Saturday, 28 August 2010

Another GAMSAT snoozefest from the desk of Dr. Thunder.

zzzzzzzzzzzzzzzzzzzzzzzz.

Yeah I know. I have an unhealthy obsession with GAMSAT. But I'm not just trying to be a bollix. It concerns me that the GAMSAT graduates I've worked with, and the senior GAMSAT course students I've taught, have been, in my opinion, less capable than their tradition course counterparts.

I've expressed that view on here numerous times. Each time the comments section has been filled with people telling me that I'm a dinosaur, and my email fills up with people saying much worse.

So, I decided to have another look through the published evidence to see if I've missed something. Though this entry won't be anything close to a literature review.

For those who have never heard of GAMSAT, it is an admissions test for admissions to medical school. It's used in Australia, Ireland and the UK. Only graduates of other degrees can sit this exam. It tests rational thinking, scientific knowledge and written skills. Looking at sample papers, it's a straight forward enough exam if you put in some work, and have some scientific knowledge. Looking at the message boards on the net, it's pretty obvious that a lot of people are doing very well in this exam after a minimum amount of study. It's also obvious that a lot of entrants to medical school are scoring less in the science section than in the other sections.

Having said that, I'm a great believer in evidence. In fact, it's become an obsession of mine in the last 2 years since I set up a journal club where I work, got involved in published research and did a masters degree with a significant stats component.

But I just can't find the evidence for GAMSAT. It doesn't seem to correlate with med school results, whereas school leaving exams correlate very well (in the UK where this type of study has been conducted).
I also read another study showing that GPA in a previous degree is a better indicator of med school performance than GAMSAT.
Yet another study shows applicant selected by their GAMSAT results are less empathetic than those who enter via the traditional route.
Then there's the study showing that GAMSAT grads are much more confident in their knowledge of cancer medicine than their tradition counterparts, but they actually know less.

I didn't leave anything out in my search. I assumed there was a sentinel GAMSAT paper, on which the widespread adoption of this exam was based. But I couldn't find it. That doesn't mean it doesn't exists, as I used Pubmed, which is a relatively new plaything for me.

I have to say that all the above rings through with me and a lot of my colleagues. I find GAMSAT grads and students to be extremely confident, regardless of how little they know. I have also long said that they have less empathy than I would have hoped. They themselves tell me the opposite is true, but I have yet to see this in practice.

That is, of course, not to say they're all bad. I've worked with some fantastic GAMSAT grads and students, who will go on to be much better doctors than me.

But I'd like to see a more evidence-based approach to med school applications. Does a degree really give people more "life experience"? I did a degree before med school. But I got more life experience outside of that....playing in bands, being involved in martial arts/boxing clubs, being involved in charities, being ill, being in relationships, summer jobs and my life in general. I don't think a few extra years studying and going on the piss has given me any more life experience.

We're also often told that their extra knowledge of other fields is an asset to medicine. Sure, a recent resident of mine was a previous IT grad, so he could fix the computer when it went down, and we were able to access blood results again. But his 3 years at uni studying computers will mean he spends 3 years less as a paediatric consultant, which would have been more useful to the world in general.

Some of the unis are telling us that their GAMSAT grads are getting higher marks than the youngsters. Maybe they are. But when the traditional entrants reach their age, they'll know a shed load more medicine.

It seems that GAMSAT was actually brought in to widen access to medicine. I think that's fair enough, if we're trying to widen access for ethnic minorities for example. But trying to widen access A) Should not include widening access to people who aren't as bright as they should be to get in and B) Shouldn't happen at the expense of producing quality doctors.

I can't see how it widens access based on socio-economic status, as it requires incurring the extra debt of two university courses. GAMSAT courses in Ireland, in particular, involve course fees of about 100,000 euro.

In Ireland, too, it has had the effect of restricting the expansion of places to those completing secondary school. Those kids work their asses off during their teenage years, while everyone else is pissing about, getting drunk and trying in vain to get laid. It takes a lot of discipline and focus to give up your high school years and hit the books. You've got to be bright, focussed and a bloody hard worker to do it. I want to see more of these people in medical school, not people who blitzed GAMSAT because they have a biomedical sciences degree.

I expect my email inbox to fill up again. But I can cope with that. I'm just hoping one of the emailers might tell me why I should support GAMSAT. I'm not closed minded. We tell students that evidence is so important in medicine. I just want to see us live by our own rules.

Dr. Thunder.



42 comments:

  1. Thanks for the post Dr. Thunder.

    RANT/ As an Irish 4th year med student studying abroad its a bit hard not to be a bit resentful towards the GEM courses, I was narrowly off the points for medicine after repeating and the HPAT system came in a year or 2 after I started studying in eastern europe. I wasn't willing to repeat again and just wanted to start college. Luckily my parents were able to afford the fees for me to study abroad. Now that my two siblings are in college at home my parents are under a massive financial strain with all the pay cuts/tax rises. When I eventually finish I'll be looking down the barrel at a minmum of a 60k student loan.

    What bugs me with the GEM concept as a whole is the country has already paid for their first degree and is now subsidising his/her second degree. On a thread on boards I read that they are able to avail of HEA grants to help with the costs of the course, whereas I cannot get any grants or even the tax back on all my tuition fees.

    Sorry for having a rant but its bloody annoying that such resources are being wasted on people who decided to do some piddly science degree for a few years and go on the piss are taking up spaces that should be allocated to undergrads who are naturally going to have a longer working life. If he/she really wanted to do med they would've repeated, its cheaper than going to college. I realise not everyone is lucky enough to be able to study in the UK/further afield but not everyone who's gone on to do GEM comes from a less well off background. /RANT OFF

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  2. I'm starting 1st Year GEM in 2 weeks or so.. what do you suggest to have me at the level of undergrad meds at the end of 4 years? Where are the GEMs coming down? The knowledge they're supposed to have, extra reading, empathy?

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  3. Interesting - refs?

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  4. I find it interesting that all of the paeds registrars I know who passed their exams this year are all graduates of graduate medical programmes, clearly they manage just fine at the business end of things...

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  5. Uhuouhuo I agree that the expansion of medical school places should have gone primarily to easing the ridiculous pressure on places at Leaving Certificate level. It's ridiculous that some of the country's brightest kids on 540 points can't get a place at a med school. I agree with you entirely.

    Anonymous 1, I don't think it will be helpful for me to tell you things to learn as such, as everything I say is all very general. Yo may be an amazing doctor, who goes much further than me. My concern is tat we're not picking the best candidates, and that a lot of the medical schools are skimming on content to facilitate a 4 year course (some GAMSAT courses do almost no dissection for example).

    Anonymous 2, I don't have the refs on my home computer here. I'll see if I still have them on my work PC on monday and I'll post them up.

    Polly I don't think "clearly" is the right word. I never said GAMSAT grads won't pass exams. I said I don't think we're picking the best students. We all know GAMSAT people who've passed exams. But how many have dropped out of training? How many ties do they sit exams? Exams are really only part of the package too. 2 Gamsat residents I had in the last year have dropped out of paeds to do GP and pathology in the last year because it was too much for them. I met them for dinner the other day and they're much happier, but they'd never have made it through training. Anecdote isn't all that useful here. I'm trying to claim we need an evidence base here, so we shouldn't rely solely on our own experiences I guess.

    Dr. T

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  6. Yes, there are many awfully bright students still with acne on their faces whose voices haven't even broken yet not getting medical school places. Being a doctor is a hell of a lot more than just brains- we want uber intelligent kids in science and research more than we do in medicine.
    The reason that many people do well in the GAMSAT with little preparation is because it is not designed to be a knowledge-based exam. It is meant to test inherent aptitude in the cognitive processes & skills that are imperative for any physician. A-level and especially degree classifications can be attained through sheer hard work and are not necessarily a reflection on medicine-specific intellectual attributes (though, of course, a med school needs to see that an applicant is able to work hard, so in that respect it is just).
    Maybe I'm just biased, as I graduated with a lower-second (admittedly, in biomedical science and from a russell group uni, but still...) and I did pretty well in the GAMSAT, but I do believe that taking med students with life experience who've been tested on their inherent aptitude as well as bright-but-young students who've had no such testing other than A-levels is a good idea- bias aside!...

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  7. The problem is that we all know these arguments. Every GAMSAT student will tell you the same thing. No offence, though, I don't think someone with a lower second in Biomedical sciences is necessarily the best candidate for medicine when we have a lot of very very intelligent people who aren't getting places.

    The point here is that GAMSAT hasn't been shown to correlate with med school outcome, but A-levels have been shown to correlate very well. I happen to think the ability to work your balls off and assimilate a lot of complex info is a huge part of being a doc.

    The real point I'm making here is that we brought in this new system without a good evidence base.

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  8. I'd love to come on here and defend GAMSAT but I haven't done enough reading on it to justifiably take a side. The publications I've read seem to have quite a heavy bias. This one (http://www.mja.com.au/public/issues/186_03_050207/gro10631_fm.pdf) is being plugged as having shown negative correlation between GAMSAT and med school performance even though the raw P-value results are mixed. Correlation between GAMSAT and exam results is P=.02, negative correlation between clinical tests and GAMSAT P=.03.
    The only result I found with any type of undergraduate control (in my admittedly brief search) is: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2755335/pdf/425.pdf
    While it identifies GAMSAT as a possible method of selection, the university in question mainly used degree classification and interview. Graduate students did outperform undergraduates though.
    GAMSAT obviously isn't ideal but neither is leaving cert/A levels. Progressive grade inflation means that the more intelligent candidates are more difficult to select for. Take a look as cso.ie for the amount of people scoring highly in the LC versus numbers sitting it.
    GAMSAT isn't easy and it definitely selects the more intelligent candidates. I suppose the requirement for a minimum degree grade was supposed to test work ethic but I don't think that says much. I'd like to see extra-curriculars taken into account somehow.

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  9. Dr. Thumper- I totally agree, a 2.1 is much more preferable on the whole, as evidenced by the fact that most british med schools stipulate it as a min requirement for GEM.
    However, I am trying to be heartened by the fact that Nottingham & St. Georges London (both reputable medical schools) accept applicants with lower seconds- the primary criteria they use is the applicant's GAMSAT score. I am sure that these institutions would use nothing less than an admissions system that only selects those able to undertake and do well in a medical course and become safe, competent doctors.
    What we are essentially doing is bringing UK medical education more into line with that of our american cousins, who must ALL be graduates and have done well on the MCAT (their version of our beloved GAMSAT) and the standard of doctors in the USA is clearly nothing to be sniffed at.
    Now, I personally think our route of starting doctor training at 18 for those with the required A-levels is great, but I also think that our other route is valid too- that of taking those who for whatever reason didn't flourish in their A-levels and who needed a year or two extra to decide they wanted to devote themselves to such a rigourous career, and I think the GAMSAT is as good a method of selection for this route as any. Having taken it once already, and managing to score in the top 15%, I can assure people it is a very thorough exam.
    Ultimately, I think we'll always have those from the traditional route wanting to look down on those who didn't do what they did, and the GAMSAT people resenting those views. Whether they're justified can only be told from finals exam results and performance in foundation years/specialty training, but from what I've seen & read so far, graduates perform noticably no worse than others in their medical careers, and can thus conclude that the GAMSAT, I worked hard for (and paid a lot for...!), is a sound, if not perfect, selection tool.

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  10. Hmmm. I one way I agree with you. I got 545 points in my leaving cert. Medicine was my first choice and I couldn't go abroad to study due to financial constraints. I then trained as a nurse and now I'm thinking of taking the GAMSAT to go on and study medicine. Do I think I should've gotten medicine with 545 points when I was 17? Yes, because I'm intelligent and I studied damn hard but just didn't quite get there,(believe me I sure as hell wasn't out getting laid and knocking back booze). I have had to work with absolute fools of interns as a nurse and there have been times when I think "why couldn't that have been me instead of this idiot?". I totally agree with lowering the points bracket for leaving cert entry to medicine. I would love to go back as a mature student and study the 6 year course, but at 23 years old finances and the fact that I'm getting on means that this isn't possible. I'm glad GEM is an option. Yes, there are people entering the GEM programme who shouldn't be there, but I would like to think that by the time I qualify I would be no worse than any other intern, regardless of whether I'm a bit longer in the tooth.

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  11. Potato, I think the balance of the evidence is not in favour of GAMSAT. None of the studies are particularly good. That's exactly why we shouldn't have introduced it.

    We're trying to encourage med students to use evidence to inform their decisions. I find it very hard to believe that the decision to use GAMSAT was informed by a solid evidence base, as I can't find it anywhere!

    In clinical medicine, it would be less than ideal to say a clinical stance was to be justified because the guys at St George's or Nottingham probably know what they're doing. And it shouldn't be acceptable when dealing with med school admissions.

    A-levels correlate with med school performance, and show a degree of hard work and discipline. I'm really loathe to keep focussing on the guy who got the 2:2 in Biomedical sciences, as it's a bit unfiar. But, biomedical sciences represents a huge amount of the work covered in a medical degree, and he/she likely came in the bottom half of their class (being that >50% of students score a 2:1 or above). Yet they get in the top 15% of GAMSAT scorers. I personally think performance in a biomedical sciences degree would be a better predictor of aptitude than GAMSAT.

    To the final anonymous poster (I hate the way most posters on the comments section are labelled "anonymous, btw)you're the type of person I think we should have encouraged into medicine. You got 545 points in the leaving certificate, so were obviously very bright. You shouldn't have had to go and do nursing, and now worrying about finances of med school. In my opinion, we should have been giving GAMSAT places to people like you at school leaving level. You're 23 now, so you'd probably be in your intern year, rather than being a 30 year old intern.

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  12. Performance at degree level is, in my opinion, a poor general indicator of aptitude. I have a good degree and good GAMSAT score and I think they complement each other to give a better picture of my ability. Many people in my undergraduate class who scored highly were really not bright (a few of whom subsequently failed GAMSAT). Terrible problem solving skills, no ability to think outside of what has been explicitly taught etc. Additionally, Gamsat has the advantage of being standardised whereas different universities may have varying standards. Having said that, I understand you're not suggesting that a university grade replace LC selection and you're just giving an alternative to GAMSAT. Given your location, I doubt you've seen the grade breakdown for this years LC. From memory there were 5 subjects which awarded over 35% As and a marked difference in grade distribution between subjects which could be rote learned and those which couldn't. The fact is that traditional methods of selection are becoming redundant.
    I agree that GAMSAT appears to be a lazy method of selection but I think it holds a lot of value if used in conjunction with interview and a sensible educational requirement. This is all conjecture though until there's some quality studies published.
    The alternative is that the only way of getting into med school is through one set of exams in one year of your teenage life.
    Lastly, why don't people just click the "Comment as" box and select a non-anonymous name?...

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  13. Slightly Offended path trainee who dropped out of Gen Med due to Academic Boredom....3 September 2010 at 16:35

    Dropping out of paeds to do pathology??? Maybe physically the workload is less, but pathology is about 8 billion times tougher academically, if they were not going to make the grade in Paeds they sure as hell will not in Path.

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  14. Yup, I should have gotten a place in med school as a school leaver, but now GEM is pretty much the only option open to me. There is no point crying over spilled milk and all that.

    Dr. Thunder, have you heard of/met any decent GEM graduates? I have absolutely no idea where to do the GEM programme as every university seems to be jumping on the bandwagon and offering a GEM programme. The only overwhelmingly positive feedback I have heard about GEM grads is not surprisingly from the universities that offer GEM. I would rather not waste my time and money doing the GEM programme if I'm going to come out the other side a second rate doctor.

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  15. Are you trying to create a Graduate Medicine VS. Undergraduate Medicine War? This is really silly - and not at all productive - you can't judge people's intelligence, empathy, brilliance, etc. or how good a doctor they will make based on leaving cert points or gamsat exams or age or life experience or whatever....everyone is an individual - I believe that the majority of Medical Undergrad and Grad students are intelligent, bright people, who are studying Medicine for the right reasons.

    Personally, I think the GAMSAT is great - I will be sitting the exam next March and it will give me the oppertunity to fulfill my ambition.

    I sat my Leaving Cert 9 years ago, I had a sprained hand and was receiving counselling that year for various peraonal problems. I received 520 points. Even If I had gotten the points, I did not have the maturity or stability in my life to pursue a career in Medicine at that time.

    Now, I have been working for 5 years, I have paid a lot of tax in this country, have saved like hell, I have travelled, and basically, I am ready to commit to the course and the career.

    If the GAMSAT did not exist I would be applying for the Undergrad course, anyway.

    I would like to wish all the Graduate and Undergrad Med students out there all the best. And Good Luck to all the GEM wannabes!!!

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  16. @Potato: I think the research shows that GPA in the undergrad degree is actually a better predictor of med school performance than GAMSAT. Plus, there was a big study a few years ago showing that A-levels correlate very well with med school performance too.
    With regard to the point about the narrowing of LC scores, the same can be said for GAMSAT scores. There's such a narrow range, and the distinction between being supposedly suitable for a medical school place and being unsuitable is very small. But the LC students now also have to do HPAT in Ireland (another crock of shite), which is supposed to test those other skills that GAMSAT tests.
    GAMSAT tests rote learning in it's science section. Then they test writing skils in the same way as the English exam tests it in the LC, and "aptitude" is tested in HPAT.
    SO I just don't know what GAMSAT offers now that the LC doesn't.

    I think the path person has a very high view of his/her own specialty. But I think path is the kind of thing that GAMSAT people might be well suited to...ie lots of learning, but no need for the rapid mental sharpness required to be, for example, the medical or paeds or ICU reg on-call out of hours.

    @an banaltra-ban: I don't know which GAMSAT schools are best. I've met some very very good GAMSAT grads, but I don't think they're as good as the traditional entrants. I've heard good things about Swansea and Hull in the UK, though I know nothing about those courses.

    @anonymous: You're using the old argument about "but how else will I have done medicine without GAMSAT?" argument. Medicine should be about the best doctors for the patients. It shouldn't be about letting people do medicine who couldn't get in otherwise. The patients should come before the students. I've said it before and I'll say it again, there are kids all over who are giving up their teenage years to work hard learning tough content in order to get into med school. THESE are the kids who are going to be the best and brightest and hardest-working people of their generation. These are the kinds who are now missing out on med school places, on the basis of flimsy educational theory.

    Dr. T

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  17. True. But there are also a great number of ultra-brainy kids who get their 4 A's at A-level without even breaking a sweat, who think 'oo, i think i'll do medicine cos i'm smart', even though they can barely tie their shoe laces or relate in conversation to a person who's not a scientist.
    Graduate entry/GAMSAT offers the people who are capable of becoming good doctors a route other than everything resting on a year's exam results in their young life.
    Yes- the patients are the most important thing, of course. They deserve the best doctors. And I believe that giving able people the opportunity to treat & care for these people can definately extend to offering places to those other than high-voiced unworldly teenagers.
    Ultimately, if someone show's they have the stuff, what difference does it make what route they took? They all have to pass the same exams in the end, so lets stop this snobby attitude that only the traditional students are gonna be any good.

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  18. It appears we fundamentally disagree on the skills GAMSAT tests. It certainly does not test rote learning in the science sections. I know people who have studied, inside out, the material recommended by ACER and have failed to achieve a competitive score. If anything, GAMSAT tests the mental sharpness of being able to make accurate decisions on limited information in a short timeframe. The marking scheme is also another basic difference between LC and GAMSAT, not a similarity. GAMSAT is percentile based and therefore will always select the top candidates whereas LC has no option for weighting. With regards HPAT, take a look at this: http://www.imj.ie//ViewArticleDetails.aspx?ArticleID=5733
    How any article gets to publication with spelling errors, I'll never know. While I'm not sure exactly what the article says about HPAT, it certainly suggests that GAMSAT is effective in selecting for those with at least a high 'on paper' aptitude.
    Just as a matter of interest, have you taken GAMSAT? I don't mean this in an inflammatory way, but you might have a little more faith in its selective ability if you sit it. Alternatively, I've a spare sample question book you can have if interested.

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  19. Didn't mean to sound insulting there Dr. Thunder, just was surprised that someone who found paeds too much was able for Path, which is a serious academic workload with a horrifyingly steep learning curve and exams that no clinician can possibly imagine how stressful they are.

    I've worked in medicine, and paeds, and surgery before I finally saw the light and went for path, and though I found clinical medicine much more stressful due to physical exhaustion, and frustration etc, I can unequivocally say I was shocked at how difficult the first year of path was. I love it, and the hours are infinitely better, no nights, minimal weekend work, but the constant pressure during the day and huge mental workload is draining too.

    The mental sharpness vs learning comment: To be honest, you have it backwards there. Mental sharpness is the single most important thing in pathology-frozen sections anyone? Also logic, reasoning and good visuospatial abilities-essential in cut-up-the histology report will only be as good as the gross! for post mortems, sharpness and alertness much more important than learning-you can look it up afterwards but you must do it properly first.

    The learning can be done at any stage, but the mental sharpness and logic are paramount for any pathologist.

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  20. Doc Thunder said "The patients should come before the students."

    Hear! Hear! I say.

    This is a highly interesting post with great comments too. I'm with Doc Lightening though when he talks about ultra-brainy kids who "can barely tie their shoe laces or relate in conversation to a person who's not a scientist."

    I know of several school students who went on to do medicine who were EXACTLY like that and I personally think, they'll make lousy doctors (one has already dropped out having suffered a breakdown). I hope I'm proved wrong!

    Here's a link to an article published in the Irish Times HEALTHplus this week, asking... Is medicine a wise choice for high achievers?

    http://www.irishtimes.com/newspaper/health/2010/0907/1224278340

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  21. Sorry, last link was incomplete...

    http://www.irishtimes.com/newspaper/health/2010/0907/1224278340185.html

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  22. I had a big post in response to your last but lost it somehow. Anyway, the gist of it was that we fundamentally disagree over what GAMSAT tests. If anything, it does test mental sharpness and it most certainly cannot be rote learned for. A number of people I know could write the recommended material backwards and still cannot achieve a competitive score.
    This article: http://www.imj.ie//ViewArticleDetails.aspx?ArticleID=5733
    certainly suggests GAMSAT is capable of selecting those who have at least a high 'on paper' aptitude.
    If you haven't already done so, you should sit GAMSAT. Alternatively, say the word and I'll email you on a few sample questions you could do under timed conditions to give you an idea what it's like.

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  23. Also, if you have any connections in the Irish Medical Journal, tell them to run a spellcheck on their articles before they're published. The article in my above post is all over the place.

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  24. I've tried to reply to your last but it ate my post. The gist of it was that we disagree over what GAMSAT actually tests. Mental sharpness is certainly required for success. I know people who could write the recommended material backwards and still cannot achieve a competitive score. This following article suggests (obviously without the use of a spellchecker) that GAMSAT, at the very least, selects those with a high 'on paper' aptitude.
    http://www.imj.ie//ViewArticleDetails.aspx?ArticleID=5733
    If you haven't already done so, you should try and sit GAMSAT. It might change your opinion slightly. Alternatively, say the word and I'll send on a PDF of sample questions you could try under timed conditions.

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  25. Ive tried 4 times to reply to your last but it never shows for some reason. To summarise what I've tried to post:
    -Give GAMSAT a go, it might change your mind. Say the word and I'll email you a sample question PDF to do timed.
    -GAMSAT can't simply be rote learned for. I know people who know the recommended material backwards and fail to score competitively.
    -GAMSAT certainly seems effective at selecting those with at least a high 'on paper' aptitude. Take a look at this (the article with the crap spelling):
    http://www.imj.ie//ViewArticleDetails.aspx?ArticleID=5733
    I don't know what the article says about HPAT really, but it certainly suggests GAMSAT is more difficult.

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  26. Vert interesting discussion. I have just started GEM as a former pharmacist. I have been pretty muc obsessed with medicine since I was old enough to read. I must admit I am pretty impressed with the class so far. There is a lot more enthusiasm than there was in the direct entry pharmacy class and I have some friends in "traditional" med classes and believe me there are plenty people there who are there because they got the points and have little interest in the profession.

    However I can definitely see the point you make about GEM students. There is a huge level of self directed study required in the GEM courses. There is a large level of assumption from the teachers and I can see how students could get through without the same basic scientific training as a direct entry student.

    There is also however an absolutely fantastic attitude and commitment to work in the class that I have never seen close to in my traditional undergraduate training. I probably have it a bit easier than most in the course with my undergraduate course being very close to a medical education, but I have no doubt the majority of the class will make fine doctors in a few years time.

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  27. @dr lightning: You're very much underestimating the abilities of the traditional entrants. Saying they can't tie their shoe laces and that they can hardly function doesn't belie the fact that A) Older students in my experience tend to solely focus on the academic side of the course, and don't embrace the life experience a much as the youngsters (if we're going to base our decisions on anecdote, my law school gaduate sister constantly comlained about how socially retared the mature students in her class were)
    B) the only study I'm aware of suggests that the GAMSAT entrance have less empathy than the traditional entrants, which is my experience. I'm not against limited graduate entry for people who came out on the to 1-5% of their year at uni in rigorous degree programmes. Also I never said only traditional entrants are any good. I've always maintained that they're better as a group. At the very worst, I think the years spent by the grads at uni doing law/english/science/whatever would have been better spent doing medicine, by and large.

    @path trainee: The point I was making is that the GAMSAT students are not as mentally sharp and agile. What I mean by that is not that they're incapable of learning a lot of stuff. I think that's the easiest bit. But what they lack, in my opinion, is the ability to rapidly assimilate complex info, work out what's happening, and come up with a plan rapidly under a lot of pressure. I used to work in a path lab for a while when I finished my biomedical degree, and I know you guys work under pressure, but it's a different type of pressure.
    I know the GAMSAT students say that their GAMSAT exam tests that kind of pressure. But sitting an exam that you can resit an infinte number of times without prejudice to your application is very different from the pressure you're under when a blue newborn is plonked in font of you out of nowhere, for example.

    @Steph: I think you're stereotyping the school leavers who enter med school. They have given up their teenage years to study like crazy, while their peers were doing more enjoyable things. We were told on the first day of med school that it will take a while for them to catch up (even to the extent that our school leavers were advised to brush up on sex ed, as they were usually miles behind their peers in terms of social contact). But it's a 5 or 6 year course, and by the end of it (in fact by the end of first term) most were well on their way to social catch up. Just compare them to a group of IT/science/engineering/law students. They'e really not very different socially. In fact they're a very diverse bunch.

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  28. @ potato: to my eternal shame, I've helped a friend do GAMSAT. It was a real dilemma. She's a science grad, and now she's a med student. She asked me to help,and I felt obliged, even though I never thought she'd be a great doc. I helped her with revision, and gave her bio and chem tutes, a well as reading all her essays. So I've a lot of exposure to sample papers etc, which I didn't think were all too taxing, especially for a graduate. Don't get me wrong, I wouldn't nail the 95th centile straight away, but I'd do well after a couple of months revision.
    Re your IMJ article, the spelling isn't the only dodgy thing about it! They didn't actually administer the HPAT to those who sat it, they just picked a handful of questions. There were no significant differences between the groups, despite what the authors conclude. The authors do have a contempt for HPAT (as do I) but they do concede that "There was no statistical differences between the groups. It's a dreadful paper, which tells us exactly nothing. GAMSAT is definitely more difficult than HPAT, but we're asking graduates to sit GAMSAT, and school leavers to sit HPAT!

    Anonymous: I guess i'm trying to get away from the whole "well I think my class are great, and I think the direct entry med students are disinterested" kind of thing. Or at least I'm trying to point out that GAMSAT was introduced on the basis of that thinking. What I want to see is good data. Because I (and a lot of my colleagues) are worried about falling standards on the wards. And we're worried about the med schools cutting back on the academic load to enbable these students to get through the course.

    Evidence, evidence, evidence. That's all I want!

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  29. Doc Thunder

    I accept your point re stereotyping.

    What you say re potential med students lacking in social maturity in lieu of time spent swotting, makes absolute sense. I know that many of these students also excel at extra curricular activities such as music and sport, as well as their academic subjects. They tend to be very high achievers.

    However, I'm also well aware that med students like to 'play' hard as well as work hard so I guess any innocence, is soon lost!

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  30. I'm confused. Swotting for 2 years in secondary school is an enormous sacrifice and these are the better docs, but swotting for 4 years in med school instead of 'embracing life' by going on the beer makes you a socially retarded mature student?

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  31. Hold your horses here, u wha.

    For starters, you're very much trying to simplify the point I'm making. Secondly, I said the mature students have a rep of concentrating "solely" on the academic side of the course, and not on the social. I never said the mature students study more. I just said they don't tend to get involved in the social side quite so much. Of course that was part of a wider discussion, and not the isolated point you seem to be making it out to be.

    The important point here is that the traditional entry students give up what many people say are the best years of your life, in order to pursue this path. I think that shows a wide range of qualities in a person. Though we can all admit they might suffer socially. But they party hard, and make up for it in record time, in my experience.

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  32. Steady on uhuohouh. Have you ever taken a second to consider who developed most of the technology that you would be but naught without ? The drugs, the machines that go ping. Yes it's your "piddly" science grads. I know there aren't many inaccurate soaps about the folks who developed the dialysis machine or the MRI scanner but show an iota respect for the other disciplines who rarely get the recognition the Medical profession enjoy.

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  33. Ok, final comment- promise.
    Firstly, I wholeheartedly disagree with Dr Thunder's opinion that GEM students focus "solely" on the academic side of medicine and "have less empathy than traditional students". A necessary entrance criterion for most if not all GEM courses is demonstration of a caring attitude and a dedication to medicine- this is often done via assessment of the applicant's work/voluntary experience. They expect a considerably larger/better amount than for traditional entry students (and reasonably so, too, as an 18y.o. who's been doing full-time A-levels and GCSEs has hardly had the same amount of spare time with which to get the same work/care experience as a graduate). But my point still stands that if the average GEM student has had to work for at least a year full-time as an auxillary nurse (for which empathy and non-academic skills are the name of the game, trust me) then I would argue that if anything, it's the GEM students who are likely to be the most empathetic. Not always though, of course.
    Finally, I find it hard to believe that a paediatric doctor in australia, who'll naturally have very limited leisure time, has nothing better to do with it than slate an assessement method used in a country on the other side of the globe. Perhaps his surfboard is in for repairs!

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  34. Just look for the one's who place a cannuala right on the elbow joint because they can't be bothered to find a proper placement. That will tell you more about their inherent empathy than any number of year of experience or academic training.

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  35. Unfortunately on the 2nd of July last summer I broke my leg I meet an intern in A & E and she seemed to be completely lacking in empty and completely unaware that I was in pain despite the fact that I was literally screaming crying by the time I got to the ward I told myself that if that intern even walked into the room I would walk out of the hospital (or more accurately hop). Fortunately the ortho intern was really nice. I work in this hospital and found out later that the A & E intern was from the 5 year program and the ortho intern was one of the first graduates from the GEM program in Ireland I studied with med students and have seen them around the wards and in every group there are those that are brilliant and those that are terrible. I don't know so much about the A-levels but with the Irish leaving cert you have one day to sit the exam, you may be sick, you may have a headache etc. and even though they may have gotten straight A's all their life and end up with straight B's which In anyone’s mind might be great but in Ireland - no medicine place also to get into medicine in Ireland in many places you only new one science so you get people who do the subjects where you can get and A very easily when compared to something like physics or maths, for example I know one girl in my year who got ordinary C3 in agricultural science & maths and got here 6 A1 in economics, economic history, business and numerous languages, she got medicine in UCD. That’s just one example I can think of at least 5 more similar cases from that one class of 200. My main point is that every system has its faults and just because you don’t know what you want to do at 16,17,18 doesn’t mean that if you figure out what that is at 25 and you have a talent for it you should be stopped.

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  36. @Dr Lightning: The "less empathy" comment was based on A) a paper that was published recently about GAMSAT entrants and B) my own personal experience.

    I also very seriously doubt that most GAMSAT entrants have done anything close to 1 year full time as a care assistant. My last residents were a computer software engineer straight from industry and a guy straight from a psychology degree at uni. In the UK work experience is taken into account (I'm not sure if that's the case everywhere in the UK though). Same with most unis in Australia, but not Ireland. Anyway, work experience is something we all had to do before med school. It's just a hurdle. I don't think it correlates with empathy. You could be a total swine, and do some work experience in order to tick the boxes. That's why I did mine. Though I like to think I'm not a TOTAL bastard.
    I'm not sure what to make of your other comment about my leisure time. A) I update the blog pretty infrequently and B) GAMSAT is used here in oz, aswell as in Ireland and the UK, so i'm surrounded by GAMSAT grads, which makes it my business.

    @Andrew: doctors often put a cannula in the antecubital fossa for a variety of reasons. I've had a few in my time and I prefer to have them there.

    @anonymous: I wasn't aware that we have GAMSAT grads practicing in Ireland yet. Can anyone confirm this? That aside, I'm not against the concept of graduate entry, as I've said a million times on this blog. I think it should be kept as a small portion of med graduates, though, and not the norm. I also object to the fact that GAMSAT is an unproven method of selection for prospective doctors. The evidence simply isn't there. The points you make about the leaving cert could easily be applied to GAMSAT.

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  37. The first class of the GEM RCSI class graduated this year

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  38. I am a final year GEM student in Ireland, the first batch graduated last year and are now interns. When I was in 2nd year I asked my friend who was in final year of the 5 year program about the differences between the GEM and traditional students. He told me the GEM students start out slow during clinical years, then zoom past the traditional students. He included himself in his assessment.

    I know this is a single anecdote without evidence to back it up, but as a GEM student myself I can say that the life experience gained in uni and in the workplace makes a huge difference in terms of the daily realities of the job, e.g. talking to difficult patients, having good interdisciplinary work relationships (e.g. between medics and nurses), and working the system to get what's best for the patient (e.g. talking to the radiology department!)

    That all being said I see exceptional students and interns who took the traditional route. And I know Dr. Thunder's original comment was specifically about the GAMSAT, but regarding GEM generally, in the US and Canada 99% of North American grads are GEM students, and quality of care is not a major problem with medicine there.

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  39. Hi Dr. Thunder,

    I know that your core issue is to seek an evidence-based approach to the performance of grad v trad entry doctors, which is admirable, but you and a few others here seem overall to be extremely hostile towards grad entry students. Surely this is not a helpful approach, especially if you are working with us? Just in the same way that I do not profess to know everything about all undergrad med students, or form overarching opinions about their capability, it is quite saddening to see doctors that I would be happy to learn from in the future slating me, and my classmates, as being essentially dilettantes, instead of people with different experiences and skills to bring to the workforce. If this is really about the patients, surely the most cohesive approach would be to accept the two entry pathways as a fact of medical education and get on with it, rather than inciting people to argue about them. If I were on a trolley in severe pain, I would hate to think that there were any doctors who could potentially wind up treating me wasting their time with hostile approaches and rants when they could be concentrating on improving their skills - and yes, this includes learning from people with different backgrounds. We're all a bit old for the school playground clique routine now. Judge the individuals as you find them - if someone is going to be a decent doctor it is because they will work their backside off to be so, regardless of personal circumstances that have dictated their entry into the field.

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  40. @Manny, I wouldn't put a lot of faith in the opinion of one intern, when so many docs are saying the opposite on the shop floor.

    @justdroppedin, I don't think any of us are ranting against GAMSAT students in lieu of tim spent upskilling :D
    The reason a lot of us get worried about GAMSAT students and grads is that we worry about patient care. Just accepting the status quo is not what doctors should do when they're concerned about something.

    Dr. T

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  41. Hey Dr. T,

    Just to give an alternative albeit anecdotal viewpoint it has to be said that in bonnie Scotland many graduate entry Medical students are rated very highly and more often than not regarded in higher esteem than their traditional entry classmates. Obviously the GAMSAT graduate students are in a slightly different situation as the test is part of the admissions procedure however you must remember that they still require a reputable degree at an appropriate level.

    By all means show concern at such students but perhaps it is a fault not of the admissions procedures but of the graduate courses themselves. Regarding your point on access to medicine I see no reason to so heavily criticize a test that opens up a wider pool of talent. Yes, obviously school leavers with good grades have possibly like you said worked hard through such precious years of life but would this not give reason to believe that they were not inherently talented but hard working. Surely the fact that graduate students have gone through a degree then jumped through a further hoop that is after all the GAMSAT showing arguably a greater commitment albeit later in life. Just because some reach academic maturity before others cannot be justified as a reason to say they could not make fine Doctors.

    Yes, you have your anecdotal evidence and murmurs to the contrary but I too have seen evidence praising such students.

    Another comment I must disagree with is that of the 'student who blitzed the GAMSAT due to the biomed degree...’ This if you actually had any of the real experience which you claim you have is complete and utter tosh. That is that half the marks are nothing to do with science and would most likely show gaps in a student’s cognitive abilities from a more holistic viewpoint. Although I have not sat the GAMSAT but know plenty who have I am also greatly aware that it is a long and laborious exam. Which requires a great deal of focus or as you might call it mental sharpness or endurance to score highly which should obviously be the criterion of entry to such programs utilizing the test. As it has previously been stated everyone has to pass the same exams, unless there is some blindingly obvious point I'm missing.

    To finish I would also like to add that I am no avid GAMSAT supporter I just feel that the opinions you have expressed appear to come from a slightly arrogant and perhaps ignorant perspective which is perhaps a result of your vast life experience. What concerns me the most about your attitude is your inability to receive anyone’s points with a truly open mind. You seem so rigid in your opinions that no matter what anyone says you won't listen or more accurately you won't give a toss.

    I can see how this might read as being aggressive or hostile which is not the way it is intended. I'm just being completely honest and I have to say that your opinions on this matter don't appear to be particuarly constructive just a rant of sorts. But then again, look who's talking.

    Regards,
    Jim

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  42. Greetings! Very helpful advice in this particular post! It's the little changes that produce the most important changes. Many thanks for sharing!

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