Excellence and equity: key elements in medical education

In Iran, similar to most countries, medicine is a prestigious and high income profession. Moreover, traditionally “best and the brightest” candidates have been considered suitable to enter medical schools. In fact, the excellency of the applicants has been measured in a highly competitive national competition, by a multiple choice knowledge test of high school materials. Accordingly, the national exam would provide equal chances for all candidates to enter medical schools based on their knowledge excellence; in addition, the test provides an “objective” assessment, which would be supported by social accountability. Moreover, using this tool is relatively feasible among about half a million applicants per year. However, a study in 2012 showed that the national exam alone or even in combination with high school Grade Point Average (GPA) has limited predictive value for medical school exams and GPA (1). Similarly, other studies have supported inadequacy of these knowledge scores in predicting success in medical training and even practicing medicine (2, 3). In fact, being a “good doctor” is required to be competent not only in knowledge acquisition, but also in non-knowledge competencies, such as communication. Therefore, it seems that the current method of candidate selection has narrowed the definition of "excellence" by focusing on theoretical knowledge. Furthermore, this method does not examine higher levels of knowledge dimension, such as metacognition and higher cognitive processes, such as creativity. In order to achieve more equity in access to education, a quota has been defined for different geographical areas of the country (central vs. marginal provinces). This would balance the chance of acceptance in medical schools for lower scored students in remote areas competing numerous high scored applicants in big cities. In the United States, since five decades ago, a quota policy has been implemented entitled “affirmative action”, to address race diversity in medicine. Such diversity has shown to improve health care and medical practice in underserved areas (3) without any adverse effect on residency training (4). In Iran, despite of implementation of the quota policy for more than half a century for selecting medical students, it seems that advantageous population -upper and middle socioeconomic groups- have a higher chance to enter medical schools even in remote areas. Indeed, they have more resources to invest on the training required for being excellent in the national knowledge exam. Therefore, equity, which addresses social justice, would not be satisfied. Moreover, it has been shown that patients of lower socioeconomic level have limited access to care and receive less medical care compared to advantageous patients (5). It can be partially because of communication problems caused by social class differences between physician and patient (6). In poorer patient's perspective, the most important criterion to choose a physician is psychosocial aspect of the patient–physician relationship (7). In addition, physicians report less interest and comfort and more anxiety in visiting patients with low socioeconomic status (8). As a result, there is a correlation between physicians’ social class and communities they serve (9). It seems that recruiting more medical students from lower socioeconomic origin might raise awareness through the socialization process (10). Therefore, the equity in access to medical education is considered as a tool for more justice in the delivery of health care rather than a means for individual social advancement (11). In other words, if just some social groups enter medical profession, specific social groups would be underrepresented in the profession and theirhealth care needs would be undermined. In summary, it seems that meaning of excellence and various excellences, which are required to provide the best care for the population, should be revisited. Accordingly, a reliable and valid measurement tool for those excellences is required to be designed. Finally, revision of policies in selecting medical students would satisfy health care needs of all social groups.