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Now in Swiss Medical Weekly, R. Krings et al. [1] present an article studying the value of high schools grades (Matura) in combination with the Swiss Aptitude Test in Medicine (EMS) to predict academic performance during the first three years of medical school in their own institution, using four cohorts. This numerus clausus approach to selecting candidates is used by the majority of medical schools in Switzerland, with a few others using the results of the first year of studying medicine, with or without a ranking competition, in order to select medical students without limiting initial admission to the university if basic criteria are fulfilled. By using hierarchical regression analysis, Krings et al. found that high-school grades predicted the results of the first three years of medical school, whereas the EMS scores added no additional prediction every time Matura grades were included in the analysis. Being in a biologychemistry major during high school was a predictor for better performance during the first study year in medicine. For the following academic years, previous performance in the medical curriculum was the best predictor for subsequent performance. The authors raise the importance of rethinking the admission process, while recognising some study limitations, such as a single-centre approach. In their opinion, future admission processes should better assess other competences such as communication, professionalism and interprofessional collaboration. Krings et al. have to be commended for having analysed in detail this admission process, taking into account the sequential use of high-school grades and of aptitude test results. The study could not assess the impact of this selection process on behavioural dimensions and interpersonal competences. Nor was the study designed to predict clinical competences. Should we then get rid of the aptitude test if Matura grades suffice to predict initial academic performance? In theory, if the objective is to predict examination scores during the first years and if these results can be reproduced on a larger scale in Switzerland, this could be considered. Relying on Matura only may be appropriate if this diploma has similar value among high schools and among regions of the country, and if the grades show variability and no inflation. However, this may not always be the case and an additional or alternative selection method would probably be needed, first to make the candidates go through an equitable selection process and second to provide a mechanism for reaching the desired numbers of students. EMS may not offer immediate, additional predictive value, but may give a perception of face validity and increased acceptability, despite additional costs, thus providing medical schools with the desired number of students. Or are there alternatives? A selection process is a necessary approach, in Switzerland as elsewhere, given the large number of candidates willing to enter medical schools, the limited capacity for training, and the finite desired annual number of new physicians in the country [2]. Beyond the political analysis to determine the right number of future physicians required to respond to society’s needs comes the question of the philosophy and related methodologies of the selection process [3]. And here arises the quest for the Grail... Should we strive to select the best students or the best needed future doctors... [4]? Many selection approaches have been used, each one with advantages and drawbacks, often hardly generalisable in different contexts and of variable predictive value, so that no single method has emerged. According to Patterson et al. [3], the majority of medical schools rely on previous academic achievements in their selection process and/or on specific admission tests assessing scientific knowledge, cognitive aptitude, or both (e.g., the Medical College Admission Test in the USA). The Swiss EMS does not test mere knowledge, but assesses some cognitive aptitude dimensions, such as the ability to elaborate knowledge from resources, apply logical rules, or concentrate and memorise, with an acceptable prediction of academic achievement [5]. As Krings et al. report, the EMS score alone was related to performance in the different examinations during the first three years, except for third-year OSCEs (objective structured clinical examinations), but did not predict success or failure of students. Many institutions apply a selection philosophy aiming at predicting the non-cognitive qualities of future physicians, rather than grades during the years at medical school. They typically use, for example, interviews, multiple mini-interviews, or situational judgement tests [3]. Use of a nongrade-based system to select in or select out candidates would hopefully allow for more diversity of candidates and more representativeness of different socio-cultural backgrounds. These tools are attractive, but their development and implementation often require a combination of different methods and significant resources [6]. The study of their predictive value suffers from several difficulties: varying definitions of the qualities of a good physician, choice of the measured outcomes, interrelation among sevCorrespondence: Prof. Mathieu Nendaz, MD, MHPE, Unit of Development and Research in Medical Education (UDREM), Department of Medicine, Faculty of Medicine, rue Michel Servet 1, CH-1211 Geneva 4, mathieu.nendaz[at]unige.ch

Medical student selection: the quest for the Grail