“Excellence” and “equity”: key elements in medical education

In Iran, similar to most countries, medicineis a prestigious and high income profession.Moreover, traditionally “best and the brightest”candidates have been considered suitable toenter medical schools. In fact, the excellencyof the applicants has been measured in a highlycompetitive national competition, by a multiplechoice knowledge test of high school materials.Accordingly, the national exam would provideequal chances for all candidates to enter medicalschools based on their knowledge excellence;in addition, the test provides an “objective”assessment, which would be supported by socialaccountability. Moreover, using this tool isrelatively feasible among about half a millionapplicants per year. However, a study in 2012showed that the national exam alone or evenin combination with high school Grade PointAverage (GPA) has limited predictive value formedical school exams and GPA (1). Similarly,other studies have supported inadequacy ofthese knowledge scores in predicting success inmedical training and even practicing medicine (2,3). In fact, being a “good doctor” is required tobe competent not only in knowledge acquisition,but also in non-knowledge competencies, suchas communication. Therefore, it seems thatthe current method of candidate selection hasnarrowed the definition of "excellence" byfocusing on theoretical knowledge. Furthermore,this method does not examine higher levels ofknowledge dimension, such as metacognition andhigher cognitive processes, such as creativity.In order to achieve more equity in access toeducation, a quota has been defined for differentgeographical areas of the country (central vs.marginal provinces). This would balance thechance of acceptance in medical schools forlower scored students in remote areas competingnumerous high scored applicants in big cities.In the United States, since five decades ago, aquota policy has been implemented entitled“affirmative action”, to address race diversity inmedicine. Such diversity has shown to improvehealth care and medical practice in underservedareas (3) without any adverse effect on residencytraining (4).In Iran, despite of implementation of the quotapolicy for more than half a century for selectingmedical students, it seems that advantageouspopulation -upper and middle socioeconomicgroups- have a higher chance to enter medicalschools even in remote areas. Indeed, they havemore resources to invest on the training requiredfor being excellent in the national knowledgeexam. Therefore, equity, which addresses socialjustice, would not be satisfied.Moreover, it has been shown that patients oflower socioeconomic level have limited accessto care and receive less medical care comparedto advantageous patients (5). It can be partiallybecause of communication problems caused bysocial class differences between physician and patient (6). In poorer patients' perspective, themost important criterion to choose a physicianis psychosocial aspect of the patient–physicianrelationship (7). In addition, physicians reportless interest and comfort and more anxiety invisiting patients with low socioeconomic status(8). As a result, there is a correlation betweenphysicians’ social class and communities theyserve (9). It seems that recruiting more medicalstudents from lower socioeconomic originmight raise awareness through the socializationprocess (10). Therefore, the equity in access tomedical education is considered as a tool for morejustice in the delivery of health care rather thana means for individual social advancement (11).In other words, if just some social groups entermedical profession, specific social groups wouldbe underrepresented in the profession and theirhealth care needs would be undermined.In summary, it seems that meaning ofexcellence and various excellences, whichare required to provide the best care for thepopulation, should be revisited. Accordingly, areliable and valid measurement tool for thoseexcellences is required to be designed. Finally,revision of policies in selecting medical studentswould satisfy health care needs of all socialgroups.