Is medical school selection discriminatory?

Being white, female, an academic high achiever, and singleminded can have its drawbacks, but when it comes to selection for United Kingdom medical schools, no one’s better placed. At least that’s the message from the analysis by McManus of the anonymised data on selection released this week (p 1111).¹ The key findings show, surprisingly, that women are more likely to gain entry to medical schools, but candidates from ethnic minorities remain disadvantaged. Concerns about the selection procedure have long inspired calls for a code of practice.²

Disadvantage—To deprive of the resources and privileges enjoyed by the majority of people

Discriminate—To treat differently because of prejudice Adapted from Chambers 20th Century Dictionary

Differences exist between ethnic minority groups. Caribbeans are less disadvantaged than Africans. Indians are less disadvantaged than Bangladeshis or Pakistanis. While wide confidence intervals hint that some of these differences may not be real, it is undeniable—and suspicions are confirmed—that overall ethnic minorities are disadvantaged. Sceptics will argue that this analysis by McManus doesn’t take into account data on predicted A level grades (which were not made available to him but which selectors rely on heavily), but previous work suggests that even when academic achievement is taken into account ethnic minority candidates are less likely to be accepted, probably on the basis of their surname.³ This adds to mounting evidence of disadvantage at all stages in the careers of ethnic minority doctors.^4–6

McManus also finds more subtle disadvantages. Applicants not wholly committed to medicine on their application forms, those choosing a gap year, and those from colleges of further and higher education and sixth form colleges may be less likely to gain admission to some medical schools. Older applicants and those from lower socioeconomic groups are also disadvantaged. One myth that is not substantiated, however, is that applicants from independent (private) schools are advantaged in terms of selection.

McManus points out that the new evidence raises the possibility of legal action against medical schools under section 17 of the 1976 Race Relations Act. But whether it proves racial discrimination is open to debate. Disadvantage does not necessarily equal discrimination. Legally, direct and indirect discrimination are separate concepts, with direct discrimination hinging solely on an individual’s race, while indirect discrimination arises from some hurdle in the selection procedure that is more difficult for ethnic minority candidates to clear. These data appear to raise issues of indirect discrimination, which may be difficult to prove in court (p 1117).

In the United Kingdom ethnic minorities as a whole are overrepresented in the medical profession. This is explained by the high proportion of applicants of Asian origin to medical schools as well as being a legacy of the days when overseas doctors were more welcome in the National Health Service. Even though they are disadvantaged in terms of selection, enough Asian students apply to ensure that they make up a larger proportion of the medical work force than they do of the population of the United Kingdom. Around 6% of the United Kingdom population are Asian, but they constitute 28% of medical school applicants and 21.7% of those receiving offers of a medical school place. AfroCaribbeans, meanwhile, constitute 2% of the UK population and 3.79% of medical school applicants but receive only 1.72% of offers. By contrast, 64.9% of applicants are white but they receive 74% of offers (IC McManus, personal communication).

Disadvantage, however, can be turned to advantage, as in the case of women applicants—although positive effects on career progression are yet to be seen. By contrast, medical schools in general appear unable to redress the inequalities faced by ethnic minority candidates, despite repeated focus on this issue in recent years.⁷,⁸

McManus confirms that some medical schools manage not to disadvantage women and ethnic minorities.³ Perhaps the answer is to learn from their admissions procedures. Alternatively, more aggressive policies may be needed; there is, for example, evidence that raising awareness of ethnic minority issues can increase recruitment.⁹ Moreover, experience from the University of Arkansas has shown that lowering entry requirements for African-American applicants need not reduce standards: those same students have gone on to score above average marks in medical exams.¹⁰

The Council of Heads of Medical Schools is to be commended for making these data available; other selection bodies such as the police and the legal profession are much less open about their procedures, and what the deans have done should serve as a model to other professions. The council has also worked with the Commission for Racial Equality to produce an eight point list of “guiding principles” for selecting of students which will be adopted by all UK medical schools. The schools promise to review the criteria for medical student selection, both academic and non-academic; ensure that all medical schools publish and monitor equal opportunities action plans; and monitor and publish the annual figures on applications. Other proposals include further research looking into why certain applicants are disadvantaged, bringing forward the deadline for medical school applications, and reducing the number of choices available on the university application form. The Commission for Racial Equality has threatened to conduct formal investigations into medical schools that fall short.

Without more evidence we cannot be sure of the best selection procedure. But the most satisfactory system would be free from bias and transparent. Best practice may require a structured combination of psychometric tests and interview, with the interview being used as another avenue for information gathering rather than the selection event (see p 1149).¹¹ Admissions tutors should scrutinise current selection procedures and also look beyond the medical world—to examples of good practice in the commercial world—to develop a more equitable system.

What is clear is that these data should continue to be made available in future years. Deans of medical schools should use them as a catalyst for change instead of viewing criticism based on them as an assault on the credibility of their institutions.

Papers p 1111, Education and debate p 1149