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HPAT redirects obsession with Leaving Cert points
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HPAT redirects obsession with Leaving Cert points

The Leaving Cert indirectly rewards desirable traits in future doctors, while the HPAT was devised to directly measure suitability for a career in medicine. Dr Siún O’Flynn reports

Entry and selection to medical school has always been contentious because medical courses are always oversubscribed. It is only appropriate that the admission and selection processes to study medicine are scrutinised and that they are perceived by all stakeholders to be fair, transparent and defensible.
Sometimes it is only when something major changes that anyone critically reviews what happened before. Historically, medical school admission was based on academic achievement. There is evidence to support the correlation between academic success prior to medical school entry and success in medical school.

However, Ferguson et al. evaluated progression data and concluded that prior academic performance may only account for 23 per cent of the variance in undergraduate exam results, with a surprising number of top students failing.
Scoring ‘A’ grades at second level is clearly not the only requirement for subsequent success at medical school.
In Ireland, the consequences of the older approach included: strategic Leaving Certificate subject selection, a steady climb in the numbers of students who were repeating the Leaving Certificate (60 per cent on average per year in medical schools) and a growth in the ‘grind’ industry and private schools – created specifically to cater for students who wished to study medicine or other high-demand courses.
The latter options were more accessible to certain demographic groups and this is not fair or defensible. The UK experience clearly shows that relying on A-levels alone favours the privileged.
The new stipulation requiring Leaving Certificates scores in matriculation subjects from a single sitting has received little attention. This eliminates strategic subject selection and levels the playing field.
The old system obviously served me well, but the message was that you only need to think about points in order to get the place. Do you need 570+ points to study medicine? Medicine is academically rigorous, no doubt, but the points have been dictated by demand. Are we convinced that a high Leaving Certificate score reliably guarantees good problem-solving, empathy, emotional intelligence, interpersonal skills, the ability to work in a team, honesty or altruism?
Do we not expect these attributes in our doctors? Are we sometimes concerned that this system of assessment might favour rote-learners and memorisers, who cannot then deal with uncertainty?
The Leaving Certificate may indirectly measure diligence and consciousness. These attributes are also clearly highly desirable attributes in doctors, as such traits are required to perform well in medicine, but the Leaving Certificate is not specifically designed to do this.
Fortunately, the reality is that performance in academic tests and the possession of the desired attributes are not inversely related. It is possible to have both. Clever and hardworking students are often empathic but, if certain traits are desired, they should be sought or, at a minimum, emphasised to prospective applicants.
The new entry and selection mechanisms represent a conscious effort to redirect attention from the obsession with Leaving Certificate points and to focus instead the student’s attention on his or her suitability for a career in medicine. This is surely worthwhile.

A vacuum
As traditional cognitive tests like the Leaving Certificate or A-levels do not directly measure desirable traits, there is a vacuum that other tests seek to fill. HPAT-Ireland (Health Professions Admission Test-Ireland) is one of a number of such tests and it is devised and administered by ACER (the Australian Council for Educational Research). This organisation is well established in the field.
It has three sections: (1) Logical Reasoning and Problem Solving; (2) Interpersonal Understanding; and (3) Non-Verbal Reasoning. It is quite similar to other tests such as UMAT (Undergraduate Medicine and Health Sciences Admission Test), which is used widely in Australia and which is also administered by ACER.
For the sake of comparison, the United Kingdom Clinical Aptitude Test, (UKCAT), which is used by 26 schools in the UK, is similar in length and format with five sections: (1) Verbal reasoning; (2) Quantitative reasoning; (3) Abstract reasoning; (4) Decision Analysis; and (5) Non-cognitive analysis. ACER has psychometric data, which suggests that HPAT tests the attributes it claims to test.
The question that then arises is whether there is evidence that such tests predict performance in medical school. Mercer et al. have produced some reassuring data about UMAT, with more data pending. The research evaluating UKCAT raises some alarm bells. Obviously, while HPAT-Ireland is similar to UMAT, it will still need to be subjected to rigorous evaluation to reassure all stakeholders. This is already under way and the National Research Group Evaluating Revised Entry Mechanisms to Medicine, of which I am a member, was convened for this purpose.
What were the alternatives for gaining entry to medical school? Other countries have used interviews, personal statements and personality profiling to inform admission decisions. The research evaluating interviews does not support their use, with the exception of specialised multiple mini interviews, which are relatively new and resource intensive.
Personal statements have not been found to be helpful and, while personality and related profiling is showing some promise in selecting for higher specialist training, the evidence that it is suitable for school leavers is still less convincing.
The Dutch have previously used a lottery-style approach for selection, but are now increasingly abandoning it, recognising that it cannot predict who would be best suited to a medical course and, furthermore, that it is unfair to highly motivated applicants.
Dutch universities are now testing several selection frameworks. Interestingly such ‘selected’ students, who had similar entry-level academic attainment as lottery students but have been selected by aptitude and related tests, subsequently perform better than those admitted via lottery.
Arguably, the new approach in Ireland now more closely aligns with what happens elsewhere. The old system was not perfect and the new one must be carefully evaluated. We may need more than our current two-test processes to make such high-stakes decisions. We may need to modify the tests we use.

Better doctors?
I personally seriously question whether the threshold of 480 points is high enough, but am prepared to review the evidence. There were winners and losers in 2009, but will there be better or different doctors because of it? The evidence to help us decide will take some time to collect. The new approach does perhaps redirect the potential applicant to reflect on what a medical career entails and whether they are in fact suited to pursuing such a path. The old approach did not require this.
l Dr Siún O’Flynn is the Head of Medical Education in the School of Medicine, University College Cork.

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