Posted on July 29, 2020

Medical School: Who Gets In and Why

Martin Van Beynen, Stuff, May 16 2020

Harry* is a bright and social 18-year-old who was always passionate about becoming a doctor. He was brought up in a well-off home by professional parents but family issues meant life was no bed of roses.

He completed the first year health science course at the University of Otago last year with an A+ average grade and also managed a top score in the required University Clinical Aptitude Test (UCAT). He was “absolutely gutted” and so were his parents when he was not accepted into Otago Medical School.

Incredibly, his academic results were not good enough. His disappointment was not helped by students with far lower grades and poorer UCAT results being accepted under special categories including Māori and Pasifika, rural and low socioeconomic.

Harry, of European descent, was not alone in his disappointment. Other European and Asian students faced similar setbacks. At least one family has threatened legal action.

It’s a touchy subject. Few would disagree that elite professions like medicine should reflect the socio-demographic make-up of the general population. Evidence suggests that doctors who have more things in common with their patients will be more empathetic and have more success in diagnosis and getting patients to follow recommended treatments.

But have the medical schools gone too far in trying to redress the balance by squeezing out a growing number of general students? And have entry requirements become too easy to manipulate?

For a long time the medical school intake from some sections of society, notably Māori and Pasifika, was much lower than their proportion of the population.

Only a decade ago, a mere 7.6 per cent of new domestic medical students at Otago identified as Māori and 2.7 per cent as Pasifika. The ramifications show up in the current medical workforce in which only 3.4 per cent are Māori and 1.8 per cent Pasifika. Their respective proportions of the total population are about 15 per cent and 8 per cent.

However, a big change was seen after more robust affirmative action policies were implemented at medical schools after 2010. By 2016 Māori and Pasifika students entering Otago Medical School had increased by 179 per cent — Māori were about 16 per cent of domestic students and Pasifika students counted for 5.6 per cent.

One group, however, showed little improvement. In 2010 only 2.4 per cent of Otago medical students had attended a secondary school with a socioeconomic decile of less than four.

By 2016, the percentage had grown to 4.7 per cent.

Wiremu*, now training to be a general practitioner, was one of those students who benefited from affirmative policies designed to increase Māori in the medical workforce. A product of kohanga reo and a low decile Māori immersion primary school, he had a flair for science and wanted to work with people.

His low decile high school had not prepared him well for the highly competitive intermediate year at Auckland University, but he worked “his guts out” and was accepted into its medical school.

His life experience in different sections of the community, including gang families, enables him to relate to patients better than a book-smart, nerdy type from a privileged background, he says.

As a junior doctor, he was often able to get through to certain Māori patients just by saying his name.

“They suddenly realised there was a Māori person on the other side. You just have to see their face when I say ‘Kia Ora I’m Wiremu’ — some of them go, ‘True Bro I thought you were Pākehā’. In certain circumstances we will have a chat in Māori and obviously that’s useful. Then we have a brief introduction period, you get to know the other person. Pronouncing someone’s name correctly is massive.”

He says getting more Māori into medical schools won’t fix the inequities in health outcomes but it will help.

“Some people can’t see the difference between equity and equality. I’ve learned so much about why Māori are the way we are today. Sometimes you have to direct more resources to some people for outcomes to be equal.”

Some students manipulate the system, but they are a small minority, he says.

For this year’s intake, Otago had 202 places available for first year students entering from its intermediate year. (Otago does not take first year students from other universities).

Of those, 120 were given to those entering under a raft of categories.

Of those, 58 were Māori, 20 were Pasifika, 1 Māori/Pasifika and 29 entered through the rural gate.  Eleven students went in under the low socio-economic category and one under a new refugee category. That left only 82 general entry places (40 per cent).

As well as the 202 places for first year students, Otago medical school fills another 80 places with graduates. Overall for 2020, Māori and Pasifika make up 32 per cent of students starting at the school, while 14 per cent have rural backgrounds, 4 per cent low socioeconomic, and 1 per cent refugee.

Auckland medical school shows a similar pattern. For the 2020 year it had 185 places for first year health science or bio-medicine students. Māori and Pasifika took up 52 places, rural got 25, disabled 2, low socioeconomic 5 and refugee 1. That left 101 places (55 per cent) for general entry students.

Looking at percentages for the 2020 intake, Māori and Pasifika students took up nearly 40 per cent of the places at Otago for first year health science students and 28.1 per cent of the total places for first year students at Auckland.

At Otago that meant general entry students had to get, as one student put it, “ludicrously” high grades to be accepted. In fact candidates needed at least a 94 per cent average mark for their seven papers to get an offer.

The father of a European student who missed out on this year’s intake at Otago despite stellar marks says he can understand why district health boards and central government want the medical workforce to be representative.

“Where I have difficulty is reconciling that with students who would make wonderful doctors and have extremely high marks being lost to the medical profession.”

The average mark for the sub-category entrants is not held by the university and it was not able to provide it before deadline.

However, sub-category entrants must get a 70 per cent minimum for each paper. Those who achieve an average of at least 70 per cent can be admitted with individual subject marks under 70 per cent so long as the admissions committee is satisfied about their academic ability to complete the programme.

At Otago, a candidate’s overall UCAT score does not count in the assessment by the admissions committee but general candidates must score in the top 80th per cent of results for verbal reasoning and in the top 90th per cent for situational judgement.

Critics say the low thresholds are farcical because no-one with good enough grades to be a doctor will go below the thresholds. The university says it uses the scores when choosing between candidates who are otherwise very similar.

The thresholds do not apply to Māori and Pasifika candidates. They are assessed “by reference to specific material provided by applicants about their engagement with their communities”.

In Auckland, admission is based on an interview (25 per cent), first year marks (60 per cent), and the UCAT result (15 per cent).

Otago University cannot say how many Māori and Pasifika students would have met the grades required by successful general applicants in this year’s intake, but Professor Paul Brunton,​ Pro-Vice-Chancellor, Health Sciences says if affirmative action had not been undertaken both Māori and Pasifika students would have been significantly under-represented in this year’s class compared with the make-up of New Zealand society.

Does the medical school have a cap on sub-category students?

Brunton says the Education Act states affirmative action places can only be offered where a relevant category of applicant would otherwise be under-represented in the medical programme.

“To date, the number of sub-category students we have been able to admit continues to be well below the needs of the health workforce.”

The Government funds 55 rural places at each of the universities of Otago and Auckland, he says.

Medical school applicants at Otago need to meet a number of requirements to be successful under the various subcategories.

The Māori and Pasifika category requires students to verify their ancestry by, for instance, an iwi registration document or, for Pasifika, a community leader’s endorsement.

Applicants under the rural category can hail from places such as Helensville and Pukekohe near Auckland, Lincoln and Rangiora on the outskirts of Christchurch and Featherston, Greytown and Martinborough near Wellington. They also include Queenstown Bay, Frankton, Cromwell and Wānaka.

Under the low socioeconomic category, candidates must have attended a decile one to three secondary school during Years 11, 12 and 13. Parental income is not considered.

In order to apply under the refugee sub-category, candidates for admission must have either been granted refugee status in New Zealand, or have parents/primary guardian(s) who have been granted refugee status.

Affirmative action is always controversial. Critics say it breeds resentment, stigmatises those students who avail themselves of the special categories and lowers the standards and prestige of an institution.

One of the objections is that it can give an unfair advantage to privileged students who actually have little in common with the minorities with whom they claim to have some genetic link. In other words, a Māori student from a relatively privileged home could be admitted over a European or Filipino student from a poorer home despite their better marks.

During his first presidential campaign, Barack Obama, said his two daughters “who have had a pretty good deal” should not benefit from affirmative action, particularly when they were competing with poor white students.

Some claim the system is open to abuse by wealthy students with a distant relative who is Māori or Pasifika. .

“These kids are attending private schools and are being allowed into medical school without achieving like the others must. It is not achieving the aims of helping Māori,” says one parent.

Another parent asked if patients were better served by doctors who were “empathetic and more academic” regardless of ethnicity.

Professor Peter Crampton,​ whose parents immigrated from England to New Zealand when he was 12, and who worked as a GP in Porirua, near Wellington, is one of the main architects of the Mirror on Society policy at Otago University.

A former dean of the Otago Medical School and now professor of public health in Kōhatu – Centre for Hauora Māori,​ he doesn’t regard the issues around special entry into medical school as highly sensitive.

He says the purpose of the university is to produce a health workforce that meets the needs of society.

Doctors who belong to a rural or ethnic minority are more likely to serve those communities and provide the care that is “not like the care provided by others”.

He draws parallels to the dearth of female doctors in the medical workforce in previous decades.

“It was thought men do that job very well and although we think of that as quaint and old fashioned, it’s not that long ago.”

Māori doctors treating Māori patients could lead to better outcomes for multiple reasons, both interpersonal and because of the way systems are set up, he says.

He agrees no guarantee exists that students admitted under the sub-categories will go on to work in those areas and says it’s too early to tell whether the special entry scheme is helping to improve outcomes for Māori and Pacific patients.

“We don’t put on any of our students, any of them, any sort of moral weight to do a particular thing.”

No affirmative system will have perfect rules and perfect compliance, he says. Defining a student’s rural credentials sounded simple but coming up with a transparent and fair system was tricky.

He doesn’t accept that students being admitted under the Māori or Pasifika sub-categories, who look European and have suffered none of the deprivations of low socioeconomic Māori or Pasifika, should not be allowed to take advantage of the easier route into medical school.

Nor does he agree that if Māori or Pasifika patients are to benefit from an affinity with the doctor, the doctor should look a bit like them.

“If you are saying it would help if you look Māori I reject your framing entirely. Would it help if you looked gay?

“We want the health workforce to broadly reflect the communities being served so that when you come into contact with the health force, whatever that touch point might be, there is some chance that system has been influenced by health professionals who share your world view, your ethnic affiliation or your gender and you meet a health professional who you might identify with and makes you feel at home within that system.”

He finds the allegation that European-looking students from well-off homes with slight Māori or Pacific ancestry are rorting the system hard to get a handle on.

‘You’re conjuring up a phenomenon that encapsulates a world view that I would like to deconstruct.”

He says Māori and Pacific students have a different socio-economic profile to general entry students although it is true the research in 2016 showed little movement in admitting more students from lower decile schools.

“Any system of exclusion or inclusion is going to run into its difficulties at the margins with definitions. It’s not perfect or watertight. Does that discredit the system, do we throw out a system because some people might not be eligible? The health workforce needs more Māori-Pacific students. We have not specified if they be rich or poor.”

Although Māori and Pasifika students coming through the intermediate year pathway into Otago medical school were exceeding their proportion of the general population, the proportion of those groups in the medical workforce “realistically will not catch up not in our lifetimes’’.

The marks required by general entry students was very high but people needed to remember “why are we are doing this”.

“The high marks phenomenon is an artefact of selection processes. If I ask people, ‘what do you like to see in your doctor?’ they say good communicator, honesty, compassion, altruism, along those lines. They never say we want them to have had straight As at school and through university.

“We can’t easily measure what we need to measure. Medicine does not need society’s brightest students, it benefits from them but doesn’t need them. That is an artefact of career aspirations occurring over decades.

“We select people to meet certain characteristics — we select them for things we can’t teach. It is a demanding and difficult course and it needs people who are bright, capable and highly motivated. That is not the same as saying we need the top academic students. We don’t have to have them.”

Medical schools were sick of using marks.

He believed the UCAT thresholds were meaningful and helped exclude candidates who could be brilliant lab scientists but no good at face-to-face medicine.

So what would he say to Harry with his tremendous marks and who had his heart set on medicine?

“I understand their bitter disappointment and in my counselling I strongly encourage them to explore other options. So many young people base their sense of their identity and ambition on a particular academic pathway and feel quite devastated when that is not achieved. The world is full of amazing career opportunities for the academically capable.”

Does he understand their resentment?

“That’s where I come back to the policy and its intention. The policies are clear. To me personally and many colleagues in the university it’s completely unacceptable that we have a health workforce devoid of Māori. We are rectifying that situation. The problem is that high marks have become the passport and because I’ve got high marks I should be a doctor.”

*Not real names.