What Is the Best Interview Format to Measure Student Aptitude for Medical School?

Problem - Based Learning to Encourage Active Learning and Teamwork Among First Year Medical Students - Student Reports in 2016 What This study aims to identify the type of interview that is the most suitable for evaluating a studentʼs personality and communication skills as part of medical school entrance examinations. Based on the importance of interviews for testing the aptitude of a student in this context, we examined different interview formats, duration, content, evaluation criteria, and scoring methods of interview performance. We further evaluated four interview formats ( i.e. , an individual interview, a several-interviewer interview, a group interview, and a group discussion) from the viewpoints of practicality, reliability, and validity, as well as 11 abilities measured ( i.e. , communication skills, enthusiasm, logical thinking/reasoning, problem-solving ability, judgment, human nature, moral standards, physical ability, cooperativeness, resourcefulness, and personality/background). Based on our analysis, we argue that the most appropriate interview exam consists of two phases: a several-interviewer interview and a group discussion, because the several-interviewer interview comes first in terms of practicality, reliability, and validity, and ability measured scores. Furthermore, by combining the several-interviewer interview with the group discussion, problem-solving ability and cooperativeness are easier to measure than in a single interview format. Moreover, we recommend some measures to improve the interview system, for example, having a 15-minute interview for each of the two interview formats, and making the evaluation criteria for grading interviews open to the public. This improvement will enable each medical school to conduct effective interviews for entrance exams to measure an applicantʼs suitability to become a medical professional.


Introduction
In order to enter medical school in Japan, almost all universities require applicants to be interviewed. The central purpose of an interview is to assess a studentʼs social and interpersonal skills that are important for medicine, and enthusiasm for pursuing this field of study 1) . These skills are difficult to assess in a written exam. Furthermore, interviews measure various abilities such as an applicantʼs ability to solve problems, logical thinking, and judgment 2) . There are many different types of interview in Japanese medical schools, but it is important to identify the type of interview that is the most suitable for evaluating a studentʼs personality and communication skills. This report will first explain the importance of interviews for testing the aptitude of a student, discuss different interview formats, and conclude by explaining which style of interview is most effective.

Current problems in Japan
Currently in Japan, the most important cause of medical lawsuits is inadequate communication between doctors and patients 3) . An article in The New York Times states that"communication failure (rather than a providerʼs lack of technical skill) was at the root of over 70 percent of serious adverse health outcomes in hospitals, indicating that the doctorʼs ability to explain, listen, and empathize has a profound impact on patient care" 4) .
There are several reasons for a lack of communication ability in doctors. One cause can be traced back to the entrance exam for university. To be more specific, an interview examination format may not have been adequate to measure an applicantʼs interpersonal skills, or an applicant could have "acted"as the ideal candidate by using conventional responses, probably taught at cram schools. For this reason, the University of Tokyo suspended interviews for medical school applicants in 2007. However, due to the discontinuation of interviews, numerous students who entered the university lacked communication skills. After recognizing the necessity of determining an applicantʼs communication skills, professionalism, and social perspective, the University of Tokyo decided to resume interviews in 2018 5) .

Interviews for applicants to medical schools in Japan
According to Nakagawa 6) , until the 1980s, students who had an adequate academic ability to pass the entrance examinations were chosen without having to go through interviews. As a result, many students entered medical universities only due to good grades, which led to an increase in doctors who had enough knowledge but lacked enthusiasm and motivation.
For this reason, the Japanese government brought a major change to the entrance examination system for medical universities. Furthermore, the Ministry of Education, Culture, Sports, Science and Technology indicated that characteristics such as awareness and motivation are qualities that are required to become a doctor 7) .
Since then, the number of medical universities that had only one academic test has decreased (see Table-1). Conversely, the number of universities that have other types of tests, such as interviews, essays, or aptitude tests, has increased.
Moreover, previous studies have demonstrated that implementing an interview had some significant effects. For example, at Yamaguchi University, the average years repeated were 0.24 years for students who scored high on the interview, whereas the average years repeated were 0.85 years for students who got a lower score 9) . This suggests that the interview can increase the probability that the university admits students who are hardworking and enthusiastic. In addition, among the students who received a high score on the interview, the percentage of those who passed the National Examination for Medical Practitioners without repeating a year was 74.5%. By contrast, this percentage for students scoring lower on the interview was 45.5%. This research suggests that interviews can be a useful tool to evaluate learning attitude or lifestyle 9) .
However, the reliability and validity of interviews are in doubt as it seems almost impossible to ensure that interviews can be as fair as a written test for judging studentsʼ abilities. Furthermore, although  the style of interview differs between universities, there seems no research about which format or content is best for evaluating the studentʼs aptitude or nonacademic abilities. In order for universities to be able to conduct highly reliable and valid interviews, it is important to discuss the most effective and fair style of interview.

Format
The content for sections 1. to 3. is taken from data from MELURIX 10) , a cram school that specializes in preparing students for medical school entrance exams. According to MELURIX, there are four interview formats used in medical schools in Japan, each having distinct characteristics and testing different abilities 10) .
The first is a one-to-one interview. In this format, students can present themselves fully to the interviewers, unlike in other formats. Additionally, an interviewer can ask in-depth questions, and achieve a thorough understanding of a studentʼs background and strengths. However, since there is only one interviewer, the evaluation can be biased, and less effective in terms of time and cost 11) .
The second format, which is the most common, consists of one applicant and two or more interviewers. Since there are several interviewers, questions from different perspectives are asked, and in some cases,"stress interviews"are conducted to test how students behave under pressure 10) . Creating a high-pressure environment may help reveal a studentʼs true personality 12) . Furthermore, a relatively unbiased score can be obtained since the evaluation is produced by several interviewers, who are assigned different tasks 12) . An example of this is Juntendo Universityʼs interview, where four interviewers are assigned a certain part of the assessment. Specifically, one interviewer examines the studentʼs behavior and psychological responses, the second asks about his/her personal background, the third enquires about his/her school life and achievements, and the fourth interviewer asks about his/her essay in either Japanese or English. By assigning different tasks, the interviewers are able to look at students from different perspectives 10) . On the other hand, this type of interview is time-consuming and costly since several interviewers are necessary 12) .
The third format type is the group interview consisting of two or more applicants, and one or more interviewers 10) . This type of interview is conducted for several students who respond one by one to the same question asked by the interviewer(s). The advantage of this format is that interviewers are able to easily compare applicants immediately. Moreover, since it is preferable for the student to differentiate his/her answer from the other applicantsʼ answers, studentsʼ flexibility and their ability to respond promptly can also be evaluated 10) . Although, at first glance, a student who answers first has an advantage, the student who answers later can also comment on earlier responses; thus, fairness is maintained. Furthermore, this style is the most time-and cost-efficient. However, the disadvantage is that a studentʼs evaluation can be affected by the interview situation and other intervieweesʼ performance in the same group, because only a limited amount of time can be used to ask individual questions. Therefore, it is difficult for students to express their feelings, and for interviewers to achieve an indepth understanding.
The fourth format is group discussion, where several students discuss their ideas on a given topic. A group discussion measures studentsʼ ability to cooperate with others, and skills such as listening and responding to other peopleʼs thoughts and opinions 10) . Furthermore, a studentʼs competency to communicate well with several people, and reach a conclusion is assessed. However, personal details and enthusiasm for entering the university are hard to evaluate.

Duration
Interview time varies from 5 to about 60 minutes. On average, the interview time is approximately 20 minutes 12) . Furthermore, universities such as Toho University, Jikei Medical University, and Japan Medical University each use several formats; thus, the interviews can be long 10) . For example, Toho University has a 20-minute group interview, and four 3-minute interviews; thus, the total interview duration is about 30 minutes. Japan Medical University has a 20-minute group interview, and a 10-minute individual interview. Additionally, Jikei Medical University has a 10-minute individual interview and a 50-minute group discussion, which is the longest interview of all the medical schools 10) .

Content
Questions asked at interviews differ depending on the university. However, most questions can be categorized into five types: personal details, school life, friends and family, knowledge, and something peculiar 13) .
Personal questions include items such as"What are your hobbies?," "What time do you get up in the morning?,"and"What kind of doctor do you want to be in the future?" 10) . These questions enable the interviewer to have a brief impression of the student.
Questions about school life include topics such as extra-curricular, volunteering, and committee activities. For example, questions such as"Do you have any extra-curricular activities?," "Did you belong to a committee?,"and"Have you had any experience in volunteering?"are frequently asked 10) . By asking about a studentʼs school life, an interviewer can gauge whether the student can communicate, and cooperate within a group.
Questions about an applicantʼs friendships or family relationships are asked to understand the studentʼs background. For example,"What do you talk about with your family?"and"Do you have good friends?" 10) are questions that are frequently asked. These questions are employed to understand the studentʼs relationships with other people, and his/her economic stability as deduced from their familyʼs background.
Furthermore, questions to test the studentʼs knowledge about medicine or society are asked (for example,"Do you know the meaning of organ transplants?"or"How do you feel about TPP (Trans-Pacific Partnership)?" 10) ). These questions can measure the studentʼs motivation to learn and his/her ability to think about social issues.
Finally, peculiar questions are sometimes asked at certain universities (for example,"Can you tell us the name of the head of this university?" ,"If you were a cookie, what cookie would you be?" 10) ) in order to assess the studentʼs flexibility and imagination.

Evaluation criteria
After researching the websites of all 80 medical universities in Japan, we found that the evaluation criteria and guidelines for assigning interview scores are not open to the public; thus, we cannot report on this.

Scoring methods
According to Igakubu Juken navi (a website that provides information on entrance examinations for medical schools), there are several different scoring methods for interviews 13) . The first is a grade evaluation based on 4 or 5 levels. The second method is to score an interview like a written exam (for example, on a 200-point basis), a practice commonly found in national or public universities. The third method consists in holistically evaluating a written exam, essay, and interview according to the universityʼs own private guidelines, which are not open to the public. In the fourth method, a written exam is heavily weighed, and an interview is only used for reference 13) .

Methods
Based on Brown and Abeywickrama 14) , three criteria (practicality, reliability, and validity) are used to measure the quality of an exam. Practicality includes efficiency in terms of time and money. Reliability consists of characteristics such as consistency and accuracy. Validity refers to whether an interview produces logically expected Table-2 Scores for the three aspects in each of the four interview formats results. The three authors discussed each of these aspects and assigned each interview format a score from 1 to 5 (5 being the highest; see Table-2). Next, we discussed each interview and assigned a score on the same scale for each of the 11 personal abilities measured in the four interview styles, in order to gain an understanding of how well these abilities are assessed depending on the interview format. The 11 abilities include communication skills, enthusiasm, logical thinking/reasoning, problemsolving ability, judgment, human nature (or empathy), moral standards, physical ability, cooperativeness, resourcefulness, and personality/background. Human nature includes features such as caring and respect for others.

Results
Table-2 indicates that, when it comes to the three aspects that measure the overall quality of an exam, the several-interviewer interview format ranks highest (Score = 10), followed by the group discussion and group interview formats (both 9). Furthermore, Table-3 suggests that the several-interviewer interview has the highest average score (3.54) for the abilities measured. However, Figure-1 shows that the several-interviewer interview fails to measure some important abilities such as cooperativeness (1) and problem-solving ability (1), which are abilities required for team work. Table-3 shows that the group discussion ranks second from the top (12.45), being effective at measuring the abilities necessary to work in a team environment (see Figure-1 Note: Abilities measured = the mean of all the scores assigned to the 11 abilities.

Table-3 Overall evaluation of interview formats
Figure-1 Evaluation score of personal abilities in the four interview formats interview formats, well-balanced abilities can be measured efficiently and effectively.

Conclusion
Our proposal for the most appropriate interview exam is as follows. First, the interview should consist of two phases: a several-interviewer interview and a group discussion. The reason is that, as stated above, the several-interviewer interview comes first in terms of practicality, reliability and validity, and ability measured scores (see Tables-2  and 3). Furthermore, by combining the severalinterviewer interview with the group discussion, problem-solving ability and cooperativeness are easier to measure than in a single interview format ( Figure-1). In this way, the strengths of an applicant can be measured from various perspectives.
Second, according to Shuchuryoku. net 15) , the average duration of a personʼs concentration is said to be 15 minutes. Thus, we argue that a 15-minute interview for each of the two interview formats is most suitable.
Third, among the five question categories, personal questions, school life, family, and knowledge should be asked equally, and one or two peculiar questions should be added to test the studentʼs flexibility and judgment.
Lastly, the evaluation criteria for grading interviews should be open to the public, so that the qualities that universities look for in an applicant are known. Furthermore, we suggest that the interview be letter graded from A to E, as this system provides the interviewer with a concrete and efficient way of evaluating the student 16) .
In conclusion, in order for universities to conduct effective interviews for entrance exams to measure an applicantʼs suitability to become a medical professional, it is essential to review their interview examination methods.