Older & wiser?

Stephanie Gapper considers the pros and cons of graduate entry medicine

You can’t poke your nose out of doors as a medical student without being bombarded with information concerning the changing face of medicine and the medical workforce. There’s Modernising Medical Careers, problem based learning, personal and professional development, and a host of other things, all designed to “ease” the transition through medical school and into your working life—and in the process, complicating things horrendously. Among all this is yet another one: graduate entry medicine.

Teaching medicine to students who already have another degree is nothing particularly new. In the United States, medicine has been exclusively a postgraduate course for generations, and Ireland has now gone the same way. Australia has been running a combination of graduate and undergraduate courses for over a decade. Britain has come to the fold rather late (the first graduate entry course was set up at St George’s in 2000), although mature students have been on undergraduate courses for as long as they’ve been going. With the first cohort of graduate entry medics released on to the wards last year, the time is ripe to compare and contrast (you can tell I was a history student in my former life) the achievements and abilities of graduate entry versus undergraduate medics.

A bit of clarification

Graduate entry medicine was introduced in Australia partly as a way to address the shortfall in doctors: a shorter course equals more doctors, faster. That was also some of the rationale for its introduction in the United Kingdom. Currently, 14 medical schools offer graduate entry medicine (or the graduate entry programme). It’s a four year course and entry is restricted to candidates with a first degree. In some schools, such as Bristol and Oxford, this must be a life science degree. In others, including Nottingham and Swansea, it doesn’t matter what it is. Some places, such as Warwick and St George’s, use a reasoning examination (for example, the graduate Australian medical schools admissions test (GAMSAT) or the medical schools admissions test (MSAT)) to screen initial candidates and then follow this up with an interview. Others, such as Southampton, base their selection entirely on your previous degree result, your A levels, and your UCAS (Universities and Colleges Admissions Service) form and don’t even call you for interview.

Entry requirements usually reflect the type of teaching in the course. Schools that require a science background tend to condense the longer undergraduate course into four years, skipping bits they assume you already know and packing the rest into a lengthened academic year. Programmes that have wider access are more innovatively structured and use teaching methods such as problem based learning, which allows science and non-science graduates to share their knowledge. Problem based learning works through the curriculum in a systems based way (cardiovascular system, renal system) rather than the traditional disciplines (pathology, microbiology).

Who applies?

There’s a remarkably broad range of applicants to graduate entry courses, especially the ones that don’t require a science background. On my course, as well as plenty of people who have come straight from their first degree, we have several accountants, two journalists, a cheesemonger, a smattering of scientific researchers, a surfing sales representative, a generous helping of engineers and bankers, a trader, and a couple of nurses. Many of them have left lucrative professions to do this course (though graduate entry medicine is heavily fundedby the NHS (see www.dfes.gov.uk/studentsupport/students/nhs_.shtml)), and their reasons for changing to medicine are as diverse as their previous occupations.

Research suggests that graduate students are more motivated and eager to learn than their undergraduate counterparts. Peter McCrorie, director of the graduate entry programme at St George’s, was quoted in the BMJ in 2002 as saying, “Graduate students are highly motivated and committed. They are much more self directed, challenging, demanding, questioning, and mature than non-graduates. I believe that mature students, whether graduate or not, are sooner and better able to handle the responsibilities of being a doctor.”¹ This may well be true, but it has to be the case if you’re going to do medicine in four years. Also, if you’ve left a good job and a settled life and taken the plunge to change career, you’re hardly going to want to squander the chance. In all likelihood, your liver took such a beating during your first degree that it can’t hack the pace of undergraduate living (though some of my course mates certainly don’t bear testament to that assumption). This would account for the main issue between graduates and undergraduates when they start to mix in the clinical phase: in broad terms, the graduates are seen as old and boring and far too keen, and the undergraduates are seen as young and immature and not nearly keen enough.

The prognosis

Graduate entry courses seem to be growing in popularity. The University of Nottingham had 10 applicants for every place in the 2004 intake. This year Swansea, which is exclusively graduate entry, had 500 applications for 70 places. The question that needs to be asked before this expansion continues is whether graduate entry medicine is indeed a good way to teach health care. Put simply, is it making good doctors?

Unfortunately, it’s too early to tell in the United Kingdom and even in Australia, since the courses are relatively new. In the United States, there’s no real comparison to be made as medicine is almost exclusively postgraduate. The research that has been done is, of necessity, highly qualitative. In the United Kingdom, too, it’s hard to separate graduate entry medicine from wider teaching innovation, and therefore difficult to work out whether differences between graduate and undergraduate medics are due to maturity or teaching experiences; not many undergraduate courses employ teaching tools such as problem based learning on a core basis.

Innovation in teaching

Is it the maturity and life experience of graduate applicants that leads them to do better in certain aspects of clinical medicine, or is it the way in which they are taught? A study on anxiety in medical students at St George’s, which is in the happy situation of having both graduates and undergraduates to investigate, concluded that it was not the increased age and maturity of the graduates which made them less anxious about the clinical phase, but the nature of problem based learning and the way the course was delivered that prepared them better for life on the wards.²

Manchester University introduced problem based learning into its undergraduate curriculum in 1997 and, three months into their preregistration house officer year, compared the experiences of graduates from the traditional course with those who completed the problem based learning course. Students were asked to rate themselves on their performances and their clinical supervisors were asked to do the same. The problem based learning graduates rated themselves more confident in 11 of 18 criteria and worse in only one: their knowledge of basic science and disease processes. The clinical supervisors also rated them more highly in several competencies, including communication, coping with uncertainty, and cultural differences, and they did not differentiate between their science knowledge and that of the traditional undergraduates.³

Similar results were reported in an Australian study of interns (preregistration house officers) from the University of Newcastle’s graduate entry programme, which uses problem based learning, and the University of Sydney’s traditional undergraduate programme. The only notable difference was that in some cases the clinical supervisors reported gaps in the science knowledge of the problem based learning students (more on this in a moment).⁴ It’s difficult to say at this stage whether problem based learning is a more effective teaching tool across the board, or whether its success so far lies in the fact that it is being applied to mature students, to whom it’s well suited. The Manchester study, however, certainly suggests it can work for younger students too.

Firm foundations

The concern about coverage of basic science is an interesting issue, although obviously only for medical schools that admit non-science graduates. Attempts to research it encounter various problems, not least the fact that some graduate students have previous exposure—sometime almost toxic levels—to science, while others arrive to start their medical course struggling to remember what a cell is. Leah Deutsch, a graduate entry medical student at Nottingham, is just one of several who have expressed concern at the lack of direction and content coverage in basic science teaching. “We only get 18 months of preclinical teaching,” she says, “and it seems quite short sighted to focus so much on clinical aspects when there’s so much biochemistry to learn. We’ve supposedly been selected for our communication skills and clinical potential, but biochemistry is a subject that really needs to be taught.” Kevin Hayes, senior lecturer and consultant in obstetrics and gynaecology at St George’s, says that these concerns are shared by the non-science students on the graduate programme there. “Lots of students feel they are under prepared science wise—to begin with. This worry decreases with time, though, and by the end of year 2 there’s essentially no difference between science and non-science graduates.”

In the studies mentioned above, it is mainly students’ own perceptions of a shortfall in the knowledge that causes the lowered response. Informal feedback from graduate entry medical students at Nottingham integrating with undergraduate students in the clinical phase also indicates a concern that their science is not on a par, although they feel their clinical knowledge is probably better. “The undergrads have better knowledge of some aspects of the course—and seem to be good at learning lists. The GEM [graduate entry medicine] students are perhaps more able to explain their thinking or work things out from some sort of principles,” says Stephanie Wagner, a Nottingham GEM student now on clinical attachments. She adds: “We are more likely to have a go and are perhaps not so worried about being wrong or looking foolish.”

The consensus seems to be that having a science background makes the first year easier, but that the differences are ironed out by the end of the first year. Research in the United States indicates that there was no difference in National Board Medical Exam performance and placement in residencies (preregistration house officer positions) between medical graduates who had science majors at undergraduate level and those who did not.⁵

Meanwhile, back on the wards

So how is graduate entry medicine performing out there in the big wide world? One of the studies already mentioned showed broadly favourable results comparing Australian interns from graduate and non-graduate courses. Unfortunately for us in the United Kingdom, all the evidence is purely anecdotal, given the short length of time graduates have been working. However, says Kevin Hayes, so far “it’s all overwhelmingly positive. Colleagues who initially asked what on earth we were doing teachingmedicine to history of art graduates have been turned around, and most say that graduate entry medics areactually better than undergraduates.” It remains to be seen if graduate entry medics have the basic grounding to take them through general training and into specialties, but so far it looks pretty good. In fact, says Hayes, “It wouldn’t surprise me if in 30 years’ time there are no school leavers doing medicine.”

The pitfalls

Graduate entry medicine is not, however, a panacea for the ills of the NHS and the medical profession in general. Part of the point of graduate entry medical courses is to widen access to medicine and diversify the health workforce. Considering applications from candidates who did not, or were not able to, apply as school leavers does this to an extent, and recognition of life experience over pure academic achievement is certainly a step in the right direction. On the other hand, by accepting applications only from people who have been to university, selection is still restricted to an already over represented socioeconomic group in medicine: educated, mainly white, mainly middle class. Graduates don’t equal diversity.⁶

Mixing graduate and undergraduate students on the clinical phase also seems to have produced some sparks. Research in Australia reported that, while graduate students were much more proactive and better at teamwork, they could also be “antagonistic” and had unreasonable expectations of rostering and working conditions.⁷ Reading between the lines of shrouded research jargon, it’s not hard to imagine a mouthy graduate entry intern, 10 years older than his registrar, not liking the way his weekend night shifts were shaping up. Intensive investigative research for this article uncovered similar sentiments held by undergraduates at Nottingham towards their graduate entry peers: “They do sometimes seem to make us look bad in front of consultants and are in fact a bit rude to them—they have to accept these people, even if they are younger than them, and are most definitely superior to them in the world of medicine.” (Online feedback from students at Nottingham after six months of mixing graduates and undergraduates on clinical attachments).

Which way now?

Opening up medicine to a wider range of applicants is a good thing. In terms of making up the shortfall in doctors, then graduate entry medicine is a very good thing as it gets more people more quickly to the level of qualification and therefore practising. It’s almost a truism to say that students who’ve already done a degree, know how to use a library, don’t go out five nights on the bounce any more because they’ve got a family, and really want to do medicine, are going to be highly motivated. This accounts for the favourable reports from teaching clinicians. It’s also fairly obvious that the older you are and the more experience you have in dealing with people, the better your general communication skills will be—if the interview panel at your medical school has done its job properly. Of course, this is not to say that undergraduate medical students will not make good doctors. What graduate courses do ensure, however, is that the decision to do medicine is not taken lightly. Perhaps this, and not the years themselves, is what makes the real difference.

The third UK conference on graduate entry medicine—Graduate Entry Medicine: What’s Working?—is on 14 July 2006 at the University of Nottingham Medical School at Derby. Tickets for students are heavily discounted at £20.

Stephanie Gapper, second year graduate entry medical student, University of Nottingham
Email: mzyysg1@nottingham.ac.uk


studentBMJ 2006;14:89 - 132 March ISSN 0966-6494

1. McCrorie P. Graduate students are more challenging. BMJ 2002;325:676.
2. Hayes K, Feather A, Hall A, Sedgwick P, Wannan G, Wessier-Smith A, et al. Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students?’ Med Educ 2004;38: 1154-63.
3. Jones A, McArdle PJ, O’Neill PA. Perceptions of how well graduates are prepared for PRHO roles—a comparison of outcomes from traditional and PBL curricula. Med Educ 2002;36:16-25.
4. Dean SJ, Barratt AL, Hendry GD, Lyon PM. Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. Med J Aust 2003;178: 163-6.
5. Dickman RL, Sarnacki RE, Schimpfhauser FT, Katz LA. Medical students from science and non-science background. JAMA 1980;243:24.
6. Searle J. Graduate entry: what it is and what it isn’t. Med Educ 2004;38:1130-40.
7. Dean SJ, Barratt AL, Hendry GD, Lyon PM. Preparedness for hospital practice among graduates of a problem-based, graduate-entry medical program. Med J Aust 2003;178: 163-6.

       

           

	Responses published this month

Articles	Responses
LIFE Older & wiser?       Stephanie Gapper (March 2006)	Rahul Potluri (March 11th, 2006) Read this response
LIFE Older & wiser?       Stephanie Gapper (March 2006)	Dr. Satheesha Nayak (March 10th, 2006) Read this response

	LIFE Older & wiser?       Stephanie Gapper (March 2006)
	Rahul Potluri (March 11th, 2006)       3rd Year Medical Student, University of Birmingham rxp289@bham.ac.uk
	The article titled "Older & Wiser?" gives a very interesting insight into the advantages and disadvantages of having undertaken a previous degree before pursuing medicine. My experience of working with fellow graduate entry medical students is concurrent with the title of the article. They do stand out from the average medical student and are a lot more focussed in their approach towards work. Also in the majority of cases, these students tended to be more settled in their life with immense experience between the correct balance between work and play and superb time management. The main reason for this is because almost all graduate entry medical students are extremely capable and hardworking, having achieved first class or upper second class degrees previously. Medical students often find it difficult to immediately come to terms with a university environment and although they are competent, may fail to achieve at their full potential. This observation coupled with the observations about graduate entry students have led me to think about the possibility that graduate entry medical students may actually make better doctors in the future compared to mainstream medical students. One of the key skills necessary as a medical student, especially during the clinical years is to organise time effectively to maximise learning. The quicker this is process is achieved, the more a student will learn and hence this may have a direct relationship to their competence as a doctor. This suggests that perhaps graduate entry medical students may actually make better doctors. Therefore, it might be feasible to suggest that medicine should be pursed after a previous related degree. In the USA they have a similar system in which the majority of medic al courses are split into 8 year programmes of premedical and medical strands. This might be an area for exploration in modernising medical training in the UK.

	LIFE Older & wiser?       Stephanie Gapper (March 2006)
	Dr. Satheesha Nayak (March 10th, 2006)       Associate Professor of Anatomy, Melaka Manipal Medical College (Manipal Campus), Madhav Nagar, Manipal, Udupi District.Karnataka State. INDIA. 576104 nayaksathish@yahoo.com
	Dear Editor, I read Stephanie Gapper's article about the graduate entry into medicine. Graduate entry into medicine is a welcome step when comes to the curriculum which involves a lot of self-directed learning, communication skills and use of library etc. Graduate students are mature and their interaction with peers and teachers will be better than undergraduates. But the fact is that, most of the people like to become doctor as fast as possible. In many countries the entry to medical curriculum is at the age of 18 years with a two years science course (pre-university) after matriculation. A common entrance examination is held as an entry criterion when it comes to India. If anybody can enter medical curriculum at the age of 18 years and come out as a doctor at the age of 22-23, why to do a degree course before joining a medical school? If there are graduate entry schools and undergraduate entry schools, definitely more students will join the undergraduate entry program. We have innovative programs like problem based learning (PBL) and the schools having PBL systems, as described by the author are taking graduate students. The graduate students can cope up with the stress better, use their prior knowledge better, and participate in group discussions better than undergraduates. The graduate entry will lessen the burdens of the teachers also. In PBL curricula, the teachers are just facilitators. They need not make the students understand the topic. The students have to do it by themselves. For this kind of a self directed learning, we need mature graduate students. That is why the PBL schools are encouraging graduate entry. If our innovations in education are going serve only mature and aged students, why to do innovations at all? Our aim has to be to do educational innovations which will make undergraduates better learners. We should aim at producing young doctors who are competent. So there is a need to innovate curricula to suit the needs of young undergraduate entry medical schools.