Effects of medical school selection on student motivation: a PhD thesis report

Abstract

Introduction:
High stakes are involved in student selection, for both medical schools and applicants. This thesis investigated the effects of selection on the medical student population and applicant pool in the Dutch setting.

Methods:
This thesis consists of six papers: two quantitative studies, one qualitative study, two mixed methods studies and one perspective paper based on a review of the literature.

Results:
(1) Compared with a lottery, selection does not result in a student population with better motivation, engagement and performance, both in the clinical and pre-clinical phases of the study. (2) Selection seems to have a temporary stimulating effect on student motivation through enhancing perceived autonomy, competence and relatedness. (3) Applicants adopt a strategic approach, based on the selection procedure, in their choice of medical school. (4) The description of an applicant's motivation is not a reliable and valid tool to assess motivation during selection. (5) Gaining healthcare experience is crucial for applicants' motivation, but inequalities in access to such experiences can demotivate certain student groups from applying to medical school. (6) The gains yielded from selection compared with a lottery seem to be small. Unintentionally induced self-selection among certain groups of students and biased selection procedures may compromise student diversity.

Discussion:
The added value of selection procedures compared with a weighted lottery for admitting students to medical school is questionable. Students are generally motivated and perform well, irrespective of how they enrolled in medical school. Selection yields only small gains, while student diversity may be hampered.

Full text

PHD REPORT
https://doi.org/10.1007/s40037-017-0398-1
Perspect Med Educ
Effects of medical school selection on student motivation: a PhD thesis
report
Anouk Wouters1,2
© The Author(s) 2017. This article is an open access publication.
Abstract
Introduction High stakes are involved in student selection, for both medical schools and applicants. This thesis investigated
the effects of selection on the medical student population and applicant pool in the Dutch setting.
Methods This thesis consists of six papers: two quantitative studies, one qualitative study, two mixed methods studies
and one perspective paper based on a review of the literature.
Results (1) Compared with a lottery, selection does not result in a student population with better motivation, engagement
and performance, both in the clinical and pre-clinical phases of the study. (2) Selection seems to have a temporary
stimulating effect on student motivation through enhancing perceived autonomy, competence and relatedness. (3) Applicants
adopt a strategic approach, based on the selection procedure, in their choice of medical school. (4) The description of
an applicant’s motivation is not a reliable and valid tool to assess motivation during selection. (5) Gaining healthcare
experience is crucial for applicants’ motivation, but inequalities in access to such experiences can demotivate certain
student groups from applying to medical school. (6) The gains yielded from selection compared with a lottery seem to
be small. Unintentionally induced self-selection among certain groups of students and biased selection procedures may
compromise student diversity.
Discussion The added value of selection procedures compared with a weighted lottery for admitting students to medical
school is questionable. Students are generally motivated and perform well, irrespective of how they enrolled in medical
school. Selection yields only small gains, while student diversity may be hampered.
Keywords Selection · Admissions · Motivation · Undergraduate medical education · Self-determination theory
Anouk Wouters
a.wouters@vumc.nl
1Research in Education, VUmc School of Medical Sciences,
Amsterdam, The Netherlands
2LEARN! research institute for learning and education,
Faculty of Psychology and Education, VU University
Amsterdam, Amsterdam, The Netherlands

A. Wouters
Introduction
Several challenges are faced by medical school selection
committees who are responsible for admitting the students
they expect to successfully complete medical programs and
become good doctors [1]. Admissions decisions should be
based on selection processes that consist of appropriate se-
lection tools and are equitable to all students. As a com-
promise between a process that provides equal opportunity
(straight lottery selection) and one that rewards achievement
(qualitative comparative selection), the Dutch Government
introduced a lottery weighted for pre-university grade point
average (GPA) in the 1970s [2]. A small number of top
pre-university GPA students, with a GPA of ≥8/10, were
granted direct access, while for other students the num-
bers of lottery tickets available were higher for those with
higher grade point averages (i.e., 3, 4, 6 and 9 tickets for
students with a GPA of <6.5, 6.5–6.9, 7.0–7.4 and 7.5–7.9,
respectively). The weighted lottery was gradually replaced
with qualitative selection procedures. During this transition
period, students who were rejected in selection automati-
cally enrolled in the weighted lottery procedure [3]. The
proportion of students admitted through selection increased
from 10% in 2000 to 100% in 2017. This transition period
created research opportunities for comparing the effects of
these different processes.
Research on selection mainly focuses on predicting aca-
demic performance [4]. This thesis also explores selection
from the perspective of student motivation, as motivation
is an important factor in student performance, as well as
student learning and well-being. Self-determination theory
(SDT) [5] was used as the theoretical framework, as it con-
siders motivation as dynamic and postulates that motivation
can be influenced by the educational environment [6]. This
allowed selection and motivation to be explored as mutu-
ally influencing factors and investigation of the underlying
mechanisms. SDT posits that motivation can change from
autonomous motivation, which reflects interest in and the
acknowledgement of the importance of an activity, to con-
trolled motivation, which reflects internal and external pres-
sure and rewards, and vice versa. SDT research has shown
that the fulfilment of three psychological needs, autonomy,
competence and relatedness, stimulates autonomous mo-
tivation. While autonomous motivation is associated with
positive student outcomes such as deep learning, positive
well-being and good performance, controlled motivation is
associated with poor student outcomes such as exhaustion
[6,7].
The effect of selection on the applicant pool is an im-
portant aspect of this thesis, as certain population groups,
such as first-generation university students, students from
ethnic minority backgrounds and students without parents
in the medical profession are underrepresented in medical
education [8,9]. This can be explained partly by biases in
selection, but may also be due to self-selection, in which
prospective applicants decide whether to apply to medical
school based on their knowledge of the medical program or
selection.
The main research question of this thesis was:
How does selection affect the motivation of the student
population and applicant pool?
Methods and results
A multi-method approach was applied, in which quantita-
tive findings were obtained throughvalidated questionnaires
with good reliability and further explored using qualita-
tive research methods. This approach allowed examining of
the mechanisms involved in selection. Power analyses were
conducted for each quantitative study. A focused review of
the literature formed the basis for a perspective paper.
Study 1 [10]: In this cross-sectional, mixed methods,
questionnaire-based study among first- and fourth-year
students (n= 357) in a six-year regular medical program
and first-year students in a graduate entry program, we
examined the effect of selection on the student population
and motivation. We used validated questionnaires, namely
the Strength of Motivation for Medical School-Revised
(SMMS-R) questionnaire [11] and the Learning Self-Reg-
ulation Questionnaire [12] to measure the quantity and
quality of motivation for the medical study, respectively.
We found higher strength of motivation among selected
students than non-selected students (p< 0.01), but no dif-
ferences in the quality of motivation. Recently selected
students reported higher strength of motivation (p< 0.01),
autonomous motivation (p< 0.01) and controlled motiva-
tion (p< 0.05) than students who were selected longer ago
and non-selected students. Open questions revealed that
students’ needs for autonomy, competence and relatedness
were fulfilled by being selected.
Study 2 [13]: In this quantitative survey study, we in-
vestigated the associations of various admissions processes
(i. e. selection, lottery and direct access) and participation in
a voluntary selection procedure with student performance,
motivation and engagement. We measured the quantity and
quality of motivation, and engagement using validated ques-
tionnaires, namely the SMMS-R scale [11], Academic Self-
Regulation Scale (SRQ-A) [14], and Utrecht Work Engage-
ment Scale-Student (UWES-S-9) [15], respectively. Par-
ticipants were first- and fourth-year students (n= 666)
from three medical schools. Top pre-university-GPA stu-
dents outperformed the other students (p<0.1andp<
0.01). Regression analyses showed highest strength of mo-
tivation among Year-1 selected students (p< 0.05), but no
differences in the quality of motivation and engagement

Effects of medical school selection on student motivation: a PhD thesis report
between admission groups. Participation in selection was
associated with higher engagement (p< 0.05) and better
clerkship performance in Year-4 students (p< 0.01).
Study 3 [16]: In this quantitative survey study, we ex-
plored the relation between students’ main reasons for ap-
plying to a specific medical school and their motivation
during medical school. We measured the quantity and qual-
ity of motivation using the SMMS-R [11]andSRQ-A[13],
respectively. Participants were first- and fourth-year stu-
dents (n= 478) from three medical schools. Most students
had strategically chosen the medical school they applied to,
i. e. based on their chances to ace the selection procedure
(56.9% and 46.9%), while a minority had made their choice
based on the curriculum (11.2% and 12.4%). The different
approaches were not related to differences in student moti-
vation during medical school.
Study 4 [17]: To investigate whether a written statement
on motivation can be used to distinguish between applicants
in selection, we carried out a thematic analysis of 96 de-
scriptions of motivation made by medical school applicants.
The validity and reliability of written statements to assess
motivation in selection are questionable. Applicants seemed
to provide similar, socially desirable responses about their
motivation, in which controlled motivation appeared to be
underreported. Applicants also seemed to use their state-
ments as a means to show their suitability for medical
school, which was outside the scope of the assignment.
Study 5 [18]: To explore how individuals develop the
motivation to pursue medical education and how selection
affects the motivation of prospective applicants from vari-
ous backgrounds, we conducted semi-structured interviews
with three high school study counsellors and 24 high school
students. The reasons for aspiring for the medical profes-
sion mainly pertain to autonomous motivation, specifically
to scientific interest and helping people. Students also have
reasons pertaining to controlled motivation, such as prestige
and a high salary. Exposure to healthcare, which is often one
of the selection criteria, seems to be a crucial factor for de-
veloping autonomous motivation for studying medicine and
helps in making an informed choice. Difficulties in gaining
healthcare experience, often due to the lack of a network
in the medical profession, can demotivate applicants from
choosing to study medicine.
Paper 6 [19]: A focused literature review provided
a holistic perspective on the issue of selection and lottery,
indicating that the gains yielded from selection versus
a lottery seem to be small. Furthermore, selection may
compromise student diversity due to (unintentionally) in-
duced self-selection among underrepresented students in
medical education and biased selection procedures.
Discussion
This thesis raises questions about the added value of expen-
sive and time-consuming selection procedures compared
with a lottery [19]. While selection is aimed at increas-
ing the quality of the student population, the findings from
the research to date indicate that selection yields only small
gains compared with a lottery procedure. The lack of sig-
nificant findings may be due to a ceiling effect, meaning
that all students score near the top on our outcome mea-
sures. Student motivation, performance and engagement in
the Netherlands can be considered good, irrespective of how
students are admitted to medical programs. Efforts to fur-
ther improve the academic success rates of medical students
might be focused more on ensuring that students receive
proper training during their six years of medical education
rather than on selection. Hubbeling argued that most ap-
plicants are likely to be able to complete their studies and
become capable doctors if properly trained [20]. Indeed,
dropout rates among medical students in the Netherlands
are low, and selection results only in a small decrease in
these rates [19]. In the research in this thesis, dropout rates
were too low to conduct further analyses. Until a reliable
and valid method for identifying unsuitable applicants at
a young age (i. e. 17–18 years), based on their non-aca-
demic personal qualities, is identified, a lottery could be the
fairest, most efficient and cheaper alternative [21]. The find-
ings in this thesis indicate that selection stimulates strategic
behaviour in applicants. To reach the desired match be-
tween student and curriculum, medical schools could use
this approach to their advantage by aligning the selection
procedure with their curriculum. This can involve includ-
ing lectures and tests that are representative of the medical
curriculum. An issue of concern is that inequality in access
to resources relevant for the selection process may compro-
mise the desired student diversity. Students without parents
in the medical profession may perceive their chances of
success in selection to be lower than those with parents in
the medical profession because they have fewer means to
prepare for selection. This can negatively affect their mo-
tivation and subsequently cause them to refrain from ap-
plying. These inequalities need attention if medical schools
wish to ensure that the medical profession reflects the ever-
increasing diversity in the society it serves [22].
The findings support the following recommendations.
Medical schools should review the cost-effectiveness of
their selection procedures. Next to financial costs, the neg-
ative effects on student diversity need to be considered. If
gains in terms of improved performance, motivation and
well-being of the student population can be expected to be
low, selection could be replaced by a lottery. If selection
prevents non-traditional potential applicants from applying
to study medicine, measures should be taken against in-

A. Wouters
equalities in admissions and to improve the student diver-
sity. These will be context-dependent and could include cre-
ating equal opportunities for all students to acquire health-
care internships and organizing pre-med weeks for under-
represented students. We do not recommend the use of
a statement on motivation to assess applicants’ motivation.
In fact, every assessment of motivation in selection should
be questioned, as applicants are likely to ‘fake good be-
haviour’. It can, however, serve as a matching tool to en-
courage applicants to become informed about the medical
course. A limitation of this thesis is that the conclusions are
based on cross-sectional data. Longitudinal research could
reveal how the different admission groups develop through-
out the medical study.
Advice
Your PhD is a learning trajectory. Make use of this ed-
ucational playground and take the chance to learn about
different research methodologies and methods. In addition,
take the opportunity to learn from others; both experienced
researchers and fellow PhD students. But above all, enjoy
this special time of your career.
University information
The defence took place at the VU University Amsterdam,
the Netherlands, on 9 February 2017. The supervisors were
Professor Gerda Croiset and Dr. Rashmi A. Kusurkar. This
thesis is available online via the university library at http://
hdl.handle.net/1871/55083. A PDF version is available
upon request from the author.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.
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Anouk Wouters is a psychologist by training and completed her PhD
in medical education, focusing on selection for medical school and mo-
tivation for studying medicine. She currently combines her research
work as a postdoc researcher in medical education with advising and
implementing educational policy on selection at the VUmc School of
Medical Sciences.