을 제시하고자 한다. 이 해결책은 이미 70년전에 제시된 바 있지만 다만 도입되지 않았을 뿐인 해결책이다. 이러한 접근법을 도입하지 않는다면 논쟁은 끝나지 않을 것이다. 

Despite the abundant supply of academically outstanding applicants to medical schools in most countries the regularly recurring debate in the academic literature, and indeed sometimes in the popular media, implies that admissions committees are still getting it wrong in a significant number of instances. How can this be so when our procedures are directed unashamedly at selecting the most highly academically and intellectually qualified students in the expectation that they will make the best doctors? Perhaps it is time for a radical change in emphasis. Instead of endeavouring to differentiate among the top ranks of a pool of outstandingly qualified applicants, the selection effort might be better focused on identifying those potentially unsuitable in terms of their non-academic personal qualities to ensure they do not gain entry. The account that follows is an analysis of the problems of medical student selection and offers a potential solution - a solution that was first suggested in the medical literature 70 years ago, but not adopted. It is the present author's contention that the cycle of debate will continue to recur unless such an approach is pursued.

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Seventy years ago, in 1944, the UK government-appointed Goodenough Committee of review into medical education reported that: [some medical students] ‘‘who, though able to pass examinations, have not the necessary aptitude, character or staying power for a medical career’’. With the Goodenough Committee report to hand, Smyth, writing in the British Medical Journal in 1946, wrote that ‘‘Existing methods of selection [of medical students] which worked well in the past may no longer be the best possible in changing conditions’’. He added: ‘‘The recent reports . . . have drawn attention to some of the problems connected with the selection of medical students . . . [and] point out the problems, without discussing ways and means of solving them’’ (Smyth 1946).

현재 어떻게 뽑고 있는가?

How were, and are, medical students selected?

The first hurdle to clear to enter medical school in most countries, both in the past and the present, is an academic achievement barrier.

There is a reasonable basis for requiring the academic hurdle: McManus et al. (2013) have described eloquently the predictive link between past academic achievement and academic progress through medical school and beyond. Their ‘‘academic backbone’’ model elegantly demonstrates the link (Figure 1).

Putting the prior academic achievement criterion into perspective a systematic review by Ferguson et al. (2002) showed that academic scores account for 23% of the variance of progress measures at medical school, but only 6% beyond medical school.

이상한 의사들 

Unsatisfactory doctors

Although everyone would freely acknowledge that many doctors are excellent, and most are entirely capable and competent, it is evident that some are not!

• Some doctors have been convicted of criminal acts.

• Some doctors are deficient in communication skills, failing to communicate adequately or appropriately with peers, mentors, patients or patients’ families. 

• Some doctors are unprofessional

• Data from the GMC annual report in 2005 showed that 1 in 15 doctors in the UK were dependent on alcohol or drugs at some stage of their professional lifetime.

• Lastly, the professional competence of some doctors is seriously compromised by mental health issues.

원인으로는 아래와 같은 것들이 있음.

Willcock et al. (2004) suggested that the high incidences of distress and burnout can be attributed inter alia to a doctor’s stressful work environment, their long working hours, possible conflict between work and personal life tasks and their individual psychological vulnerability, a view echoed by Wallace et al. (2009) in their literature review.

이상한 학생들

Unsatisfactory medical students

Most medical educators have had experience of students who cause concern. They comprise a small proportion of any cohort, and may even be progressing adequately academically through medical school, but they exhibit attitudes and/or behaviours that many would consider unacceptable in an aspiring doctor.

몇몇은 유급을 하기도 하지만, 유급의 이유가 늘 학업문제 때문인 것은 아니다.

Notwithstanding the exceptionally high academic standard required to gain entry to medical school it is clear that some students do fail academically during their course. (...) Perhaps the reason for their academic failure lies beyond their academic ability.

자살 충동

And in Australia journalist Amanda Davey, quoting Jessica Dean, President of the Australian Medical Students’ Association (Davey 2014), stated ‘‘that mental illness [is] rife among med students’’ – ‘‘one in five admitting suicidal thoughts in the last year’’ [of their studies].

부적절한/프로페셔널하지 못한 행동

Besides distress to the students concerned ‘‘burnout’’ has been shown to be associated with unprofessional behaviour (Dyrbye et al. 2010), manifested by poor reliability and responsibility, poor initiative and motivation and a severely diminished capacity for self-improvement. Unprofessional behaviour at medical school has been shown to have a strong association with subsequent disciplinary action by a medical board Papadakis et al. (2005).

지원자에 대해서 우리가 알고 있는 것은? 

What do we know about Medical School applicants?

면접에 최종 합격에 중요하나, 전적대학 GPA가 면접 대상자 선정에 가장 중요하다.

In the USA and Canada an overview of medical school admission processes (based on data from 120 informed respondents) by Monroe et al. (2013) reported that although an interview recommendation was the most important determinant (4.5/5) of a candidate receiving an offer, the cumulative undergraduate GPA determined who were invited to interview.

학업적으로 우수한 지원자가 이렇게 많다면, 그들 사이에 구분을 어떻게 할 것인가?

Given the surfeit of academically well-qualified applicants how do medical schools currently differentiate between them?

지금까지는 학업적 수월성에 주로 관심을 두고 있다. 그러나 과연 이것이 옳은가에 대한 의문은 끊이지 않는다.

The focus is clearly still on identifying academic excellence and cognitive (reasoning) skills with only a fairly superficial and subjective investigation of the applicants’ personal qualities. The quest for the presumed ‘‘best’’ applicants remains the prime focus. Contemporary commentators have continued to ask the question: Is this the right way? (Hughes 2002; Powis 2003, 2008; James et al. 2010; Mercer & Puddey 2011; Wilson et al. 2012; Eskander et al. 2013; Leinster 2013).

Barr (2010), writing in The Lancet, ‘‘found no scientific evidence that supported the power of performance in undergraduate science courses as a way to predict clinical or professional quality as a physician’’ and ‘‘found . . . consistent evidence that performance in the premedical sciences is inversely associated with many of the personal, non-cognitive qualities so central to the art of medicine’’.

패러다임 시프트가 필요한가? 

Time for a paradigm shift?

The vast majority of medical school applicants are more than adequately equipped academically for their studies and their later professional careers.

기존의 선발도구로 부적합한 학생을 가려낼 수 있겠는가?

The practical question now becomes: Can we identify the potentially unsuitable at the outset using tools currently or

potentially available? 

• academic record
• cognitive skills tests
• personal statement
• referees’ reports
• interview – panel, MMI
• non-cognitive tests (personality measures)

학업 기록을 통해서 의과대학 학업을 따라가기에 어려워보이는 지원자를 가려낼 수 있다.

The academic record will identify those potentially academically inadequate to undertake medical studies.

일정 수준 이상의 학업성취도를 보유한 지원자를 가려냈다면, 이후에는 이에 따른 영향이 없어야 한다. 그렇게 된다면 사회경제적 수준이 낮은 인구집단의 지원자에게도 좀더 입학기회가 확대될 것이다. 

It could be argued that academic marks above the threshold should play no further part in student selection. This would have positive effects on widening access to applicants from lower socio-economic groups (Powis et al. 2007).

인지적 역량 Cognitive skills

보통 직원을 선발할 때는 지능이 직무수행능력의 가장 좋은 예측인자라고 하지만, 의과대학에서는 인지검사가 이후 수행능력 예측이라는 측면에서 선발에 별 도움이 되지 않는다. 

In the general field of employment selection, it has long been recognised that ‘‘Intelligence is the best predictor of job performance’’ (Ree & Earles, 1992). However, the cognitive skills tests used in medical school selection procedures have usually been found to add little to academic scores in predicting outcomes

반면, GPA에 추가적으로 MCAT점수를 보는 것은 도움이 된다.

On the other hand, in the opinion of the respondents to the survey of Monroe et al. (2013), MCAT does offer added value to GPA scores.

자기소개서 Personal statements

여러가지 문제가 있음.

There are many problems that undermine the usefulness of personal statements for informing medical school selectors.

추천서 Referees’ reports

신뢰도는 높일 수 있으나 타당도가 낮다.

Munro et al. (2012) have asserted that referees’ reports have low validity even when structured to increase reliability.

개별 추천인들의 내적일관성은 높지만, 추천인간 비교에 있어서 일치도가 매우 낮다.

The study found that while the internal consistency of individual referees responses was high, agreement between the referees in terms of individual candidates’ strengths and weaknesses was very low, almost as if they were evaluating different people.

그러나 낮은 점수에 있어서는 일치도가 충분한 것들이 있어서, 부족한 지원자를 걸러내는데는 좋은 방법이 될 수 있다.

Interestingly, there was sufficient agreement on the small number of low scores to suggest that such referees’ reports may be better suited for deselecting weak candidates.

면접 Interviews

어떻게 구조화되느냐에 따라서 신뢰도가 다르다.

An interview is a commonly included component of medical student selection procedures. However their reliability can be low depending, in part, how they are structured.

패널 인터뷰는 MMI에 비해서 신뢰도가 낮다.

Panel interviews have been shown to be rather less reliable than the ‘‘multiple mini-interview’’ (MMI) procedure, first described in the medical student selection context in articles from McMaster University, Canada (see Eva et al. 2004, and subsequently).

비인지역량 검사 Non-cognitive tests

The Newcastle, Australia medical school has focused on the following qualities to develop a battery of tests that has become known as the Personal Qualities Assessment (PQA, www.pqa.net.au):

• Moral orientation (on a continuum ranging from ‘‘libertarian’’, the rights and needs of individuals versus ‘‘communitarian’’, the expectations and needs of society as a whole).
• Resilience (vs. inability to cope with stress; emotionally volatile, ‘‘neurotic’’).
• Self-control (conscientious, orderly, restrained, industrious vs. disorderly, unrestrained, unreliable, impulsive, permissive, anti-social).
• Involvement (empathic, confident in dealing with others, co-operative, agreeable vs. aloof, narcissistic, disagreeable, manipulative, uncomfortable with others).

PQA 점수분포에서 상 하위 2.5% 안에 들어가는 학생은 선발에서 배제될 것을 고려해볼 수 있다.

The working hypothesis is that those individuals represented in the extreme region of the trait score distribution, the top and bottom 2.5%, should be excluded from consideration for entering medical school.

A model for medical school selection

In conclusion I present a model for medical student selection proposed by Bore et al. (2009), a model which Smyth (1946) would surely have approved as evidenced by his remark:

‘‘We want . . . two independent tests, or sets of tests – the one for ability, the other for character’’.

• Besides Selecting in for
• academic ability (academic record)
• cognitive skills (‘‘aptitude’’ tests)
• ability to communicate appropriately (interview)
• good interpersonal skills (interview)

• Select out (non-cognitive tests) those applicants who
• demonstrate traits of psychological vulnerability (inability to handle stress appropriately; low resilience)
• high levels of neuroticism
• low levels of conscientiousness
• extreme detachment, extreme emotional involvement
• high levels of impulsiveness and permissiveness

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Med Teach. 2015 Mar;37(3):252-60. doi: 10.3109/0142159X.2014.993600. Epub 2014 Dec 23.

Selecting medical students: An unresolved challenge.

Powis D1.

Author information

• 1The University of Newcastle , Australia.

Abstract

Abstract Despite the abundant supply of academically outstanding applicants to medical schools in most countries the regularly recurring debate in the academic literature, and indeed sometimes in the popular media, implies that admissions committees are still getting it wrong in a significant number of instances. How can this be so when our procedures are directed unashamedly at selecting the most highly academically and intellectually qualified students in the expectation that they will make the best doctors? Perhaps it is time for a radical change in emphasis. Instead of endeavouring to differentiate among the top ranks of a pool of outstandingly qualified applicants, the selection effort might be better focused on identifying those potentially unsuitable in terms of their non-academic personal qualities to ensure they do not gain entry. The account that follows isan analysis of the problems of medical student selection and offers a potential solution - a solution that was first suggested in the medical literature 70 years ago, but not adopted. It is the present author's contention that the cycle of debate will continue to recur unless such an approach is pursued.

PMID:

 

25532428

 

[PubMed - in process]