Future proofing graduate entry medicine
How to make it viable in a Shape of Training world
In 2015, 10% of medical school places have been allocated to graduate entry programmes and 90% to traditional 5-6 year undergraduate courses. Graduate entry medicine (GEM) courses were established in the UK in 2001—despite this being the model in North America for a century before—and they arose from two concerns. Firstly, the United Kingdom was not producing enough doctors (in 1999 there were 1.9 doctors per 1000 UK population compared with a European Union average of 3.1, and, secondly, there were concerns about the lack of socioeconomic diversity of medical student applicants. Things had changed little over decades. The UK government advisory committee recommended an extra 1000 medical students per annum to be trained and this rose by another 1000 places in 2000. Half the existing UK medical schools established four year GEM programmes and two new schools—Warwick and Swansea—established themselves as exclusively GEM schools.
In the ensuing 15 years, evidence has confirmed the success and viability of GEM courses. Demand for places continues at twice the level (4-5 applicants for each place) compared with standard five year undergraduate programmes (2-3 for each), and these programmes have helped broaden the socioeconomic profile of students. GEM graduates are at least as good, in terms of medical school finals, as graduates from five year programmes, and evidence suggests that a higher proportion of students complete GEM programmes.     There is also some indication that graduates from GEM programmes are more likely to enter general practice. 
Despite the growth of these courses and their benefits, graduate entry medicine has come under several threats in recent years, as Sullivan’s article has highlighted. The Shape of Training report presents the biggest threat to the existence of four year GEM courses, because of its recommendation to move the point of GMC registration to the point of graduating from medical school. The European Directive for medical training specifies that a minimum of 5500 hours and five years of instruction and training is required to become a qualified medical practitioner. Currently, medical students on GEM courses make up their fifth year of training during the first year of the foundation programme. This first year essentially enables them to top up their training to meet the required quota. If the Shape of Training recommendations are fully implemented, four year graduate entry courses would no longer comply with the EU directive. 
Some medical schools, such as Imperial College London, have already decided to extend their four year graduate entry course to five years, but it is of interest to examine how graduate entry could adapt under these new circumstances. Firstly, all previous degrees and experience of graduate entry medics should be fully acknowledged and accredited on admission to medical school. For example, for someone with a degree in microbiology, modules covering the science of different human pathogens—bacteria, viruses, helminths—and the ways they evade immune defences and adapt to the selective pressures of antibiotics might be accredited. As well as giving some currency to previous learning, medical schools could also ensure that students do not duplicate earlier learning, but fill in gaps in their knowledge and invest their learning where they most need it. However, this idea is more likely to be applicable to graduates from related degrees, such as life science or biology, rather than the arts.
A closely related tactic could be to consider what prior experiential learning could be accredited, such as working as a healthcare assistant. This approach is less familiar in universities and would require certification so that suitable recording, standards, and outcomes from that experience could be counted as direct components of the medicine curriculum. Another approach could be to formally recognise that the four-year GEM programmes already compress learning into a shorter timeframe by lengthening the academic year. For instance, the Nottingham GEM student studies for 36 weeks in year one and 35 weeks in year two, whereas a student taking the five year course has a standard university year of 30 weeks.
With the increasing spread of distance learning using Massive Open Online Courses (MOOCs), medical schools could move some of the basic learning to before the student formally begins the course. Students could pre-register with the university, take online modules as a distance student, and complete linked assessments to gain the credits before they start. Funding of these students during this pre-course phase would need careful consideration. A pre-GEM year would not be eligible for governmental support through access to loans or an NHS bursary, and universities who saw this as an opportunity to levy full time fees would not be popular. Collaboration, with different medical schools providing distance learning modules and agreeing a suitable, low pre-registration enrolment fee might be a suitable option.
Lastly, what might happen to graduate entry if, as has already happened at Imperial College, the existing four year courses are lengthened to a full five years as a registered medical student. Entrants will already have at least a bachelor’s degree and a broad range of skills, so we should be thinking how the extra year could be used to enhance the curriculum and achievements of graduate entrants. For five year courses a Masters degree could be awarded or, as Liverpool pioneered years ago, the final year could be made up entirely of assistantships, with final exams being completed at the end of year four. If we take on board the acute need to recruit more general practitioners and family doctors, these extended placements in primary care and other community services would be beneficial to the individual student and the NHS.
The Shape of Training recommendations represent the most immediate threat to GEM, but other challenges to the public funding of GEM include private medical schools, access to tuition fee loans, and continuation of the NHS bursary. However, 15 years of GEM in the UK has broadened access to medicine, resulted in graduate doctors who are as competent as those from non-GEM programmes, and provided more doctors for our population—about 2.79 per 1000 in 2012. Moving the point of registration should not mean the end of graduate entry medicine, we just need to find a way to make it work for students, medical schools, and the NHS.Paul Garrud, assistant director of medical education1, Ajay Clare, graduate entry medical student2
1School of Medicine, University of Nottingham, Royal Derby Hospital, 2University of Nottingham
Correspondence to: firstname.lastname@example.org
Competing interests: None declared.
Provenance and peer review: Not commissioned; not externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h3282