How to make the selection of medical students effective, fair, and open has been contentious for many years.^w1 A levels are a major component of selection for entry of school-leavers into UK universities and medical schools,^w2 but intellectual aptitude tests for the selection of medical students are burgeoning—they include the Oxford medicine admissions test1 and the Australian graduate medical school admissions test 2 (table). Tests such as the thinking skills assessment^w3 are being promoted for student selection generally. The reasons include a political climate in which government ministers are advocating alternatives to A levels, some support for them in the Schwartz report on admissions to higher education,3 lobbying from organisations such as the Sutton Trust,^w4 and the difficulty of distinguishing between the growing numbers of students achieving three A grades at A level. We examine the problems that intellectual aptitude tests are addressing, their drawbacks, any evidence that they are helpful, and alternatives.

Medical schools need selection procedures that are evidence based and legally defensible. We therefore explored a series of questions around these developments.

Many UK school leavers apply to university with other educational qualifications, including the international Baccalaureat and Scottish highers. Medical schools are increasingly admitting entrants other than directly from school. These different mechanisms of entry require separate study. We discuss the main school-leaver route through A levels.