It was impossible to read HSJ's recent coverage of medical school selection and poorly performing doctors without a very strong sense of history repeating itself.1,2
The year that springs to mind is 1939, when the Foreign Office complained that the existing method of selection by academic examination and interview was producing too many people who failed in their jobs.
Reactions then were very similar to those expressed this year.2 But the situation at that time was not really so bad - the ineffective simply dropped out.
Most pervasive and pernicious was the belief in the inspired amateur. Many interviewers claimed to have an innate understanding of what the job required without being able to offer any kind of definition.
Further, one was given to understand that they possessed an ability to penetrate to the essential person behind the interview appearance. Then - as now - there was no evidence to support them and a great deal to discredit them. But interviewers of this type still thrive today and are highly damaging.
Realism
Efficient selection demands realism. The objective is to reduce the error rate to a significant degree, and to achieve this several points must be considered.
People are a mixture of strengths and weaknesses. It is far too easy to set impossibly high requirements. In any profession, even the best people can be seen to have weaknesses - sometimes to a serious degree.
People do not come ready-made with all the qualities needed - they can adapt and grow, and assessors will often be looking for latent powers.
There are few absolute requirements. A well-known menace in selection is the assessor who declares: 'The one thing I always look for is...'
Integrity, mental and physical health are clearly crucial, but essentially one is looking for a balance of qualities.
There is an urgent need for close professional examination of what doctors actually do. The views of practitioners are invaluable, but they need to be placed in perspective. People engaged in a profession have been shown to place undue emphasis on personal experience and the more dramatic aspects of the job, and to lack the overall view offered by an experienced outsider.
Individual experience can also vary. One GP observed that he had no idea what happened in his colleagues' consulting rooms. In this situation there is an obvious need to take a representative sample of a range of practitioners and their work.
Such investigations notoriously result in a job description which demands an impossible person. A description of the qualities required for a postman or storekeeper can easily read like a blend of Tarzan and Einstein. The essential point is that these descriptions must be read as a list of relevant qualities and not one of absolute requirements.
It would be tedious to insert 'adequately' or 'competently' in front of every description. But such a description is a vital tool for selection. But like any other, it must be employed with a proper understanding of its use and limitations.
The human mind can take on board no more than about a dozen factors in reaching a decision. But these must be taken as broad headings only, to be used in conjunction with a detailed understanding of what the job requires and the individual candidate's strengths and weaknesses.
The qualities required
These cover intellectual, interpersonal and personal qualities. As far as the intellect is concerned there is one established fact and any number of superstitions. The fact is that the measured intelligence of doctors in the US is higher than that of any other profession, with the exception of mathematicians.
Legend has it that people who are very clever must be handicapped in other ways. But research has demonstrated that intelligent people tend to lead better-adjusted lives than those who are not.
Given the speed at which medicine is developing, there is an obvious requirement for people who can assess new developments quickly and accurately and apply them in a relevant way.
Outsiders who make broad claims that selectors place too much emphasis on academic ability at the expense of personal qualities need to reconsider.
One quality that is called for in any profession is judgement: what will work and what will not, what people can accept and what they cannot handle, when to persist and when to give up. Doctors constantly need to make these sorts of decisions in a broad range of situations, and judgement is clearly necessary.
It is also important to be realistic about personal qualities. Patient groups make much of the need for empathy in doctors, but research has demonstrated that doctors who get too involved with their patients suffer from unacceptable levels of stress. The ways in which empathy and detachment should best be combined ought to be made explicit.
Ability to communicate is a well-recognised requirement and must include eliciting the facts from inarticulate, muddled or fearful patients and the ability to get across to them what they need to understand and do.
One is looking for potential, not final achievement. Assessors need to understand what fundamental qualities people must possess and what they can acquire or be taught. It is always gratifying when one comes across a candidate with highly developed communication skills, but these can be taught to most people who are not unduly self-centred or aggressive.
Under 'personal' one looks for such qualities as stamina, energy and staying power. But it should be emphasised that these can be badly misjudged from a candidate's behaviour at interview.
Some who appear highly energetic and forceful merely possess dramatic skills. Some who appear slow or even lifeless can be highly energetic. Accurate assessment is possible, but it requires time and skill.
Even more complicated is the question of stress resistance. No-one would deny that the doctor's job is one of high stress, or that multiple misfortunes may overcome the most resilient of people. But the principal cause of stress in any job is that the person doing it does not have the right personality for it.
A major reason for seeking to improve selection is that stress among doctors - as measured by lack of job satisfaction, drug and alcohol abuse, suicide and the like - is at a higher level than in comparable professions.3 This is clearly serious. A less-than-competent GP, for example, can adversely affect the lives of some 2,000-3,000 people.
Stress is not a simple matter. Situations which some find stressful, others find stimulating and even rewarding. So a closer understanding of the sort of stresses involved, the sort of person who can deal with them and the tactics they employ to cope is needed.
Assessment procedures
Procedures for assessing these qualities are long-standing. The army produced a selection system at high speed in 1942. It produced an immediate improvement in those selected for officer training and has been copied in many countries.
Immediately after the war, the civil service selection board was set up to assess candidates for the fast streams of the home and diplomatic services. A follow-up study after 25 years showed that the system was highly successful. There was a correlation of 0.666 between prediction and performance.4
It is difficult to think of a profession that has not adopted a similar procedure. For many years this was known as the extended interview system. But for some time now the more obscure American term 'assessment centre' has been used. Some will object that medicine is different, but this is exactly why a skilled professional study of the work that doctors do is necessary.
Systems analysis
Making every conceivable allowance for the unique features of a medical career, there is no compelling reason to suppose that medicine is the only one for which systematic selection is impossible. But an immediate adaptation of existing techniques would be inappropriate and could be disastrous. One medical school spent a great deal of money on a battery of psychometric tests, which produced worse results than its existing procedure. Any procedure must be designed to meet the specific requirements of the job.
Medicine is uniquely problematic in recruiting people at 18 or 19 - one must envy those countries where medicine is a postgraduate career. If there is one thing to say in favour of university courses, it is that most people find them a maturing experience.
Selecting students after graduation is easier than assessing A-level students. It would be sensible to devise a new system with mature applicants. Existing methods which depend on candidates' ability to present themselves at interview emphasise social skills at the expense of more fundamental qualities.
Conclusions
Effective selection is neither simple nor cheap. But it is easy to point to the far higher price paid for ineffective selection: the cost of wasted training on those who drop out, the personal cost to those who discover too late that they have chosen the wrong profession, the cost to patients of ineffective doctors.
The problem is to get those who control budgets to weigh the costs of effective and ineffective selection against each other - they are currently perceived as involving different sorts of money.
The connection is not admitted. We must hope to find someone able to equate the two who has the power to do something about it. Once this has been achieved the remaining problems can be dealt with.
Jim Dukes is former directing psychologist at the Home Office.
REFERENCES
1 Moore W. 'Back from the brink'. HSJ 1999; 109 (5651): 24-27.
2 Crail M. 'Which doctors?' HSJ 1999; 109 (5643): 10-11.
3 Sutherland and Cooper. Understanding stress. Chapman and Hall, 1990
4 Anstey. A 30-year follow-up of the CSSB procedure with lesson for the future. J of Occupational Psychology 1977; 50: 149-159
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