first person:

These days you'll need a sympathetic bank manager if you want to study medicine. The books alone cost£1,200. A public school background also helps.

Every year 4,500 students enter one of the 25 UK medical schools but it is becoming more difficult to gain a place. Many schools require three A grades at A-level (or equivalent in Scotland), at least two in science subjects.

The lowest offer is currently A, B, B. Five years ago admissions departments were more flexible and it was possible to gain a place with three Cs. Now most admissions departments cannot cope with the large number of applicants.

The easiest way to reduce applicant numbers is to increase the grades - which in turn produces less diverse applicants.

Achieving top grades if you come from an inner-city school which is bottom of the league tables is virtually impossible. Medical schools are reluctant to lower 'standards' of entry so places are disproportionately filled by young people who have had the benefit of education in the independent sector.

Medical schools have been criticised for discriminatory practice against ethnic minority applicants, and research supports this view.1,2.

I attended a school which was one of the worst offenders, according to this research. As a final-year medical student I sat in on the interviews and saw the system work against one individual in a way I felt was unfair. Many medical schools are in the process of reviewing their admissions procedures.

Some schools are inviting people from the local community to be part of the interview panel. There should be flexibility in the system to make some students lower offers since you don't have to be particularly academic to complete a medical degree. Other skills such as good communication, learning style and commitment are also important.

Few resources go into selecting our future doctors. No industry would invest so little in selecting people that cost so much to train.

Training offered at different schools varies. The General Medical Council criticised the traditional split between the pre-clinical and clinical parts of the curriculum and urged schools to encourage self-learning, critical evaluation and earlier patient contact.3

Places such as Manchester Medical School have radically altered their curriculum. They have changed their teaching methods from didactic, lecture- based, to problem-based small-group learning. I am convinced that such schools will produce doctors keen to pursue evidence-based medicine.

My end-of-term exams were extremely stressful and the exam timetabling particularly harsh. We sat five separate exams, each covering a vast topic area without a day's break.

We spent two weeks out in the community. I undertook a placement in an area with substantial Somali and Bangladeshi populations. I began to appreciate some of their health and social needs. For many students this module was their first contact with a deprived inner-city community.

Our last term was spent studying sociology and psychology and undertaking project work.

That summer was our last long break, an opportunity to earn funds and go on holiday. We returned refreshed and excited at the prospect of our first proper contact with patients.

During this period we attended a course on ethics and law. Understanding ethics is a crucial part of becoming a good doctor. In these sessions we discussed patients' rights and the duty of care, and covered issues such as consent, confidentiality, rationing and complaint handling. We also studied medical case law.

The clinical part of the training is an intense period. There are great pressures on the timetable with so many specialties and skills to be learned. During a three-year period we rotated through various medical and surgical areas, accident and emergency, and psychiatry.

It is a privilege to be party to so many others' life experiences. I remember how emotional I felt as I delivered my first baby, how isolated it felt out in the community as I accompanied a community psychiatric nurse on home visits to patients with schizophrenia.

Medical students tend to be particularly apprehensive about dealing with dying patients and breaking bad news. I shadowed some excellent healthcare professionals and benefited a great deal from their wisdom. But there were some notable gaps in learning.

Only one day was timetabled on the subject of learning disability, but the lecturer forgot to turn up.

The trend towards specialisation of medical and surgical firms meant that students did not always get the breadth of experience that their predecessors enjoyed. My main experience while a surgical student was on firms specialising in bowel cancer. The winter crisis, Christmas ward closures and the slowdown of elective surgical work all reduced our exposure to patients and thus experience. Decisions to close beds or reduce elective work are not taken lightly, but the consequences for medical education are rarely considered.

Teaching is a major role for the NHS and it is responsible for training 20,000 future doctors. Trusts are well rewarded for their contribution. Most of this money is concentrated in teaching hospitals, but increasingly placements are in district general hospitals or in the community. Generally, we gained much better general experience and teaching in district general hospitals. More and more teaching occurs in the district general hospital setting and it is important that they are adequately funded for this.

I attended only one outpatient clinic in three years that had reduced patient numbers. Outpatient teaching is a key part of clinical training, and service increment for teaching money is supposed to support this activity. Instead, our presence and desire to learn put increased pressure on the clinic and its staff.

Most clinical training takes place in a hospital setting. Approximately two-thirds of medical students become GPs, yet during my training only three weeks of the three-year clinical training period was formally allocated to general practice. How can students realistically assess a career in general practice with so little exposure? It is not surprising that by the end of their training, most medical students favour hospital medicine.

Yet there is a crisis in GP recruitment. There are, however, some schools, such as Southampton Medical School, which have courses that are more community- oriented. With a trend towards medical students going on hospital placements earlier in the course, an increase in medical student numbers, shorter lengths of stay and reduced bed numbers, the need for primary care-based training is increasing. General practice offers much potential. However, teaching in general practice should not be viewed as a cheap option and needs to be adequately funded, not left to rely on the goodwill of the same few GPs.

Our final year was spent shadowing house officers on senior medical and surgical firms. We undertook a pathology dissertation, clinical pharmacology projects and sat final exams in pathology. We also undertook special study modules. These present students with the chance to pursue their own interests. Medical jobs for life are becoming a thing of the past and future doctors may well develop portfolio careers with interests within and outside medicine.

The final year also included elective periods in which students have the opportunity to gain additional medical experience - often abroad. Before the elective periods, we applied for house jobs.

The house officer grade is the transition from student to doctor. All doctors need to undertake jobs in both medical and surgical specialties to become fully registered with the GMC.

Some medical schools have a matching scheme where both students and consultants state their preferences and a computer generates the best matches for the greatest number. It is meant to be a fair system, but inevitably it is undermined. Consultants tend to pick their preferred students before the process has formally begun and the school ensures that powerful consultants get their first choices. There is little equality of opportunity, which surprised me since house officers hold formal trust contracts. Students get their first taster of how to get on in medicine.

The last hurdle was finals: five three-hour written papers in medicine, surgery, clinical pharmacology, obstetrics and gynaecology covering the past three years' work. We then had a clinical long case - in which a student presents a patient's history to a consultant - an obstetric and gynaecology case and sat a three-hour objective-structured clinical examination.

Results were out a week after the last exam. Everyone waited expectantly. The change-over date for doctors in the NHS, 2 August, was looming. Despite the five-year training period we still felt ill-prepared to become house officers.

Kate Adams is an accident and emergency senior house officer at the Royal London/Homerton Hospital.

REFERENCES

1 Esmail A, Nelson P, Primarolo D, Toma T. Acceptance into medical school and racial discrimination. BMJ 1995; 310

(501-2).

2 McManus I. Factors affecting likelihood of applicants being offered a place in medical schools in the UK in 1996 & 1997: retrospective study. BMJ 317: 1,111 (P).

3 General Medical Council. Tomorrow's Doctors. 1993.