Miriam Longmore: Iran puts MTAS in its place

Iran has done what the United Kingdom has not dared: it has devised a single exam to be taken by its 20,000 doctors who are competing for 1600 residency positions. The UK system seemed to me unfair, but then an Iranian doctor explained Iran’s system. Rather than the UK’s online medical training application service (MTAS), set up in 2007 to rank medical students according to their 150 word answers about teamwork, prioritisation skills, and professional behaviour, Iran has one simple exam. Held yearly, it comprises 200 multiple choice questions that cover all aspects of clinical medicine, from psychiatry to ophthalmology. Unsurprisingly, just to pass this exam can take 2-3 years of 10 hours’ training a day. Whether those 6000 hours cooped up over books actually makes you a better doctor is debatable because it is difficult to gain any clinical experience during this critical time in training.

The specialty you join depends on your score, with paediatrics requiring a lower mark than surgery, for example. Problems arise because ranking devalues those specialties at the bottom. Specialties with lower pass marks become less popular because they are seen as “cop-out specialties.” Inevitably, all but in the highest echelon feel dissatisfied.

Controversially, rankings for training posts are not solely dependent on achievement in this exam. Doctors are further discriminated into four classes: A—female, B—you or a first degree relative is a veteran of the Iran-Iraq war, C—two years’ work as a rural general practitioner, and D—the rest.

In most specialties, 50% of positions are reserved for female doctors, and they will be accepted if they get 90% of the mark of group D (see CMAJ 2002;166:645). War veterans in contrast only have to get 80% of the mark achieved by non-combatants, as a sign of appreciation for their fighting. The same applies to doctors who have spent more than two years working as general practitioners in a rural area. The unfairness of this method is compounded by the fact that the number of applicants in class D is roughly equal to those in A, B, and C; therefore, competition among Iranian men is fierce.

So are UK medical students justified in their furore over MTAS? British medical students argue that ranking students in each university into fourths is unfair because different medical schools have different criteria and different standards of achievement. But these concerns pale into insignificance in comparison with what Iranian medical students experience. At least UK medical students can partly control their ranking, whereas Iranian medical students cannot decide their sex or whether their relatives chose to fight in a war. Would you prefer the Iranian or British system?

Miriam Longmore is a second year medical student at Somerville College Oxford.