We often hear nostalgic reminiscences about great doctors from yesteryear, who managed to enter the medical school with A Level results of just four simple (S) passes. There is no doubt that many doctors who entered medical school with just four S passes 50 years ago had performed exceptionally well. What is erroneous is trying [...]

Sunday Times 2

What should be the minimum grades to study medicine?


We often hear nostalgic reminiscences about great doctors from yesteryear, who managed to enter the medical school with A Level results of just four simple (S) passes. There is no doubt that many doctors who entered medical school with just four S passes 50 years ago had performed exceptionally well. What is erroneous is trying to justify three simple passes as the current minimum entry criteria based on that argument. It is similar to the fact that what you could do with Rs.100 fifty years ago, cannot be done with Rs.100 now.

What exactly has happened over the years? An analytical look at the historical developments will put us in the correct perspective. As far back as 1965, the minimum aggregate to enter a medical school in Sri Lanka was 145 out of a total of 400 (ie. average of 36.5 marks. The pass score was 40 marks even during that period). This was gradually increased with time. In 1983, it was 170 out of 400. The Universities Act no 16 of 1978 stipulated four simple passes as the minimum eligibility criteria for university entrance based on these figures.

However, since then, a progressive inflation of grades obtained by students was observed. (ie. the grades obtained by students in successive years have become progressively higher). This decade has witnessed exponential grade inflation with over 500 students obtaining A grades for all three subjects in 2016 in the Biology stream.

The reasons for this grade inflation may be at least four fold.

1. When the same examination has been conducted for a number of years, the later generations have more opportunity to prepare for the examination by studying the past papers.
2. The high demand and competition for medicine.
3. Successive generations of students (supported by the theory of evolution) should be performing better than their previous generations.
4. Over the years, private tuition and school-level coaching of the students for A Levels has increased exponentially, and this has also contributed to the inflation of results.

Meanwhile, in early 2000, two major technical changes in the structure and pass or fail criteria of the A Level examination had occurred. In 2003, the number of subjects for the A Level examination was brought down from four to three. A new grading system was introduced in 2009 and the pass mark of the A Level subjects was brought down to 35. In the biology stream alone, these two technical changes has led to an almost 100% increase of the number of students who pass the A Level examination within a time span of less than a decade (from 11, 000 to over 20, 000). This misleading numerical anomaly cannot be attributed to any meaningful improvement in the quality of education or the performance of students. These developments have made the minimum eligibility criteria of three simple passes redundant and outdated when it comes to selection of students for studying medicine in Sri Lanka.

In 2009, the Sri Lanka Medical Council (SLMC) stipulated minimum entry grades of 2 Cs and 1 S. This criteria was derived considering the baseline performance of students during the 2006-2009 period.

However, the last 10 years have witnessed a rapid grade inflation in the Advanced Level Biology stream. Therefore, when considering the current situation, what should be the minimum eligibility criteria for medicine for Sri Lankan students?

Medical education all over the world is designed to select the most able students in a given generation. The predictive validity of a selection examination is the most important determining factor when selecting the best out of a cohort of students.

Worldwide evidence show that academic merit demonstrated during selection exams is the best predictor of medical school performance compared to other methods such as interviews, aptitude tests and letters of recommendation. Evidence from a large scale meta-analysis conducted in the UK suggest that A Level performance is an excellent predictor of performance along the continuum of medical education starting from undergraduate to entry in to the specialist register of the GMC. According to another meta-analysis on US medical school entrance, the biological sciences subset of the MCAT was the best predictor of medical school performance. In Sri Lanka, a study conducted at the Faculty of Medicine, Colombo showed a 0.4 correlation between the z-score and the medical school performance (In statistical terms, 0.4 is a moderately high correlation.)

The decision regarding students’ selection should depend on the baseline performance applicable to that population. The current baseline performance of those who are selected to follow medicine is very high particularly due to grade inflation. For example, in 2016, over 580 students obtained 3 As at the GCE A Level Biology stream. With such grade inflation, the rational and logical measure should be to make the bar higher. For example, UK is now considering A+ or A++ as minimum criteria.

For the current Sri Lankan Biology stream applicants, 3 Bs could be argued as the baseline for selection to follow medicine,

1. Even within the underprivileged districts, those who are getting these low grades are a very small minority of outliers out of a total of over 1,300 students selected for medicine. For example in 2014, 30 students from Nuwara Eliya had 3Bs and above and 32 students were selected for medicine, ie. only two students had got grades below 3 Bs.

2. Even the grades of those who have been selected based on the lowest Z-scores have been on the rise and have approached 3 Bs.
2010 C C S
2011 C S B
2012 C C C
2013 C C B
2014 C B B
2015 B B B

3. The extremely low dropout rate of Sri Lankan medical students (less than 1%) also suggests that the selection method has been effective in selecting those who are capable of completing the medical course.
4. Only 50% of the 3,000 students who got 3 Bs and above succeed in securing medical school admission. Therefore, even in the unlikely scenario the number of seats to study medicine in Sri Lanka is doubled, 3 Bs could remain the minimum eligibility criteria as far as the grades are concerned.
5. Since the current lowest Z-score cutoffs are comparable with 3 Bs (or equivalent), this approach will ensure fairness to both high performers and students from under-privileged backgrounds.

Therefore, 3 Bs (or equivalent) as the minimum required entry criteria provide a rational and fair mid-point allowing selection of best students to study medicine while not being restrictive. (The writer is an expert on medical education with local and international experience and has conducted extensive research.)

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