Ethnic and sex differences in selection for admission to medical school

British Medical Journal, Dec 4, 1999 by Derek Roskell, Bruno Rushforth, James L Chen, Sanjay Kinra, David James, Lisa Driver

Don't let's discriminate against academic brilliance

EDITOR--It seems naive to suggest that Nottingham Medical School's selection process avoids discrimination.[1] Academic ability is scored as pass or fail, whereas a questionnaire about work experience, extracurricular activities, and positions of responsibility is scored quantitatively, as are the applicant's and referee's statements and interview. This process is presumably based on the idea that doctors need only a minimum academic ability. It would be equally true that potential doctors need only an acceptable level of achievement in extracurricular activities, positions of responsibility, and the other factors that are highly rated.

A questionnaire on work experience, extracurricular activities, etc might measure some objective markers of suitability, but the required answers could probably be inferred from the questions and suitable experience could be arranged if it seemed necessary. Students from less privileged backgrounds have less opportunity to develop skills in sport or music or to gain voluntary work experience. Equally, while candidates who have been given awards and positions of responsibility would be ranked highly, putting great weight on this may only perpetuate unfair discrimination that has been made by others.

Medicine encompasses a huge range of careers; our numbers include leaders and followers, workhorses and creative thinkers, the quietly compliant and the revolutionary. We need to recruit a similarly wide range of students, including the academically excellent.

Of course potential medical students need communication skills; extracurricular interests probably reflect a balanced personality; and it is useful to have some knowledge of the health service before applying to study medicine. But to attempt to quantify these things and discount academic achievement ignores one of the few objective criteria we have. Academic ability must, like everything else, be interpreted in the context of the applicant's background, and it will rarely be the overwhelming factor in selection.

The Nottingham approach risks two things. Firstly, well organised schools will see that any potential medical student is sent for work experience in hospital, put in a sports team, made secretary of the debating society, coached in interview skills, told what to write in the personal statement on the application form, and given a glowing reference. Secondly, we may populate our medical schools with affable clones, all of whom are quite good at sport and will go on to make very ordinary doctors. Given the subjectivity of assessing the factors that Nottingham holds paramount, regardless of what numbers are attached, surely there is room to give a little credit for academic excellence.

Derek Roskell clinical tutor in pathology John Radcliffe Hospital, Oxford OX3 9DU derek.roskell@ ndp.ox.ac.uk

[1] James D, Driver L. Ethnic and sex differences in selection for admission to Nottingham University Medical School. BMJ 1999;319:351-2. (7 August.)

Discrimination is not always explicit

EDITOR--James and Driver's analysis of applications to Nottingham Medical School by candidates from the United Kingdom and the rest of the European Union in 1997 found that significantly more white than non-white applicants were offered a place.[1] They state that the higher rates of offers to white applicants do not represent discrimination because they arise at stages in the selection process which are objectively scored without reference to ethnic group.

We now know, however, that discrimination does not have to be explicit, overt, and readily identifiable for it to exist within institutions. As the Macpherson report--prepared after the murder of a black youth in London--makes clear,[2] institutional discrimination can exist where the allegedly objective practices, protocols, and procedures of an organisation result, albeit unintentionally, in deleterious outcomes for certain groups. In other words, discrimination can be subtle and insidious too.

The fact that a procedure is shown to result in significantly fewer applicants from one group being successful is, in itself, evidence that discrimination may be occurring. Reference to ethnic group being explicitly/made is not a necessary condition for discrimination.

Bruno Rushforth second year undergraduate Manchester University Medical School, Manchester M13 9PL bj.rushforth@stud.man.ac.uk

[1] James D, Driver L. Ethnic and sex differences in selection for admission to Nottingham University Medical School. BMJ 1999;319:351-2. (7 August.)

[2] Macpherson W. The Stephen Lawrence inquiry. Report of an inquiry by Sir William Macpherson. London: Stationery Office, 1999. (Cm 4262-I.)

Might selection criteria be surrogates for other determinants?

EDITOR--In their study on differences in the rate of accepted applications for a place at Nottingham Medical School by ethnic group and sex, James and Driver conclude that the higher rate of offers to white and female applicants does not represent discrimination.[1] They claim that the academic and questionnaire stages of the decision process are "objectively scored without reference to ethnic group or sex." The data presented, however, clearly show that nonwhite students and men are more likely to be rejected because they do not meet the minimum academic and extracurricular standards.