To the Editor: The University of Queensland (UQ) study of medical student selection criteria and academic performance reported by Wilkinson and colleagues1 has shortcomings beyond those pointed out by Powis.2

The outcome measure of “academic performance” was assessed by student performance in exams. These exams vary in content from year to year and are, in Years 1 and 2 of the program, mostly multiple-choice and short-answer written exams. A finding that grade point average (GPA) in a previous degree correlates with academic performance in medical school may simply mean that the exams are written and marked in a way that rewards the competencies one acquires in getting a high GPA, and ignores the skills and personal qualities that generate a high interview score.

There is thus a danger that the researchers have themselves created the phenomenon they are now discovering — that you can set exams in such a way that people who do well at sitting exams will do well. Those study authors who identify themselves as holding leadership and teaching positions in the UQ School of Medicine do not state whether they held those positions during the years in which they analysed student performance. If they did, then the researchers are also participants in the study by virtue of the fact that they set and marked exams. Even if they did not, their academic positions expose them to at least the risk of partiality, and potentially to the appearance of a conflict of interest — there are logistical and personal pressures on administrators to reduce the time, energy and expense of evaluating students, especially in a school with so many students. It is not clear from the article what, if any, measures were taken to control for these things, nor what, if any, caution this led the authors to exercise in drawing the policy conclusion that interviews should be abandoned.

The proper research question is not “How do we select students who will do well on the sort of examinations we set?”, but “How do we select students who will create an atmosphere of excellence in the school, and who will carry that with them into the health system and into society as a whole?” The UQ study does not address the broader questions of the social purpose of schools of medicine in general, or the philosophy and ideals of the UQ School of Medicine in particular. Yet the action UQ has taken — to abandon assessment of the personal qualities of its students — risks a profound impact on the realisation of those ideals.

To the Editor: The article by Wilkinson and colleagues1 and the accompanying editorial by Powis2 remind me of the medieval debate about the number of angels who could dance on the head of a pin.

While there is obvious merit in selecting students able to actually pass medical school examinations,3 preferably at their first attempt, where is the evidence that this correlates with their later performance as medical chemists, physicists, researchers, puzzle-solvers, mechanics, artists, analysts or “jacks of all trades”?

What is the point of trying to select students on the basis that they would make good “doctors”, when medicine, perhaps the broadest of all churches, offers professional scope to people of almost every imaginable natural bent and talent?

Selecting for interpersonal relationship skills is fine if selecting general practitioners and psychiatrists. How relevant is it, however, for someone whose talents and skills are intellectual curiosity or manual dexterity?4

Powis wants us to produce doctors who have “the required skills”. Is this not the role of postgraduate educational bodies, helping the undifferentiated graduate pursue a course relevant to their abilities and interests?

If, faced with an almost infinite variety of doctoring, we cannot define “doctor” other than by possession of a medical degree, how can we possibly define the attributes needed to be one?

There are many more important issues in health care that could benefit from the time and money being wasted on chasing this particular chimera.

In reply: I am sorry Arnold considers that, in the context of selecting medical students based on their suitability to be a doctor, interpersonal relationship skills are qualities necessary only for general practitioners and psychiatrists. He is presumably unaware that the most frequent complaints made by patients about doctors of all kinds concern the very absence of such skills.

I agree with his statement that medicine is a broad church, with many professional pathways to suit individual preferences and skills, but that doesn’t mean that anybody is suitable to fill the positions, or indeed fit to be any sort of doctor.1,2

In any country, medical boards and medical indemnity insurers could give many examples of inadequate practitioners. We should remember that all of these practitioners were admitted to medical school, passed their exams and graduated as fit to practise medicine. If there is any chance of identifying such individuals before they start their medical training, then it would be unethical not to do so.1 This means we have to select students based on more than their academic achievements at school, and a suitably structured interview has been shown to be a reasonably effective tool in this context.3,4