A path analysis of medical school and residency performance. Implications for housestaff selection.

The selection and subsequent performance of 212 internal medicine residents was examined by factor analysis and path analysis. A three-factor solution accounted for most of the variance among the nine selection variables. These three factors, labeled Board Scores, Faculty Evaluations, and Academic Distinction, were then combined with in-training residency performance evaluations and composite scores on the ABIM certifying examination to produce a comprehensive path model of house staff selection and performance. The Academic Distinction factor emerged as the strongest predictor of residency performance,; the Faculty Evaluations factor was also a significant component of the model. Standardized test scores correlated poorly with clinical performance. The data suggest that increased attention to the content of letters of reference could substantially improve their predictive validity. Other means of reporting subjective evaluations may also be needed to increase the stature of non-cognitive attributes in house staff selection decisions.     

The decision-making process: implications for the medical school organization

In this article, the authors make use of some contemporary models of decision-making to show how the process of decision-making can become more self-conscious, and thus both more enlightened and more assured. The approach is an examination of several models examined both from the perspective of the steps in the process itself, as well as general observations about the decision-making process. The practical focus is on the medical school organization with its unique characteristics. This article also examines the decision-making process through a comparison of two types of organizational structure (pyramidal and matrix) found in most medical schools. Certain constants emerge from this article that positively enhance good decision-making. These elements are: (1) the rapidity of change; (2) the critical need for a wide range of alternatives; (3) an understanding of both the organizational structure and human factors involved; and (4) the necessity of involving others in the decision-making process. By analyzing various modes of decision-making and presenting options, this article should be of real assistance to administrators.     

Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching

INTRODUCTION: Debate continues with respect to when to introduce interprofessional education for maximal potential benefit. One perspective is that interprofessional education should be introduced early in the undergraduate curriculum before students develop stereotyped impressions of other professional groups. However, it may be that students at entry to medical school have already developed these stereotypical impressions. This study examines perceived professional characteristics of doctors and nurses by students entering medical school. METHODOLOGY: Year 1 medical students in 4 consecutive years completed a questionnaire on their perceptions of the characteristics and backgrounds of nurses and doctors and on their attitudes to shared teaching. RESULTS: Year 1 medical students were found to perceive the characteristics of doctors and nurses differently. They considered nurses to be more caring and doctors to be more arrogant. They considered nurses to have lower academic ability, competence and status, although comparable life experience. They were generally very positive about beginning shared learning at an early stage of training. DISCUSSION: Whilst it is encouraging that medical students are positive about shared teaching, it is of concern that they have a poor perception of the academic ability, status in society and professional competence of the nurse at entry to medical school. These perceived impressions, which may reflect societal misconceptions regarding the roles and responsibilities of nurses within a modern health care system, may have an impact on the success of early interprofessional teaching initiatives in undergraduate curricula.     

Uncertainties in the selection of applicants for medical school

Decisions about admissions to medical school are based on assessments of the applicants’ cognitive achievements and non-cognitive traits. Admission criteria are expected to be fair, transparent, evidence-based and legally defensible. However, unlike cognitive criteria, which are highly reliable and moderately valid, the reliability and validity of the non-cognitive criteria are low or uncertain. Their uncertain predictive value is due not only to their limited validity, but also to the unknown prevalence of the desirable non-cognitive traits in the applicants’ pool. Consequently, the use of non-cognitive admission criteria inevitably leads to rejection of an unknown proportion of applicants who have a desirable trait and selection of applicants who lack this trait. We propose that, rather than using non-cognitive admission criteria, admission officers should assist prospective applicants to make informed decisions based on a reflective self-appraisal whether or not to apply to medical school. To this end, medical schools should disseminate information on the strains of medical training and practice, the frequency of medical errors and the most common causes of dissatisfaction and burn-out among practicing physicians. Such information may improve the self-selection process and thereby enrich the applicants’ pool for individuals with appropriate motivation. The final selection of medical students may then be based either on past academic achievements, or on a lottery, or on various combinations thereof.     

Decline in lung function and mortality: implications for medical monitoring

Aim

To investigate the risk of death associated with selected cut‐off points for rate of decline of forced expiratory volume in one second (FEV₁).

Methods

Mortality rates of a cohort of 1730 coal miners who had performed two pulmonary function tests 12.8 years apart were followed up for an additional 12 years. Based on previous studies, cut‐off points for FEV₁ rate of decline (ml/year) were selected as 30, 60 and 90 ml/year. Cox proportional hazard regression was used to estimate multivariate risk ratio of death in each category.

Results

The risk ratios (compared to “below 30 ml/year”) were 1.39 (95% CI 0.99 to 1.97) in the “60 to less than 90 ml/year” category and 1.90 (95% CI 1.32 to 2.76) in the “90 ml/year and above” category. Rates of decline above 90 ml/year were consistently related to excess mortality. In non‐smokers and those with neither restrictive nor obstructive patterns at the first survey, rates of decline above 60 ml/year were significantly associated with increased mortality.

Conclusions

Risk of death increases in individuals with rates of decline above about 60 ml/year and is statistically significant with declines of 90 ml/year or more. These results should be useful to healthcare providers in assessing lung function declines observed in individuals.Pulmonary function has been recognised as an important predictor of mortality.^{1,2,3,4,5,6,7,8,9,10} Studies have conclusively demonstrated that the level of pulmonary function, measured using various functional parameters, is inversely associated with subsequent mortality from all causes, lung cancer and cardiovascular disease.^{1,2,3,4,5,6,7,8,9,10} Additionally, an association between the rate of decline in lung function and both cardiovascular and all‐cause mortality has been observed in several studies.^{11,12,13,14,15} Although previous studies have shown an association between rate of decline and mortality,^12,13,14,15 they did not define the degree of mortality risk associated with categories of rates of decline that may be useful in screening for respiratory impairment and preventing lung disease. Such risk information may be helpful in guiding the interpretation of lung function decline in relation to the risk of impairment, disability and, ultimately, death. When monitoring lung health, the rate of pulmonary function decline in an individual provides information that can be used for triggering interventions before an individual develops irreversible respiratory impairment and disability. The question addressed in this study is: what rate of sustained forced expiratory volume in one second (FEV₁) decline indicates a significant risk for death? In healthy adults, FEV₁ declines on average between 25 and 30 ml/year as part of the normal aging process.¹⁶ Mean FEV₁ declines of 60 ml/year, double the rate in healthy individuals, have often been observed in cigarette smokers,^17,18 while declines greater than 90 ml/year, or triple what is expected, may be seen in susceptible individuals who progress to chronic obstructive pulmonary disease (COPD).¹⁹ Rate of FEV₁ decline cut‐off points, such as 60 ml/year and 90 ml/year could be considered clinical benchmarks.The aim of this study is to further investigate in a male working population the relation between rates of decline in pulmonary function and subsequent mortality, and to quantify the excessive mortality risk associated with different categories of decline considered important in clinical practice and research.     

Why people apply to medical school: implications for widening participation activities

OBJECTIVES: This research aims to identify the influences contributing to students' decisions to study medicine and to apply the findings to the design and targeting of outreach activities aimed at widening participation. METHODS: Semi-structured interviews were carried out with 15 medical students at a UK medical school. Framework analysis was used to identify themes and subthemes and findings relating to becoming a doctor were analysed further in the context of a theory of career decision making. RESULTS: Five themes and subthemes were identified. We report the results for the 3 main aspects relating to becoming a doctor from the theme School to Medical School Transition: early motivation; inhibitory factors, and facilitating factors. Many students spoke about having always wanted to study medicine. Early exposure to the possibility of being a doctor allowed the idea to flourish and motivated students to achieve high academic goals. Inhibitory factors included discouragement from application by teachers on the grounds of not being 'doctor material'. Factors which facilitated access to medicine included the support of family members, particularly mothers, and other close friends, and having positive role models. CONCLUSIONS: Our analysis provides evidence of important factors in career decision making for medicine which can be used to inform widening participation interventions in 3 areas, namely, those of school support, home support and raising aspirations.     

The medical school as a social organization

The paper reviews sociological research on the medical school as a social organization from the 1950s to the present. Despite significant differences between societies in the organization of medical education, such research has been largely confined to the USA. Some reasons for this are suggested. Ways in which the climate and organization of medical schools--at least in Great Britain--have changed in the recent past are described as well as reasons for such changes. It is argued that more research into these processes and into the organizational obstacles to change, including cross-national studies, are needed.     

Selecting candidates for a medical school: an evaluation of a selection model based on cognitive and personality predictors

Two studies were conducted to attempt to evaluate the selection procedures used in Hadassah Medical School. The predictors assessed were the Israeli high school matriculation examinations, a general aptitude test, an interview and a semi-projective test designed to assess personality pathology. In the first study 145 students of the 1975 and 1976 cohorts were assessed, the criteria being a combination of peer evaluations, evaluation of supervisors and academic record. Results showed the matriculation average score to be the only effective predictor for all criteria. In the second study 155 students of the 1979, 1980 and 1981 cohorts were assessed, the criteria being evaluation of supervising doctors, BSc grades and grades during the clinical period. Results again indicated that the matriculation test is the most effective predictor. In this study, however, the other variables added to the prediction of criteria based on clinical evaluations. The results were discussed, raising several possible explanations for the relatively high validity of the matriculation scores. It was suggested the matriculation scores capture personality dimensions, such as motivation and adjustment to the learning environment, which are important factors for success in medical training.     

The multiple mini-interview for selection of international medical graduates into family medicine residency education

Context The multiple mini‐interview (MMI) was used to measure professionalism in international medical graduate (IMG) applicants for family medicine residency in Alberta for positions accessed through the Alberta International Medical Graduate (AIMG) Program. This paper assesses the evidence for the MMI’s reliability and validity in this context. Methods A group of 71 IMGs participated in our 12‐station MMI designed to assess professionalism competency. A 10‐point scale evaluated applicants on ability to address the objectives of the situation, interpersonal skills, suitability for a residency and for family medicine, and overall performance. We conducted generalisability and decision studies to assess the reliability of MMI scores. We assessed the validity by examining the differences in MMI scores associated with session, track and socio‐demographic characteristics of applicants and by measuring the correlations between MMI scores and scores on compulsory examinations, including the AIMG objective structured clinical examination, the Medical Council of Canada Evaluating Examination (MCCEE) and the Medical Council of Canada Qualifying Examination Part I (MCCQE I). We measured the correlation between MMI and non‐requisite MCCQE Part II (MCCQE II) scores that were provided. Results The reliability as indicated by the generalisability coefficient associated with average station scores was 0.70 with one interviewer per station. There were no statistically significant differences in total MMI scores or mean station sum scores based on session, track, applicant age, gender, years since medical school completion, or language of medical school. There were low, non‐significant correlations with OSCE overall (r = 0.15), MCCEE (r = 0.01) and MCCQE I (r = 0.06) scores and a higher non‐significant correlation with MCCQE II scores (r = 0.33). Conclusions There is evidence that the MMI offers a reliable and valid assessment of professionalism in IMG doctors applying for Canadian family medicine residencies and that this clinically situated MMI assessed facets of competency other than those assessed by the OSCE.     

Moral reasoning as a criterion for admission to medical school

To determine whether admission interviews could differentiate applicants on their personal qualities (such as integrity, empathy and commitment) 456 applicants from two medical schools were tested on the Defining Issues Test (DIT), which measures the amount of principled or post-conventional moral reasoning. No difference was found between the DIT scores of the accepted and the rejected applicants of the school in which the admission criteria are the traditional scholastic ones. On the other hand, a great difference was shown in the school which admits students for their personal characteristics as assessed by interviews. Yet only moderate correlation was shown between the DIT and the interview scores. Since moral reasoning is a key concept in medical professional behaviour and is correlated with clinical performance, the findings deserve special attention. A possible use of the DIT in the student selection process is discussed.     

Long-term outcomes of primary care residency choice by graduating medical students in one medical school

The ratio of primary care physicians to subspecialists is of major importance to the future of American medicine. This study examined the output of primary care physicians by a state-supported medical school that has a goal of placing 50% of its graduates in primary care. Data were obtained from alumni office questionnaires and published board-certification listings for 1102 graduates of the University of Kentucky College of Medicine from 1973 through 1983. Fifty percent of these graduates chose residency training in primary care. Of all 1102 graduates, 37% are categorized as practicing primary care physicians; 29% of the total are board certified in a primary care discipline. Attrition from primary care as an initial career choice at entry into residency was 26%. With declining medical student interest in primary care and a shortage of primary care physicians, new initiatives in medical education and in the practice of medicine are necessary to balance the specialty distribution of physicians more favorably toward primary care.