Doctor, doctor, you're not on my wavelength

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The Independent Online
You don't need to be a top-flight scientist to palpate an abdomen or administer an enema. So why do we select only students with top exam marks to become bored GPs?

Every summer, as the A-level results are published, Britain's medical schools move in to sweep up the brightest and the best of the new generation's scientific elite. This year, 10,016 students applied to train as doctors and 4,471 were accepted. On a scale that gives 10 points for an A grade, eight for a B and so on, the average A-level score of those who were successful was 28.3, better than two As and a B. Even when the 5,000-plus who were unsuccessful are included, the average score is 24.5, only slightly worse than an A and two Bs. Only veterinary science demanded a higher score, of 29.1, but that was for only 494 places.

It may seem comforting to know that those who will hold our lives in their hands are the brainiest in the land. The field of medicine is now so vast, and the pace of advance so rapid, that only the best minds have a chance of acquiring the necessary expertise. But there is more to medicine than making a diagnosis. It is also about listening, understanding and providing reassurance based on secure knowledge - the soothing hand on the brow. Are we sure we are selecting the best men and women for the job?

One country is said to have adopted a radical approach to this problem. In the Seventies, so the story goes, Israel required all medical school applicants to undergo an IQ test. Those who scored over 130 were automatically rejected.

The story may be apocryphal, but it highlights an important truth. Medical practice, like other jobs, is often routine and repetitive. While there are openings for the super-bright, there is also the risk that the profession will not offer enough to keep them intellectually stretched.

And after 20 years of seeing patients, most of them with one of only half-a-dozen complaints, many doctors are seeking a way out. One editor of a medical magazine used to boast that his largest ever postbag followed publication of an article by a doctor who said he was bored at 40.

Medicine is a broad church. There should be a place for everyone - the brilliant research scientist as well as the dextrous surgeon and the empathic general practitioner. There is even a place for those who abhor patients (and prefer looking down microscopes in the pathology lab) and those who come over queasy at the sight of blood (but do a good job running public health departments). But can one criterion of choice - academic attainment - select for all these?

Selection has to be fair to the applicants, fair to the public and fair to the nation. On all counts there is evidence that the selection procedure is failing. There are the drop-outs from medical schools, who are both an expensive loss and sad casualties. They have wasted their time and denied a place to others who were more suited to the course.

There is the loss of medical graduates in the early years, some of them casualties of the punishing hours and heavy workload, others of an outmoded medical hierarchy that still relies on education by humiliation. Some estimates put their numbers as high as 25 per cent, but that includes temporary losses, including twentysomethings seeing the world, and women wanting to start a family. The true figure is probably nearer 6 to 7 per cent.

More disturbing are the complaints from patients about poor communication and a lack of care. The charge runs that the emphasis on academic attainment may be ruling out people with the personal qualities necessary for developing the intuitive ear and bedside manner that are essential to good medicine.

The evidence here comes from Isobel Allen, a research fellow at the Policy Studies Institute, who has spent the best part of two decades following doctors as their careers progress or falter. She observes that many of those who become doctors do so simply because they were good at science, without having any idea what doctoring involves. She noted high levels of regret among young doctors, some of whom were quite open about their dislike of patients, and who might have been better off as scientists.

In Choosing Tomorrow's Doctors, a collection of papers published by the institute, she quotes some of the remarks made to her by newly qualified medics, whose training costs around pounds 200,000 each. "Medicine was OK except for the people," said one. "I found the whole thing of having to look after people too difficult. I felt I couldn't do them any good - and I didn't give a damn anyway."

Another said: "I didn't realise how much other people irritated me. I wanted to slap their faces and say 'Pull yourself together'." A third said: "I will always regret becoming a doctor. Ten years of my life would have been better spent doing something else."

Ms Allen describes these interviews as heartbreaking. "These were the brightest and the best of their generation, but by the time we interviewed them we were hearing some very sad tales."

There has to be a better way, and in New Zealand they believe they have found it. For the last five years the medical school in Auckland has pioneered a new form of medical student selection which relies less on academic grades and more on personality assessment. It also includes a group exercise which is designed to explore individuals' capacity to work as members of a team. This is given equal weight with academic performance in awarding places, and the initial experience is said to be encouraging.

Other research shows that learning style may be as important as A-level grades in determining success as a doctor, but cannot be picked out by exams. So-called "surface learners" who absorb a lot of facts, may do as well in their exams as "deep learners," who spend longer grasping the basic principles, are more reflective, and are thought to be better suited to the lifelong study that medicine requires.

Medical schools in the UK must now bite the bullet and recognise the need to accept lower A-level grades in order to provide the flexibility to select on other criteria.

If they do not, we risk training a generation of doctors who will become frustrated, dissatisfied and unable to engage with their patients over a career that should last 40 years.