Graduate entry medicine under threat
What’s the future for fast track four year courses?
Is this the beginning of the end for graduate entry medicine in the United Kingdom? Fifteen medical schools in the UK offer graduate entry to medicine (GEM), mostly through a fast track four year course, but in the past 18 months these courses have faced a number of challenges that have brought their long term existence into question.
The first threat came from a European Parliament directive in 2013 that tried to impose a minimum of six years of medical training for all doctors practising in the European Economic Area. This was revised to five years after protests from the BMA, among others, who said that the 5500 hours’ mandatory training time is achievable within this time frame. Currently, fast track four year medical degrees, such as the graduate entry programmes in the UK, use the first year of foundation training (FY1)—which is seen as a provisional year of registration for all junior doctors on the medical register—to make up this extra training time.
The next threat came from the Shape of Training report, which was published in 2013 and included several recommendations on the future direction of medical training. One of these proposals was to move the point of registration on the medical register with the General Medical Council from the end of FY1 to the point of graduation from medical school. However, this clear cut off between a junior doctor’s medical school and deanery would also make four year courses untenable, because the additional training time would no longer be available to graduate entry medics, who make up this extra training during their first year of being a junior doctor.
Although it remains to be seen whether the Shape of Training report’s recommendations will be implemented in full, some universities offering four year graduate entry courses have already decided to withdraw this course. In 2014, Imperial College London cited the potential changes as a result of the review as a reason that it decided to close its four year GEM programme, in favour of a five year course. In a statement Chris Harris, quality and educational development manager at Imperial, wrote: “This decision was taken in the light of the 2012 graduate entry review, student feedback about the intensity of the programme and the lack of opportunities to pursue research and scholarship, and the potential of full registration with the GMC being conferred on graduation, which would mean a four-year programme does not meet the requisite training hours to meet current EU requirements.”
Other cuts in graduate entry medicine courses include St George’s Medical School, which announced that it was cutting places from 120 to just 50 in 2014 in response to the national reduction in numbers of medical student places, and the impact of higher tuition fees and uncertainty over future government funding.
What makes graduate entry courses attractive to applicants is that they offer an opportunity to complete their medical training within a shorter amount of time, albeit more intensively. For many, the accelerated GEM programmes make medical school more affordable. The changes being proposed would necessitate graduate entry students to reach the minimum level of training before they graduate and the most obvious solution appears to be to add an extra year of training at medical school. However, for many this would act as a deterrent to studying graduate entry medicine because of the additional time and costs that would be incurred.
Currently, the long term financial implications of studying postgraduate medicine are substantial. GEM students have to pay £3465 (€4841; $5465) of their first year tuition fees up front, and apply for a student finance loan to cover the rest. The student finance loan will be repaid once the student starts earning, with repayments tiered to their salary. Although the first £3465 of subsequent years is covered by an NHS bursary, a student finance loan is needed to cover the rest of their tuition fees. Alongside this, students will also have to fund their living costs through either their personal finance or a maintenance loan. A NHS maintenance grant is available for living costs but this is means tested and can range from £2000 to £6000.
What will be lost?
What are the consequences of fewer graduate entry medical students for the future of the profession, and what do these students add to the mix? An advantage of the GEM programme is that it increases the diversity of students entering medical school. It provides another chance for those who are not ready or able to commit to being a doctor at the age of 16. It also opens up the profession to graduates who have trained in similar or sometimes very different backgrounds, which in turn diversifies the types of people who work as doctors.
Annabelle Painter, a third year graduate entry medical student at the University of Oxford, believes she benefited from choosing medicine later in her academic career. “Doing graduate medicine has meant that I have made a mature and informed decision about dedicating my life to medicine. This is in contrast to many of my undergraduate friends who are now questioning if they really made the right choice aged 16,” she said.
The maturity and motivation that come with being a graduate entry student can be great advantages when dealing with the challenges of the clinical setting. Colin Melville, head of the postgraduate medical programme at Warwick University, was recently quoted as saying: “In our hospitals, our clinicians think [that GEMs] make better doctors.”
Graduate entry medicine also helps to diversify the medical profession and give a second chance to people who found it difficult to apply to medical school as an undergraduate. GMC research published in 2013 found that, although only 7% of all schools in the UK are private, one third of medicine and dentistry undergraduate students came from such schools.  GEM offers people interested in studying medicine another opportunity to become doctors, in a situation where the quality of their degree and previous experience are more important than the quality or the support offered by their sixth form or school.
As well as providing opportunities for those from different socioeconomic backgrounds, graduate entry provides a second chance for people who didn’t take the required subjects at school and for those who choose to study arts and humanities for their first degree. Some schools prefer arts graduates to take an Access to Medicine course, while others are happy to train those with good humanities degrees without additional training.
It might be assumed that graduates without a scientific background would be at a severe disadvantage. Yet, when it comes to clinical medicine, skills of communication, empathy, and human interaction are as important as theoretical science. In these skills, the arts and humanities students may have an advantage. Research shows that a strong performance at school for English, not maths, is more strongly associated with success at medical school, and one study suggests that English is the best predictor of success in “clinical science.”
Jessica Macaro, a second year graduate entry medical student at Warwick, said: “I’ve noticed how the non-science students are able to bring a different perspective, often questioning concepts which the rest of us have just accepted as true without thoroughly understanding them. This helps us to think more critically instead of relying on superficial learning.”
It seems that losing fast track graduate entry and extending the training at medical school would be an unpopular move, which could put off a diversity of applicants from opting for a career in medicine. Both the BMA and the Medical Schools Council have said that they are committed to supporting these courses. But government funding of medical school places, financial realities for students, and the uncertainty caused by the proposal to shift the point of GMC registration suggest that there may be a fight ahead.
Some glimmers of hope exist for GEM going forwards. A spokesman for the Medical Schools Council (MSC) pointed to the success of graduate entry schools in turning out general practitioners. Given the mounting workforce crisis among GPs, and the Health Education England targets to increase the numbers of medical graduates opting for this career, this could be a valuable argument for retaining and nurturing GEM to meet future workforce needs.
“Given the Health Service’s strategy for increased care in the community, it is notable that the two all graduate entry schools—at Warwick and Swansea—have more graduates entering GP training than other medical schools,” he said.
He also welcomed the contribution that graduate entry makes to widening access to medicine, saying, “MSC will work to try to ensure that the graduate entry programmes endure beyond potential changes to the medical education system, including the proposed shift of GMC registration to the point of graduation.”
Looking to the future, it is important that fast track graduate entry programmes survive because they have an important role in widening participation in medicine. As our working lives are becoming longer, it is to be expected that we will have multiple careers. GEM provides people from a range of backgrounds with a mature entry point into the world of medicine and in doing so it makes the medical profession richer, more diverse, and more representative of the patient population that it serves.Adam Sullivan, fifth year medical student
1Imperial College, London
Correspondence to: firstname.lastname@example.org
I gratefully acknowledge the following friends and colleagues, whose insights and input were essential for this piece: Paul Dennis, Annabelle Painter, Lucy Jefferson, Charlie Bell, Jessica Macaro, Felicia Bamgbose, Rose Harvey, and Peter Sullivan.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.
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Cite this as: Student BMJ 2015;23:h3283