HPAT redirects obsession
with Leaving Cert points
Cert indirectly rewards desirable traits in future doctors, while the HPAT was
devised to directly measure suitability for a career in medicine. Dr Siún
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
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.
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
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
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
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
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
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.
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.