Why I want to be a Doctor

Asif Rajah

“The more we care for the happiness of others, the greater our own sense of well being becomes.”  The Medicine of Altruism: Dalai Lama

Introduction

The fundamental mission of any medical school is to select those individuals who possess the qualities and personality traits best suited to becoming a good doctor. The first part of this article takes a critical look at how United Kingdom (UK) medical schools select doctors, which can vary considerably, and asks whether it can be improved. The qualities needed to be a good doctor are discussed and asks whether work experience illustrates at least some of these personal qualities and should therefore be an essential prerequisite for applying to medical school. Such experience helps the student to make an informed career choice and exploring it at interview can reflect student motivation to study medicine. My experience in Ghana gave me the opportunity to find out at first hand if I had what it takes to become a doctor. The trip was totally inspirational. It made me realise that medicine is much more than being master of all sciences. In Ghana I saw many of the qualities one needs to be a doctor, how this contrasts with the current selection criteria in the UK, and made me wonder whether the UK system offers our society the best practice available.

Critique of UK medical school selection           

Applying to medical school has become increasingly competitive. Selection into medical schools is not an exact science but one assumes that best available evidence is being used. The present system almost certainly turns away students who would make good doctors and accepts some who are mediocre or poor or even drop out of medicine altogether. The selection criteria for entry into medicine have to be accurate. However, no system is fool proof and the number of drop-outs in UK training stands at 6.8 – 12%.^1,2,3 I believe that better selection criteria would reduce the drop-out rate and save personal distress among those who made an unwise choice. This makes economic sense. There is widespread agreement that we should select medical students on wider criteria than scores of academic success,^{4, 5} though in practice many medical schools have valued academic scores at the expense of other considerations.^{6, 7} A Levels alone should not be sufficient to gain a place at medical school. True communication calls for some shared life experiences and empathy with others. I believe that students who are totally absorbed in their studies to the exclusion of almost everything else are less likely to make good doctors. In one study, a ten-year follow-up after entry into medical school showed no correlation between academic score at entry and drop-out rate, but significant correlation between low interview scores and later drop-out.⁸ Reasons for drop-out were a variety of personal reasons including lack of motivation for study or for medicine. In a medical school that carefully evaluates applicants, empathy and motivation to be doctors were found to be particularly important in predicting both clinical and academic success.⁹

Another major study, looking at the dropping out from medical schools in the UK over a ten year period (1990-2000), ¹⁰ showed that drop-out rates increased during this period and concluded that the probability of dropping out of medical school is 20% lower for students with a parent who is a doctor. The authors comment that this may be the result of greater commitment or better preparation and insight before starting the course. Ethnic background of students was recorded only between 1998-2000. The study found that Indian females were around 1.9% less likely to drop out compared with white females, whereas Indian males were no different from white males. Other ethnic groups were less likely to drop-out by around 0.8%.  A concerning fact in this paper was the degree to which drop-out rates varied between different medical schools. No study to date has been done to find the reasons for these differences. Surely potential applicants need to be aware of these results. The differences could be accounted for by variable selection processes among the medical schools.¹¹ Some medical schools shortlist for interview only on predicted academic performance or the number of A* GCSEs or decide by the UK Clinical Aptitude Test (UKCAT) / BioMedical Admissions Test (BMAT) scores. Some use information presented in the candidate’s personal statement and referee’s report while others ignore this because of concern over bias. In some cases candidates fill in a supplementary questionnaire. Interviews vary in terms of length, panel composition, structure, content, and scoring methods. Some schools do not interview.

The commonest reasons cited in many papers for dropping out of medical school were because it is not for them, they found it boring, they did not like patients, the work environment was not what they want to spend their time on, or they did not like responsibility.¹² Essentially they had realised too late that Medicine was not for them. They had failed to find out what they were letting themselves in for before applying and the medical school had failed to pick this up. There is a strong argument for pooling resources so that applicants get one good assessment instead of four poor ones.                  

A levels, used for medical selection, do not indicate any personality attributes of the candidate and are affected by socio-economic bias. The UKCAT was introduced to level the playing fields. This test doesn’t examine acquired knowledge and candidates can’t be coached to pass, so in theory it should provide a fairer assessment of aptitude than A level grades. It was also thought that the various components of the UKCAT, namely verbal reasoning, quantitative reasoning, abstract reasoning, and decision making, could help to pick the students who have the personality attributes to make good doctors. Unfortunately, a recent paper suggests that the UKCAT does not provide any more assessment of aptitude than A levels.¹³ However, an inherent favourable bias towards students from well-off backgrounds or from grammar and independent schools was also found. Moreover the test does not compensate for talented candidates whose education has been affected by attending a poor school. Another paper looked at the predictive validity of the UKCAT.¹⁴ This showed that UKCAT scores did not predict Year 1 performance at two medical schools. Although early prediction is not the primary aim of the UKCAT, there is some cause for concern that the test failed to show even the small-to-moderate predictive power demonstrated by similar admission tools.   

There is no doubt that potential doctors must have enough intellectual capacity to do the job but they must also possess other important traits (Table 1):

What patients rate highly among the qualities of a good doctor are high levels of empathy and interpersonal skills.¹⁵ Personality traits such as conscientiousness have been positively associated with pre-clinical performance.¹⁶ 

The criteria being used more and more by admission tutors include the candidate’s insight into medicine including as evidenced from work experience.¹⁷Surprisingly, very little has been written on work experience and the value placed on it varies considerably between medical schools. Many would regard this experience as a prerequisite for entry into medical school. It enables a student to experience at first hand what he/she is letting him/herself in for. Some find the experience fascinating and challenging while others may find it is not for them. Work experience should not be seen as a hurdle to climb, but part of the decision-making process in determining whether medicine really is for you. I fear that another contributing factor to the increase in drop-out rates from medical schools is the increasing difficulty in obtaining work experience. Gone are the days when students could join theatre staff and watch an exciting operation or shadow doctors in Accident and Emergency (A&E). Useful work experience is so important and it is becoming harder and harder to get, but is still possible. Therefore considerable desire, commitment and motivation by the student are required to obtain it. The work does not need to be medically related, but work experience in any care setting is essential. These placements can be used to illustrate at least some of the personal qualities that are sought after in a good doctor including: appreciation of the communication skills required of a doctor; a thorough awareness of the realities of medicine and the National Health Service (NHS); an understanding of teamwork; an ability to balance commitments; and observation of the caring and compassionate nature of the doctors. Furthermore, as demonstrated in general practice,¹⁸ personal experiences can have a highly positive influence on an individual’s attitude to a particular speciality. Encouraging school students to experience general practice would therefore not only increase their awareness of the life to which they are about to commit, but could aid recruitment to general practice as a speciality.

My Ghana Experience

I decided that, as part of my work experience, I would go to Ghana with a charity organisation (Motec UK Life). The reason was not to impress medical admissions tutors, but to discover if I had what it takes to become a doctor. I realised how comfortably we live in our small bubble, with little appreciation of what goes on in the rest of the world. Ghana is a third world country, which not only has great poverty and malnutrition but also has many deadly diseases such as Acquired Immunodeficiency Syndrome (AIDS)/Human Immunodeficiency Virus (HIV), malaria, hepatitis, typhoid and sickle cell disease. My trip was demanding as I was stripped of my luxuries and removed from my comfort zone, but it helped me to understand the real values in life through helping the most needy and vulnerable people. I felt the suffering and the pain they went through, day in and day out, but knew that making even the slightest difference to their lives motivated me and enabled me to persevere through my time there.

One of the hospitals we stayedwas Nkawkaw, which was in the middle of a shantytown with houses made of metal sheets. Yet, despite the presence of great poverty and disease, I did not find a single person who was not extremely kind and welcoming and always smiling. It made me think of the contrasting situation back home in the UK where people were relatively well off, and yet so unhappy. I spoke to as many people as possible, not realising that I was developing my people- and communication-skills. I played football with the children and made them smile. I was able to visit the AIDS/HIV clinic and gained a first-hand account of how this devastating disease was controlled and dealt with in a third-world country. The pain, grief and suffering were immense and difficult to comprehend unless one was actually there witnessing it. AIDS here hurts everyone, but children are always the most vulnerable. The children were born with HIV from their mothers, or infected through breast milk, or in the past infected by unsafe medical treatments. They were often orphaned and destitute, having to build their own homes, grow their own food, and care for younger brothers and sisters. That is the cruel reality.

Equally heartbreaking was seeing so many people in the HIV clinic who could

not afford the anti-retroviral drug that would improve the quality and duration of life. This feeling of helplessness motivated me even further to pursue a career in medicine in order to help people at their most vulnerable. On this trip I was greatly impressed by the dedication, commitment and professionalism shown by the doctors in difficult situations. I saw doctors working with little supervision and little equipment, and yet they seemed confident, well organised, and adapted themselves well to the conditions. Their enthusiasm and compassion never waned despite working long hours.

I saw many types of operation being performed including joint replacements, hernia repairs and caesarean sections. On one particular day, I observed the team performing many knee and hip joint replacements. The deformities of the joints were much more severe than seen in the UK. I enjoyed and appreciated the skills of the orthopaedic surgeons in carrying out these operations, which were being done under spinal anaesthesia, and so I was able to talk to the patients and comfort them. Throughout the day, after seeing many operations, I did not flinch or feel queasy at the sight, and this further encouraged me to believe that I could handle a career in medicine. On watching the caesarean sections, the excitement of bringing new life into the world was overwhelming. Seeing another baby being born with severe hydrocephalus marred this. No treatment facilities for this condition were available for hundreds of miles and the baby was too ill to be transferred such a large distance. I witnessed the doctors conveying the heartbreaking news to the family with compassion. It became clear to me that there are negative aspects to this career. There is a great deal of emotion and stress to cope with in such circumstances but I believe that, given training, I would be mentally stronger to take control of these situations.

I was always allowed to follow the doctors on their ward rounds, and was encouraged to ask questions and make comments, so that I often felt that I was being treated as a medical student, which was strange in some ways but also very gratifying. On this trip I was involved in teaching and in helping to set up a workshop, which lasted for a whole day for doctors from all over Ghana. This involved lectures as well as demonstrating the latest surgical and theatre equipment. I was impressed by the teamwork and organisation shown by the group. The communication skills of the group had to be of the highest quality in order to get the message across. I found that teaching about the devastating effects of HIV, in a local school in Ghana, was particularly challenging as some of the students before me were sufferers and so I found it difficult to look them in the eye, knowing that although they were being taught the safety precautions, many did not have much of a future. This reinforced my feeling of helplessness but, although this situation was heartbreaking, I remained enthusiastic for the children, to keep their morale high in order to prepare them for their inevitable future.

Conclusion    

My trip was totally inspirational. It made me realise that medicine is much more than being a master of all sciences. In Ghana I observed in doctors the real passion and drive needed for medicine as well as many other essential qualities I believed doctors needed. This contrasts with the current selection criteria in the UK; sadly we are missing out on too many good doctors because of our obsession with grades rather than looking for real qualities that are going to make a difference to our patients.I discovered that seeing the immense suffering, and the close bond of doctors and patients in an entirely different social and economic context, helped me to evaluate and shape my own emotions and personal values. My motivation in wanting to become a doctor has increased tremendously since this trip. My trip to Ghana also inspired me to create a medical journal in my school as a fund-raising initiative. I brought together a group of fellow students to write articles about common teenage problems (teenage drinking, anorexia, obsessive compulsive disorder (OCD), stress, smoking, sexually transmitted diseases (STDs)) as well as articles on euthanasia and assisted suicide, stem cell research and the NHS. I wrote about my personal experiences in Ghana in addition to editing and publishing the school journal. All the funds raised from the school medical journal will be going to the HIV victims in Ghana.

References

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