Selection into medicine using interviews and other measures: Much remains to be learned
The University of Sydney
Peter Harris, Andrew Cole, Phil Jones and Boaz Shulruf
University of New South Wales
The objectives of this study were to identify the effectiveness of the panel admission interview as a selection tool for the medical program and identify improvements in the selection tools battery. Data from 1024 students, representing four cohorts of students were used in this study. Exploratory factor analysis using principal component analysis was used to identify underlying factors within the admission tools. A series of hierarchical linear regressions was employed to identify the predictability of performance in the medical program by the admission tools. Although the admission tools yielded low correlations with one another (r<.30), correlations between interview sub-scores were high (.435<r<.640). All interview sub-scores loaded on to a single factor explaining over 60% of the variance. The admission tools and the interview overall scores explained less than 13.5% and 3.8% (respectively) of the variance in the key outcome measures. We concluded that each admission tool measured different attributes, and suggest that admission interview procedures and the interview questions should be assessed independently.
Previous academic performance, measured by GPA, was found to be the strongest predictor of subsequent academic success and future career placement, yet the predictability of academic success is stronger for the early years and drops towards the end of the program (Cohen-Schotanus et al., 2006; Collins & White, 1993; Dowell et al., 2011; McManus et al., 2005; Shulruf, Poole, Wang, Rudland & Wilkinson, 2012; Silver & Hodgson, 1997; Wilkinson et al., 2008). Aptitude and achievement tests such as the Undergraduate Medicine and Health Sciences Admissions Test (UMAT), Medical College Admissions Test (MCAT) and the UK Clinical Aptitude Test (UKCAT) are also becoming prevalent in the medical program admissions process. Of the three mentioned, both the UMAT and UKCAT are considered to be purely aptitude tests, while some sections of the MCAT (which are used for graduate entry programs) are deemed to measure academic knowledge previously acquired (Prideaux et al., 2011).
UMAT scores have been shown to be a weak predictor of academic performance in medical school (Mercer, Abbott, & Puddey, 2012; Shulruf et al., 2012; Wilkinson et al., 2011). Likewise, the UKCAT has also been shown to be a poor predictor of study success after admission (Lynch, MacKenzie, Dowell, Cleland & Prescott, 2009). Aptitude and achievement tests were found to interact with ethnicity and socioeconomic factors, which suggest that additional admission tools are required (Davis et al., 2013; Puddey & Mercer, 2013).
Some medical schools utilise interviews as an important part of the selection process, aiming to assess a broader range of a candidate's attributes, such as interpersonal skills, motivation and personality, that are not as readily assessed through GPA and admission tests scores (Albanese, Snow, Skochelak, Huggett & Farrell, 2003). For example, a recent study from Australia reported that removing interviews from the selection process was associated with gender bias as it increased the proportion of males being admitted to the medical program (Wilkinson, Casey & Eley, 2014). Nonetheless, the research on admission interviews suggests that interviews only poorly predict future performance, academic or otherwise (Prideaux et al., 2011; Shulruf et al., 2012; Wilkinson et al., 2008).
Moreover, Kulatunga Moruzi and Norman (2002) suggested that despite achieving an acceptable (0.66) inter-rater reliability for the overall rating of the admission interviews, there was no significant relation between interview scores and performance in clinical tasks. The only exception to this is the Multiple Mini Interview (MMI) which utilises a format similar to that of the OSCEs and shows a significant relationship with success on OSCE performance during the clinical years, probably due to the similarity between those two assessments (Eva et al., 2012; Pau et al., 2013; Reiter, Eva, Rosenfeld & Norman, 2007).
In Australia, ten schools offer undergraduate entry medical programs, with the majority of students entering directly after secondary school graduation. Applicants are required to undergo an assessment process comprising a structured interview, an aptitude test (UMAT), a high secondary school GPA and a rural score if applicable (Monash University, 2014; University of New South Wales, 2012; University of Western Australia, 2014).
UNSW medical school makes use of an integrated selection process which takes into account the items mentioned previously. Part of this process includes the interview, from which a recent study showed a strong relationship between its communication dimension and clinical competency in the medical program (Simpson et al., 2014). The interview process in our medical school involves a structured 40 minute interview by two interviewers who each score the interview independently at the its conclusion and are then required to reach a consensus score. On the rare occasions this consensus is not reached a later second interview is needed. Interviewers are required to undergo training every two years to recalibrate. This interview process was designed and implemented two years before the curriculum change and independently of the associated assessment system. In the interview, proficiency is considered across six predefined domains: communication skills, motivation, empathy towards others, self-awareness, responding to diversity and ability to cope with uncertainty (Simpson et al., 2014).
The aim of this study was to identify the ability of the admission tools to predict medical student performance in later core assessment tasks within the medical program.
Exploratory factor analysis (EFA) (employing principal component analysis) was then conducted to identify any discrete factors within the six expected domains of the interview questions. Multiple linear regression analysis was used to determine the predictability of students' examination scores throughout the three phases of the medical program by the interview scores.
|UMAT Sec 1||61.12-63.31||60.71-63.08||58.37-60.28||59.27-61.43|
|UMAT Sec 2||66.64-69.94||57.66-60.40||56.68-58.72||56.10-57.98|
|UMAT Sec 3||62.64-64.88||61.11-64.29||61.38-63.89||61.97-64.28|
|Interview Sec 1||5.84-6.04||5.56-5.81||5.65.-5.85||5.53-5.73|
|Interview Sec 2||5.84-6.06||5.71-5.98||5.69-5.91||5.54-5.74|
|Interview Sec 3||5.72-5.92||5.57-5.81||5.63-5.84||5.45-5.64|
|Interview Sec 4||5.59-5.81||5.50-5.77||5.51-5.72||5.35-5.54|
|Interview Sec 5||5.75-5.98||5.76-6.00||5.69-5.91||5.59-5.79|
|Interview Sec 6||5.65-5.88||5.57-5.83||5.48-5.72||5.39-5.59|
Exploratory factor analysis (principal component analysis) for all six domains of the interview (each cohort separately) identified only a single factor, which explained over 60% of the variance (variance explained by cohort: 2004 - 61.3%; 2005 - 64.7%; 2006 - 63.4%; 2007 - 61.0%).
In order to identify associations across the admission tools used, Pearson correlations were calculated between each of them (ATAR; UMAT 1-3; and scores of interview domains 1-6). The results demonstrate that ATAR was not highly correlated with any of the other measures. The highest correlation was with UMAT3 (r=.284 p<.01); UMAT 1-3 scores had low correlations with each other, while UMAT2 scores did not correlate with the other UMAT scores; UMAT 1-3 did not have any meaningful correlations with any of the interview domains' scores, which did have relatively high correlations with each other (.435<r<.640, p<.01) (Table 2).
|Year||Measured outcomes**||Regression model*||Var 1||Var 2|
|Model 1||Model 2||Model 3|
|2||Clinical communication skills||3.1%||3.6%||7.5%||3.9%||4.4%|
|End of phase exam||18.6%||31.4%||32.1%||0.7%||13.5%|
|4||Integrated clinical assessment||1.1%||3.9%||6.2%||2.3%||5.1%|
|6||Biomedical sciences viva||2.6%||8.3%||9.7%||1.4%||7.1%|
|Integrated clinical exam||4.1%||5.1%||6.7%||1.6%||2.6%|
To identify the predictability of key outcomes in the medical program by the three admission tools, a series of hierarchical multiple linear regressions models was employed. The models used three blocks: block 1 demographic variables (gender, cohort); block 2 ATAR and UMAT scores; and block 3 interview scores. Table 3 presents the outcomes' variance explained for each of the models. Overall the admission tools did not predict the key outcomes (Table 3). Altogether, the admission tools explained 13.5% of the variance in end of Year 2 written examination scores, followed by 7.1% of the variance in Year 6 (final) Biomedical Sciences Viva scores, 6.8% and 6.3% of the variance in Year 2 and Year 4 (respectively) Portfolio scores. The interview scores explained only 3.9% of the variance in Year 2 Clinical Communication Skills, 2.3% in the variance of Year 4 Integrated Clinical Assessment and 1.6% of the variance in Year 6 Integrated Clinical Examination (Table 3).
The first explanation is that the selection process had been very successful. Generally the dropout from medical programs is low (O'Neill, Wallstedt, Eika, & Hartvigsen, 2011). For example reports form the UK suggest 3.8 to 4.2% dropout rate (Arulampalam, Naylor & Smith, 2004, 2007) and a recent study from our institute reported less than 2% of year 1 discontinuation of students who studied in the program, which is about a half of the rate observed before the current admission process was put in place (Simpson et al., 2014). Thus it is possible that very few students selected were not suitable for the program, which means that the selection tools worked well, as intended in distinguishing between the suitable and non-suitable applicants rather than predicting achievement within the program. This could explain the low predictive power of any of the admission tools including the interviews. It is noted that similar correlations between admission interview scores with clinical and communication skills assessed later in the program were found in studies undertaken previously on similar but not identical populations (Mercer, 2007; Mercer et al., 2012; Puddey, Mercer, Carr, & Louden, 2011; Simpson et al., 2014).
An alternative explanation is that the interviews were not efficient enough. Although aimed to measure six discrete domains, our analysis suggests that the interview scores all measured the same trait. The correlations between the domain scores were high (Table 3) All the scores loaded on to a single factor which explains about 60% of the variance. Given that the interview schedule was designed by a professional team to measure different traits, it is possible that the first impression the interviewee made on the interviewers was the strongest, or any other particular strong impression that overshadowed responses to most of the questions asked throughout the interview (McLaughlin, 2014; Wood, 2014).
It is also suggested that more general issues related to reliability, and predictive validity of admission interviews, which have been widely reported, may have impacted on the effectiveness of the interviews undertaken in our institution as well (Edwards, Johnson, & Molidor, 1990; Lumb et al., 2010; Poole, Shulruf, Harley, et al., 2012; Salvatori, 2001). A possible avenue for improvement might be employing a mini multiple interview (MMI) technique which has been reported to yield better predictive validity, particularly predicting performance in clinical skills assessments (Eva et al., 2012; Pau et al., 2013). The MMI is a series of sequential short interviews each of which focuses on a particular set of skills and each is conducted by a single interviewer.
Therefore, possible ways to improve the predictive validity of the admission interviews in our institution might be by splitting the panel interview to six MMI stations, each measuring one of the domains as currently intended to be assessed. Using this practice may provide some more insight into the admission interview process. A comparison of the predictive validity of the suggested MMI with the currently used panel interview may identify the impact of 'first impression' on the interview results (McLaughlin, 2014; Wood, 2014). This is a low risk change as it only requires operational change without changing the content of the interview questions. Given the low risk, this practice could be applicable for any medical program that currently utilises a similar admission interview process and might enable those programs to make better informed decisions about which way to go in the future. This approach will not address other "softer" outcomes nor issues of career selection.
The other important finding of this study is the low correlations that were found between the different selection tools (Table 3). Although similar findings had been reported previously, the issue of such low correlations has been scarcely discussed in detail (Basco, Lancaster, Gilbert, Carey & Blue, 2008; Carr, 2009; Kulatunga Moruzi & Norman, 2002). If selection tools did not correlate but were found to provide reliable (not implying validity here) measures, then each tool may be deemed to measure a discrete trait, or a set of attributes, different from the others.
Given that medical professional practice is comprised of different sets of skills and qualities, it is suggested that admission tools' validity be measured by comparing each admission tool separately against its corresponding attribute as manifested within the medical school assessment schedules. Applying such a student selection policy may bring some new opportunities for the medical workforce. Different medical specialties require different strengths (Harrold, Field & Gurwitz, 1999; Smetana et al., 2007). Our literature search did not identify any medical program that applied a differential admission policy based on forecast medical workforce needs. A recent study from New Zealand (Poole & Shulruf, 2013) identified that medical school applicants who had strong interest in general practice (GP) scored between 3-5 points lower on UMAT tests (p<.02) than those who did not have interest in GP. Interestingly, admission GPA and interview scores did not differ across those groups. Such findings demonstrate that applying an admission policy of 'one size suits all' may not be the most efficient in fulfilling society's needs. The Consensus statement and recommendations from the Ottawa 2010 Conference (Prideaux et al., 2011) alluded to this by recommending a focus on multi-method programmatic approaches which are fit for purpose while considering medical schools' social accountability in relation to social inclusion and workforce issues.
It is acknowledged that this study has some limitations. The major limitation was the availability of data, particularly the lack of information on the interviewers. Those data were not available and therefore it was impossible to measure inter-rater reliability. Another limitation is that the study included only students who have completed the program. No data from those who were not admitted to the program or dropped out were analysed. This is a common limitation in similar studies undertaken within a single institute and no remedy could be offered unless the measured outcome includes discontinuation (Callahan, Hojat, Veloski, Erdmann & Gonnella, 2010; Shulruf et al., 2012) or includes multi-institutional data where applicants who had not been admitted to one institute could be admitted to others (Kaur, Roberton & Glasgow, 2013).
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|Authors: Dr Colleen Ma is a Junior Doctor at St Vincent's Health Australia. She graduated from Sydney Medical School in 2015.|
Dr Peter Harris is Senior Lecturer in clinical education in the Office of Medical Education at UNSW. His interests are curriculum, clinical teacher development and assessment with a focus on programmatic assessment.
Dr Andrew Cole is Conjoint Associate Professor in Rehabilitation & Aged Care in the School of Public Health & Community Medicine at the University of New South Wales, Sydney, Australia, and Chief Medical Officer of HammondCare. Andrew's research interest is in development of healthcare and aged care services and their staff, with particular interests in student and staff selection, interdisciplinary training, and measurement of educational outcomes, and relating these to improving the provision of service to older and disabled people in need of care.
Professor Philip Jones was the Deputy Dean Education in the Faculty of Medicine, University of New South Wales, Sydney, Australia. His research interest is in educational assessment with a particular focus on the assessment of clinical competence. He is currently the Senior Assessment Consultant in the Office of the Deputy Vice Chancellor Education.
Dr Boaz Shulruf (corresponding author) is Associate Professor in Medical Education Research at University of New South Wales, Sydney, Australia. Boaz's research interest is in educational assessment, with particular focus upon topics related to setting of standard setting, student selection, and measurement of educational outcomes.
Please cite as: Ma, C., Harris, P., Cole, A., Jones, P. & Shulruf, B. (2016). Selection into medicine using interviews and other measures: Much remains to be learned. Issues in Educational Research, 26(4), 623-634. http://www.iier.org.au/iier26/ma.html