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1.  The UK clinical aptitude test and clinical course performance at Nottingham: a prospective cohort study 
BMC Medical Education  2013;13:32.
Background
The UK Clinical Aptitude Test (UKCAT) was introduced in 2006 as an additional tool for the selection of medical students. It tests mental ability in four distinct domains (Verbal Reasoning, Quantitative Reasoning, Abstract Reasoning, and Decision Analysis), and the results are available to students and admission panels in advance of the selection process. Our first study showed little evidence of any predictive validity for performance in the first two years of the Nottingham undergraduate course.
The study objective was to determine whether the UKCAT scores had any predictive value for the later parts of the course, largely delivered via clinical placements.
Methods
Students entering the course in 2007 and who had taken the UKCAT were asked for permission to use their anonymised data in research. The UKCAT scores were incorporated into a database with routine pre-admission socio-demographics and subsequent course performance data. Correlation analysis was followed by hierarchical multivariate linear regression.
Results
The original study group comprised 204/254 (80%) of the full entry cohort. With attrition over the five years of the course this fell to 185 (73%) by Year 5. The Verbal Reasoning score and the UKCAT Total score both demonstrated some univariate correlations with clinical knowledge marks, and slightly less with clinical skills. No parts of the UKCAT proved to be an independent predictor of clinical course marks, whereas prior attainment was a highly significant predictor (p <0.001).
Conclusions
This study of one cohort of Nottingham medical students showed that UKCAT scores at admission did not independently predict subsequent performance on the course. Whilst the test adds another dimension to the selection process, its fairness and validity in selecting promising students remains unproven, and requires wider investigation and debate by other schools.
doi:10.1186/1472-6920-13-32
PMCID: PMC3621812  PMID: 23442227
2.  The UKCAT-12 study: educational attainment, aptitude test performance, demographic and socio-economic contextual factors as predictors of first year outcome in a cross-sectional collaborative study of 12 UK medical schools 
BMC Medicine  2013;11:244.
Background
Most UK medical schools use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the United Kingdom Clinical Aptitude Test (UKCAT), and its four sub-scales, along with measures of educational attainment, individual and contextual socio-economic background factors, as predictors of performance in the first year of medical school training.
Methods
A prospective study of 4,811 students in 12 UK medical schools taking the UKCAT from 2006 to 2008 as a part of the medical school application, for whom first year medical school examination results were available in 2008 to 2010.
Results
UKCAT scores and educational attainment measures (General Certificate of Education (GCE): A-levels, and so on; or Scottish Qualifications Authority (SQA): Scottish Highers, and so on) were significant predictors of outcome. UKCAT predicted outcome better in female students than male students, and better in mature than non-mature students. Incremental validity of UKCAT taking educational attainment into account was significant, but small. Medical school performance was also affected by sex (male students performing less well), ethnicity (non-White students performing less well), and a contextual measure of secondary schooling, students from secondary schools with greater average attainment at A-level (irrespective of public or private sector) performing less well. Multilevel modeling showed no differences between medical schools in predictive ability of the various measures. UKCAT sub-scales predicted similarly, except that Verbal Reasoning correlated positively with performance on Theory examinations, but negatively with Skills assessments.
Conclusions
This collaborative study in 12 medical schools shows the power of large-scale studies of medical education for answering previously unanswerable but important questions about medical student selection, education and training. UKCAT has predictive validity as a predictor of medical school outcome, particularly in mature applicants to medical school. UKCAT offers small but significant incremental validity which is operationally valuable where medical schools are making selection decisions based on incomplete measures of educational attainment. The study confirms the validity of using all the existing measures of educational attainment in full at the time of selection decision-making. Contextual measures provide little additional predictive value, except that students from high attaining secondary schools perform less well, an effect previously shown for UK universities in general.
doi:10.1186/1741-7015-11-244
PMCID: PMC3827332  PMID: 24229380
Medical student selection; Educational attainment; Aptitude tests; UKCAT; Socio-economic factors; Contextual measures
3.  Can personal qualities of medical students predict in-course examination success and professional behaviour? An exploratory prospective cohort study 
BMC Medical Education  2012;12:69.
Background
Over two-thirds of UK medical schools are augmenting their selection procedures for medical students by using the United Kingdom Clinical Aptitude Test (UKCAT), which employs tests of cognitive and non-cognitive personal qualities, but clear evidence of the tests’ predictive validity is lacking. This study explores whether academic performance and professional behaviours that are important in a health professional context can be predicted by these measures, when taken before or very early in the medical course.
Methods
This prospective cohort study follows the progress of the entire student cohort who entered Hull York Medical School in September 2007, having taken the UKCAT cognitive tests in 2006 and the non-cognitive tests a year later. This paper reports on the students’ first and second academic years of study. The main outcome measures were regular, repeated tutor assessment of individual students’ interpersonal skills and professional behaviour, and annual examination performance in the three domains of recall and application of knowledge, evaluation of data, and communication and practical clinical skills. The relationships between non-cognitive test scores, cognitive test scores, tutor assessments and examination results were explored using the Pearson product–moment correlations for each group of data; the data for students obtaining the top and bottom 20% of the summative examination results were compared using Analysis of Variance.
Results
Personal qualities measured by non-cognitive tests showed a number of statistically significant relationships with ratings of behaviour made by tutors, with performance in each year’s objective structured clinical examinations (OSCEs), and with themed written summative examination marks in each year. Cognitive ability scores were also significantly related to each year’s examination results, but seldom to professional behaviours. The top 20% of examination achievers could be differentiated from the bottom 20% on both non-cognitive and cognitive measures.
Conclusions
This study shows numerous significant relationships between both cognitive and non-cognitive test scores, academic examination scores and indicators of professional behaviours in medical students. This suggests that measurement of non-cognitive personal qualities in applicants to medical school could make a useful contribution to selection and admission decisions. Further research is required in larger representative groups, and with more refined predictor measures and behavioural assessment methods, to establish beyond doubt the incremental validity of such measures over conventional cognitive assessments.
doi:10.1186/1472-6920-12-69
PMCID: PMC3473297  PMID: 22873571
4.  Widening access to UK medical education for under-represented socioeconomic groups: modelling the impact of the UKCAT in the 2009 cohort 
Objective To determine whether the use of the UK clinical aptitude test (UKCAT) in the medical schools admissions process reduces the relative disadvantage encountered by certain sociodemographic groups.
Design Prospective cohort study.
Setting Applicants to 22 UK medical schools in 2009 that were members of the consortium of institutions utilising the UKCAT as a component of their admissions process.
Participants 8459 applicants (24 844 applications) to UKCAT consortium member medical schools where data were available on advanced qualifications and socioeconomic background.
Main outcome measures The probability of an application resulting in an offer of a place on a medicine course according to seven educational and sociodemographic variables depending on how the UKCAT was used by the medical school (in borderline cases, as a factor in admissions, or as a threshold).
Results On univariate analysis all educational and sociodemographic variables were significantly associated with the relative odds of an application being successful. The multilevel multiple logistic regression models, however, varied between medical schools according to the way that the UKCAT was used. For example, a candidate from a non-professional background was much less likely to receive a conditional offer of a place compared with an applicant from a higher social class when applying to an institution using the test only in borderline cases (odds ratio 0.51, 95% confidence interval 0.45 to 0.60). No such effect was observed for such candidates applying to medical schools using the threshold approach (1.27, 0.84 to 1.91). These differences were generally reflected in the interactions observed when the analysis was repeated, pooling the data. Notably, candidates from several under-represented groups applying to medical schools that used a threshold approach to the UKCAT were less disadvantaged than those applying to the other institutions in the consortium. These effects were partially reflected in significant differences in the absolute proportion of such candidates finally taking up places in the different types of medical schools; stronger use of the test score (as a factor or threshold) was associated with a significantly increased odds of entrants being male (1.74, 1.25 to 2.41) and from a low socioeconomic background (3.57, 1.03 to 12.39). There was a non-significant trend towards entrants being from a state (non-grammar) school (1.60, 0.97 to 2.62) where a stronger use of the test was employed. Use of the test only in borderline cases was associated with increased odds of entrants having relatively low academic attainment (5.19, 2.02 to 13.33) and English as a second language (2.15, 1.03 to 4.48).
Conclusions The use of the UKCAT may lead to more equitable provision of offers to those applying to medical school from under-represented sociodemographic groups. This may translate into higher numbers of some, but not all, relatively disadvantaged students entering the UK medical profession.
doi:10.1136/bmj.e1805
PMCID: PMC3328544  PMID: 22511300
5.  Comparison of the sensitivity of the UKCAT and A Levels to sociodemographic characteristics: a national study 
Background
The UK Clinical Aptitude Test (UKCAT) was introduced to facilitate widening participation in medical and dental education in the UK by providing universities with a continuous variable to aid selection; one that might be less sensitive to the sociodemographic background of candidates compared to traditional measures of educational attainment. Initial research suggested that males, candidates from more advantaged socioeconomic backgrounds and those who attended independent or grammar schools performed better on the test. The introduction of the A* grade at A level permits more detailed analysis of the relationship between UKCAT scores, secondary educational attainment and sociodemographic variables. Thus, our aim was to further assess whether the UKCAT is likely to add incremental value over A level (predicted or actual) attainment in the selection process.
Methods
Data relating to UKCAT and A level performance from 8,180 candidates applying to medicine in 2009 who had complete information relating to six key sociodemographic variables were analysed. A series of regression analyses were conducted in order to evaluate the ability of sociodemographic status to predict performance on two outcome measures: A level ‘best of three’ tariff score; and the UKCAT scores.
Results
In this sample A level attainment was independently and positively predicted by four sociodemographic variables (independent/grammar schooling, White ethnicity, age and professional social class background). These variables also independently and positively predicted UKCAT scores. There was a suggestion that UKCAT scores were less sensitive to educational background compared to A level attainment. In contrast to A level attainment, UKCAT score was independently and positively predicted by having English as a first language and male sex.
Conclusions
Our findings are consistent with a previous report; most of the sociodemographic factors that predict A level attainment also predict UKCAT performance. However, compared to A levels, males and those speaking English as a first language perform better on UKCAT. Our findings suggest that UKCAT scores may be more influenced by sex and less sensitive to school type compared to A levels. These factors must be considered by institutions utilising the UKCAT as a component of the medical and dental school selection process.
doi:10.1186/1472-6920-14-7
PMCID: PMC3893425  PMID: 24400861
Medical student selection; Educational attainment; Aptitude tests; UKCAT; Socio-economic factors
6.  Construct-level predictive validity of educational attainment and intellectual aptitude tests in medical student selection: meta-regression of six UK longitudinal studies 
BMC Medicine  2013;11:243.
Background
Measures used for medical student selection should predict future performance during training. A problem for any selection study is that predictor-outcome correlations are known only in those who have been selected, whereas selectors need to know how measures would predict in the entire pool of applicants. That problem of interpretation can be solved by calculating construct-level predictive validity, an estimate of true predictor-outcome correlation across the range of applicant abilities.
Methods
Construct-level predictive validities were calculated in six cohort studies of medical student selection and training (student entry, 1972 to 2009) for a range of predictors, including A-levels, General Certificates of Secondary Education (GCSEs)/O-levels, and aptitude tests (AH5 and UK Clinical Aptitude Test (UKCAT)). Outcomes included undergraduate basic medical science and finals assessments, as well as postgraduate measures of Membership of the Royal Colleges of Physicians of the United Kingdom (MRCP(UK)) performance and entry in the Specialist Register. Construct-level predictive validity was calculated with the method of Hunter, Schmidt and Le (2006), adapted to correct for right-censorship of examination results due to grade inflation.
Results
Meta-regression analyzed 57 separate predictor-outcome correlations (POCs) and construct-level predictive validities (CLPVs). Mean CLPVs are substantially higher (.450) than mean POCs (.171). Mean CLPVs for first-year examinations, were high for A-levels (.809; CI: .501 to .935), and lower for GCSEs/O-levels (.332; CI: .024 to .583) and UKCAT (mean = .245; CI: .207 to .276). A-levels had higher CLPVs for all undergraduate and postgraduate assessments than did GCSEs/O-levels and intellectual aptitude tests. CLPVs of educational attainment measures decline somewhat during training, but continue to predict postgraduate performance. Intellectual aptitude tests have lower CLPVs than A-levels or GCSEs/O-levels.
Conclusions
Educational attainment has strong CLPVs for undergraduate and postgraduate performance, accounting for perhaps 65% of true variance in first year performance. Such CLPVs justify the use of educational attainment measure in selection, but also raise a key theoretical question concerning the remaining 35% of variance (and measurement error, range restriction and right-censorship have been taken into account). Just as in astrophysics, ‘dark matter’ and ‘dark energy’ are posited to balance various theoretical equations, so medical student selection must also have its ‘dark variance’, whose nature is not yet properly characterized, but explains a third of the variation in performance during training. Some variance probably relates to factors which are unpredictable at selection, such as illness or other life events, but some is probably also associated with factors such as personality, motivation or study skills.
doi:10.1186/1741-7015-11-243
PMCID: PMC3827328  PMID: 24229353
Medical student selection; Undergraduate performance; Postgraduate performance; Educational attainment; Aptitude tests; Criterion-related construct validity; Range restriction; Right censorship; Grade inflation; Markov Chain Monte Carlo algorithm
7.  Comparison of A level and UKCAT performance in students applying to UK medical and dental schools in 2006: cohort study 
Objectives To determine whether the UK Clinical Aptitude Test (UKCAT) adds value to the selection process for school leaver applicants to medical and dental school, and in particular whether UKCAT can reduce the socioeconomic bias known to affect A levels.
Design Cohort study
Setting Applicants to 23 UK medical and dental schools in 2006.
Participants 9884 applicants who took the UKCAT in the UK and who achieved at least three passes at A level in their school leaving examinations (53% of all applicants).
Main outcome measures Independent predictors of obtaining at least AAB at A level and
UKCAT scores at or above the 30th centile for the cohort, for the subsections and the entire test.
Results Independent predictors of obtaining at least AAB at A level were white ethnicity (odds ratio 1.58, 95% confidence interval 1.41 to 1.77), professional or managerial background (1.39, 1.22 to 1.59), and independent or grammar schooling (2.26, 2.02 to 2.52) (all P<0.001). Independent predictors of achieving UKCAT scores at or above the 30th centile for the whole test were male sex (odd ratio 1.48, 1.32 to 1.66), white ethnicity (2.17, 1.94 to 2.43), professional or managerial background (1.34, 1.17 to 1.54), and independent or grammar schooling (1.91, 1.70 to 2.14) (all P<0.001). One major limitation of the study was that socioeconomic status was not volunteered by approximately 30% of the applicants. Those who withheld socioeconomic status data were significantly different from those who provided that information, which may have caused bias in the analysis.
Conclusions UKCAT was introduced with a high expectation of increasing the diversity and fairness in selection for UK medical and dental schools. This study of a major subgroup of applicants in the first year of operation suggests that it has an inherent favourable bias to men and students from a higher socioeconomic class or independent or grammar schools. However, it does provide a reasonable proxy for A levels in the selection process.
doi:10.1136/bmj.c478
PMCID: PMC2824099  PMID: 20160316
8.  Use of UKCAT scores in student selection by UK medical schools, 2006-2010 
BMC Medical Education  2011;11:98.
Background
The United Kingdom Clinical Aptitude Test (UKCAT) is a set of cognitive tests introduced in 2006, taken annually before application to medical school. The UKCAT is a test of aptitude and not acquired knowledge and as such the results give medical schools a standardised and objective tool that all schools could use to assist their decision making in selection, and so provide a fairer means of choosing future medical students.
Selection of students for UK medical schools is usually in three stages: assessment of academic qualifications, assessment of further qualities from the application form submitted via UCAS (Universities and Colleges Admissions Service) leading to invitation to interview, and then selection for offer of a place. Medical schools were informed of the psychometric qualities of the UKCAT subtests and given some guidance regarding the interpretation of results. Each school then decided how to use the results within its own selection system.
Methods
Annual retrospective key informant telephone interviews were conducted with every UKCAT Consortium medical school, using a pre-circulated structured questionnaire. The key points of the interview were transcribed, 'member checked' and a content analysis was undertaken.
Results
Four equally popular ways of using the test results have emerged, described as Borderline, Factor, Threshold and Rescue methods. Many schools use more than one method, at different stages in their selection process. Schools have used the scores in ways that have sought to improve the fairness of selection and support widening participation. Initially great care was taken not to exclude any applicant on the basis of low UKCAT scores alone but it has been used more as confidence has grown.
Conclusions
There is considerable variation in how medical schools use UKCAT, so it is important that they clearly inform applicants how the test will be used so they can make best use of their limited number of applications.
doi:10.1186/1472-6920-11-98
PMCID: PMC3248371  PMID: 22114935
9.  Pilot study of the roles of personality, references, and personal statements in relation to performance over the five years of a medical degree 
BMJ : British Medical Journal  2003;326(7386):429-432.
Objectives
To compare the power of three traditional selection procedures (A levels, personal statements, and references) and one non-traditional selection procedure (personality) to predict performance over the five years of a medical degree.
Design
Cohort study over five years.
Setting
Nottingham medical school.
Participants
Entrants in 1995.
Main outcome measures
A level grades, amounts of information contained in teacher's reference and the student's personal statement, and personality scores examined in relation to 18 different assessments.
Results
Information in the teacher's reference did not consistently predict performance. Information in the personal statement was predictive of clinical aspects of training, whereas A level grades primarily predicted preclinical performance. The personality domain of conscientiousness was consistently the best predictor across the course. A structural model indicated that conscientiousness was positively related to A level grades and preclinical performance but was negatively related to clinical grades.
Conclusion
A teacher's reference is of no practical use in predicting clinical performance of medical students, in contrast to the amount of information contained in the personal statement. Therefore, simple quantification of the personal statement should aid selection. Personality factors, in particular conscientiousness, need to be considered and integrated into selection procedures.
PMCID: PMC163931  PMID: 12595384
10.  Selecting the right medical student 
BMC Medicine  2013;11:245.
Medical student selection is an important but difficult task. Three recent papers by McManus et al. in BMC Medicine have re-examined the role of tests of attainment of learning (A’ levels, GCSEs, SQA) and of aptitude (AH5, UKCAT), but on a much larger scale than previously attempted. They conclude that A’ levels are still the best predictor of future success at medical school and beyond. However, A’ levels account for only 65% of the variance in performance that is found. Therefore, more work is needed to establish relevant assessment of the other 35%.
Please see related research articles http://www.biomedcentral.com/1741-7015/11/242, http://www.biomedcentral.com/1741-7015/11/243 and http://www.biomedcentral.com/1741-7015/11/244.
doi:10.1186/1741-7015-11-245
PMCID: PMC3827327  PMID: 24229397
Medical School Admission; Predictors of performance; Aptitude testing
11.  Admission selection criteria as predictors of outcomes in an undergraduate medical course: A prospective study 
Medical Teacher  2011;33(12):997-1004.
Background
In 1998, a new selection process which utilised an aptitude test and an interview in addition to previous academic achievement was introduced into an Australian undergraduate medical course.
Aims
To test the outcomes of the selection criteria over an 11-year period.
Methods
1174 students who entered the course from secondary school and who enrolled in the MBBS from 1999 through 2009 were studied in relation to specific course outcomes. Regression analyses using entry scores, sex and age as independent variables were tested for their relative value in predicting subsequent academic performance in the 6-year course. The main outcome measures were assessed by weighted average mark for each academic year level; together with results in specific units, defined as either ‘knowledge'-based or ‘clinically’ based.
Results
Previous academic performance and female sex were the major independent positive predictors of performance in the course. The interview score showed positive predictive power during the latter years of the course and in a range of ‘clinically' based units. This relationship was mediated predominantly by the score for communication skills.
Conclusions
Results support combining prior academic achievement with the assessment of communication skills in a structured interview as selection criteria into this undergraduate medical course.
doi:10.3109/0142159X.2011.577123
PMCID: PMC3267525  PMID: 21592024
12.  To what extent does the Health Professions Admission Test-Ireland predict performance in early undergraduate tests of communication and clinical skills? – An observational cohort study 
BMC Medical Education  2013;13:68.
Background
Internationally, tests of general mental ability are used in the selection of medical students. Examples include the Medical College Admission Test, Undergraduate Medicine and Health Sciences Admission Test and the UK Clinical Aptitude Test. The most widely used measure of their efficacy is predictive validity.
A new tool, the Health Professions Admission Test- Ireland (HPAT-Ireland), was introduced in 2009. Traditionally, selection to Irish undergraduate medical schools relied on academic achievement. Since 2009, Irish and EU applicants are selected on a combination of their secondary school academic record (measured predominately by the Leaving Certificate Examination) and HPAT-Ireland score. This is the first study to report on the predictive validity of the HPAT-Ireland for early undergraduate assessments of communication and clinical skills.
Method
Students enrolled at two Irish medical schools in 2009 were followed up for two years. Data collected were gender, HPAT-Ireland total and subsection scores; Leaving Certificate Examination plus HPAT-Ireland combined score, Year 1 Objective Structured Clinical Examination (OSCE) scores (Total score, communication and clinical subtest scores), Year 1 Multiple Choice Questions and Year 2 OSCE and subset scores. We report descriptive statistics, Pearson correlation coefficients and Multiple linear regression models.
Results
Data were available for 312 students. In Year 1 none of the selection criteria were significantly related to student OSCE performance. The Leaving Certificate Examination and Leaving Certificate plus HPAT-Ireland combined scores correlated with MCQ marks.
In Year 2 a series of significant correlations emerged between the HPAT-Ireland and subsections thereof with OSCE Communication Z-scores; OSCE Clinical Z-scores; and Total OSCE Z-scores. However on multiple regression only the relationship between Total OSCE Score and the Total HPAT-Ireland score remained significant; albeit the predictive power was modest.
Conclusion
We found that none of our selection criteria strongly predict clinical and communication skills. The HPAT- Ireland appears to measures ability in domains different to those assessed by the Leaving Certificate Examination. While some significant associations did emerge in Year 2 between HPAT Ireland and total OSCE scores further evaluation is required to establish if this pattern continues during the senior years of the medical course.
doi:10.1186/1472-6920-13-68
PMCID: PMC3667098  PMID: 23663266
Selection; Medical; Student; Validity; Predictive; HPAT-Ireland; Assessment; Cognitive; Ability
13.  The Academic Backbone: longitudinal continuities in educational achievement from secondary school and medical school to MRCP(UK) and the specialist register in UK medical students and doctors 
BMC Medicine  2013;11:242.
Background
Selection of medical students in the UK is still largely based on prior academic achievement, although doubts have been expressed as to whether performance in earlier life is predictive of outcomes later in medical school or post-graduate education. This study analyses data from five longitudinal studies of UK medical students and doctors from the early 1970s until the early 2000s. Two of the studies used the AH5, a group test of general intelligence (that is, intellectual aptitude). Sex and ethnic differences were also analyzed in light of the changing demographics of medical students over the past decades.
Methods
Data from five cohort studies were available: the Westminster Study (began clinical studies from 1975 to 1982), the 1980, 1985, and 1990 cohort studies (entered medical school in 1981, 1986, and 1991), and the University College London Medical School (UCLMS) Cohort Study (entered clinical studies in 2005 and 2006). Different studies had different outcome measures, but most had performance on basic medical sciences and clinical examinations at medical school, performance in Membership of the Royal Colleges of Physicians (MRCP(UK)) examinations, and being on the General Medical Council Specialist Register.
Results
Correlation matrices and path analyses are presented. There were robust correlations across different years at medical school, and medical school performance also predicted MRCP(UK) performance and being on the GMC Specialist Register. A-levels correlated somewhat less with undergraduate and post-graduate performance, but there was restriction of range in entrants. General Certificate of Secondary Education (GCSE)/O-level results also predicted undergraduate and post-graduate outcomes, but less so than did A-level results, but there may be incremental validity for clinical and post-graduate performance. The AH5 had some significant correlations with outcome, but they were inconsistent. Sex and ethnicity also had predictive effects on measures of educational attainment, undergraduate, and post-graduate performance. Women performed better in assessments but were less likely to be on the Specialist Register. Non-white participants generally underperformed in undergraduate and post-graduate assessments, but were equally likely to be on the Specialist Register. There was a suggestion of smaller ethnicity effects in earlier studies.
Conclusions
The existence of the Academic Backbone concept is strongly supported, with attainment at secondary school predicting performance in undergraduate and post-graduate medical assessments, and the effects spanning many years. The Academic Backbone is conceptualized in terms of the development of more sophisticated underlying structures of knowledge ('cognitive capital’ and 'medical capital’). The Academic Backbone provides strong support for using measures of educational attainment, particularly A-levels, in student selection.
doi:10.1186/1741-7015-11-242
PMCID: PMC3827330  PMID: 24229333
Academic Backbone; Secondary school attainment; Undergraduate medical education; Post-graduate medical education; Longitudinal analyses; Continuities; Medical student selection; Cognitive capital; Medical capital; Aptitude tests
14.  Should applicants to Nottingham University Medical School study a non-science A-level? A cohort study 
Background
It has been suggested that studying non-science subjects at A-level should be compulsory for medical students. Our admissions criteria specify only Biology, Chemistry and one or more additional subjects. This study aimed to determine whether studying a non-science subject for A-level is an independent predictor of achievement on the undergraduate medical course.
Methods
The subjects of this retrospective cohort study were 164 students from one entry-year group (October 2000), who progressed normally on the 5-year undergraduate medical course at Nottingham. Pre-admission academic and socio-demographic data and undergraduate course marks were obtained. T-test and hierarchical multiple linear regression analyses were undertaken to identify independent predictors of five course outcomes at different stages throughout the course.
Results
There was no evidence that the choice of science or non-science as the third or fourth A-level subject had any influence on course performance. Demographic variables (age group, sex, and fee status) had some predictive value but ethnicity did not. Pre-clinical course performance was the strongest predictor in the clinical phases (pre-clinical Themes A&B (knowledge) predicted Clinical Knowledge, p < 0.001, and pre-clinical Themes C&D (skills) predicted Clinical Skills, p = < 0.01).
Conclusion
This study of one year group at Nottingham Medical School provided no evidence that the admissions policy on A-level requirements should specify the choice of third or fourth subject.
doi:10.1186/1472-6920-9-5
PMCID: PMC2650695  PMID: 19159444
15.  Predicting the “strugglers”: a case-control study of students at Nottingham University Medical School 
BMJ : British Medical Journal  2006;332(7548):1009-1013.
Objective To identify potential predictors of undergraduate students who struggle during their medical training.
Design Case-control study. Cases were students who had experienced academic or personal difficulties that affected their progression on the course (“strugglers”). Controls were selected at random from the corresponding year cohorts, using a ratio of four controls for each struggler.
Setting University of Nottingham Medical School.
Participants Students who entered the course over five consecutive years.
Main outcome measures Likelihood ratios for independent risk factors for struggling on the course
Results 10-15% of each year's student intake were identified as strugglers. Significant independent predictors of students being in this category were negative comments in the academic reference (likelihood ratio 2.25, 95% confidence intervals 1.44 to 3.50), lower mean examination grade at A level (2.19, 1.37 to 3.51), and the late offer of a place (1.98, 1.19 to 3.30). Male sex was a less significant risk factor (1.70, 1.09 to 2.65) as was a lower grade at GCSE science (2.13, 1.12 to 4.05). In UK students whose ethnicity was known, not being white was a significant predictor of struggling (2.77, 1.52 to 5.05) but the presence of negative comments was not. Age at entry to the course and the possession of a previous degree were not predictive.
Conclusions Our results support retention of existing selection practices relating to academic achievement and critical review of students' references. We plan to undertake further investigation of the reasons why some students, including men, those with late offers and those from ethnic minority backgrounds, may do less well on the Nottingham course.
doi:10.1136/bmj.38730.678310.63
PMCID: PMC1450046  PMID: 16543299
16.  Same admissions tools, different outcomes: a critical perspective on predictive validity in three undergraduate medical schools 
BMC Medical Education  2013;13:173.
Background
Admission to medical school is one of the most highly competitive entry points in higher education. Considerable investment is made by universities to develop selection processes that aim to identify the most appropriate candidates for their medical programs. This paper explores data from three undergraduate medical schools to offer a critical perspective of predictive validity in medical admissions.
Methods
This study examined 650 undergraduate medical students from three Australian universities as they progressed through the initial years of medical school (accounting for approximately 25 per cent of all commencing undergraduate medical students in Australia in 2006 and 2007). Admissions criteria (aptitude test score based on UMAT, school result and interview score) were correlated with GPA over four years of study. Standard regression of each of the three admissions variables on GPA, for each institution at each year level was also conducted.
Results
Overall, the data found positive correlations between performance in medical school, school achievement and UMAT, but not interview. However, there were substantial differences between schools, across year levels, and within sections of UMAT exposed. Despite this, each admission variable was shown to add towards explaining course performance, net of other variables.
Conclusion
The findings suggest the strength of multiple admissions tools in predicting outcomes of medical students. However, they also highlight the large differences in outcomes achieved by different schools, thus emphasising the pitfalls of generalising results from predictive validity studies without recognising the diverse ways in which they are designed and the variation in the institutional contexts in which they are administered. The assumption that high-positive correlations are desirable (or even expected) in these studies is also problematised.
doi:10.1186/1472-6920-13-173
PMCID: PMC3880586  PMID: 24373207
Selection; Predictive validity; Admissions policy
17.  Graduate entry to medicine: widening psychological diversity 
Background
At Nottingham University more than 95% of entrants to the traditional 5-year medical course are school leavers. Since 2003 we have admitted graduate entrants (GEM) to a shortened (4-year) course to 'widen access to students from more disadvantaged backgrounds'. We have recently shown that the GEM course widens academic and socio-demographic diversity of the medical student population. This study explored whether GEM students also bring psychological diversity and whether this could be beneficial.
Methods
We studied: a) 217 and 96 applicants to the Nottingham 5- and 4-year courses respectively, applying in the 2002-3 UCAS cycle, and, b) 246 school leavers starting the 5-year course and 39 graduate entrants to the 4-year course in October 2003. The psychological profiles of the two groups of applicants and two groups of entrants were compared using their performance in the Goldberg 'Big 5' Personality test, the Personal Qualities Assessment (PQA; measuring interpersonal traits and interpersonal values), and the Lovibond and Lovibond measure of depression, anxiety and stress. For the comparison of the Entrants we excluded the 33 school leavers and seven graduates who took the tests as Applicants.
Statistical analyses were undertaken using SPSS software (version 16.0).
Results
Graduate applicants compared to school leaver applicants were significantly more conscientious, more confident, more self controlled, more communitarian in moral orientation and less anxious. Only one of these differences was preserved in the entrants with graduates being less anxious. However, the graduate entrants were significantly less empathetic and conscientious than the school leavers.
Conclusion
This study has shown that school leaver and graduate entrants to medical school differ in some psychological characteristics. However, if confirmed in other studies and if they were manifest in the extreme, not all the traits brought by graduates would be desirable for someone aiming for a medical career.
doi:10.1186/1472-6920-9-67
PMCID: PMC2784445  PMID: 19912642
18.  Predicting academic outcomes in an Australian graduate entry medical programme 
BMC Medical Education  2014;14:31.
Background
Predictive validity studies for selection criteria into graduate entry courses in Australia have been inconsistent in their outcomes. One of the reasons for this inconsistency may have been failure to have adequately considered background disciplines of the graduates as well as other potential confounding socio-demographic variables that may influence academic performance.
Methods
Graduate entrants into the MBBS at The University of Western Australia between 2005 and 2012 were studied (N = 421). They undertook a 6-month bridging course, before joining the undergraduate-entry students for Years 3 through 6 of the medical course. Students were selected using their undergraduate Grade Point Average (GPA), Graduate Australian Medical School Admissions Test scores (GAMSAT) and a score from a standardised interview. Students could apply from any background discipline and could also be selected through an alternative rural entry pathway again utilising these 3 entry scores. Entry scores, together with age, gender, discipline background, rural entry status and a socioeconomic indicator were entered into linear regression models to determine the relative influence of each predictor on subsequent academic performance in the course.
Results
Background discipline, age, gender and selection through the rural pathway were variously related to each of the 3 entry criteria. Their subsequent inclusion in linear regression models identified GPA at entry, being from a health/allied health background and total GAMSAT score as consistent independent predictors of stronger academic performance as measured by the weighted average mark for the core units completed throughout the course. The Interview score only weakly predicted performance later in the course and mainly in clinically-based units. The association of total GAMSAT score with academic performance was predominantly dictated by the score in GAMSAT Section 3 (Reasoning in the biological and physical sciences) with Section 1 (Reasoning in the humanities and social sciences) and Section 2 (Written communication) also contributing either later or early in the course respectively. Being from a more disadvantaged socioeconomic background predicted weaker academic performance early in the course. Being an older student at entry or from a humanities background also predicted weaker academic performance.
Conclusions
This study confirms that both GPA at entry and the GAMSAT score together predict outcomes not only in the early stages of a graduate-entry medical programme but throughout the course. It also indicates that a comprehensive evaluation of the predictive validity of GAMSAT scores, interview scores and undergraduate academic performance as valid selection processes for graduate entry into medical school needs to simultaneously consider the potential confounding influence of graduate discipline background and other socio-demographic factors on both the initial selection parameters themselves as well as subsequent academic performance.
doi:10.1186/1472-6920-14-31
PMCID: PMC3931285  PMID: 24528509
19.  Predictors of Preclinical and Clinical Performance of Minority Medical Students 
Although several studies have examined the relationship between minority students' admissions profiles and performance in the preclinical curriculum, there is a dearth of information about the ability of admissions variables to predict performance in the clerkships and on National Boards, Part II. Consistent with other research, a study of 59 minority students at the Albert Einstein College of Medicine found that the Medical College Aptitude Test (MCAT) chemistry score is the most consistent predictor of performance on internal examinations in years 1 and 2, and on National Boards, Part I. On the Part II examination, however, the only significant correlation is with the MCAT reading score, while the MCAT quantitative score and the recommendation of the premedical advisor are the best predictors of clerkship grades. Since students' mean MCATs and grade point averages (GPAs) are similar to those of all minority students accepted to medical schools in 1982, these findings may be generalized to that larger population.
PMCID: PMC2571388  PMID: 3746929
20.  Predictors of Performance of Minority Students in the First Two Years of a BA/MD Program 
This study examines cognitive and noncognitive selection variables as predictors of multiple criteria of performance for minority and nonminority students entering the University of Missouri-Kansas City School of Medicine between 1972 and 1977. Data analysis aims at identifying characteristics associated with success in the crucial first two years of the combined BA/MD program. Pearson product moment correlations and multiple regression equations have been determined for all selection variables and three criteria measures. A number of nontraditional variables are significantly predictive of minority student performance. The cognitive variables of aptitude test and high school science/mathematics preparation are significant predictors of all three performance measures in both racial groups. The data support the position that separate equations are not necessary to predict performance of minority and nonminority students, but that admission committees, when selecting minority students, should recognize both personal attributes and academic preparation as indicators of potential success or failure.
PMCID: PMC2552906  PMID: 7120493
21.  Comparative attainment of 5-year undergraduate and 4-year graduate entry medical students moving into foundation training 
Background
Graduate entry medicine is a recent innovation in UK medical training. Evidence is sparse at present as to progress and attainment on these programmes. Shared clinical rotations, between an established 5-year and a new graduate entry course, provide the opportunity to compare achievement on clinical assessments. To compare completion and attainment on clinical phase assessments between students on a 4-year graduate entry course and an established 5-year undergraduate medicine course.
Methods
Overall completion rates for the 4 and 5 year courses, fails at first attempt, and scores on 14 clinical assessments, were compared between 171 graduate-entry and 450 undergraduate medical students at the University of Nottingham, comprising two graduating cohorts. Percentage assessment marks were converted to z-scores separately for each graduating year and the normalised marks then combined into a single dataset. Z-score transformed percentage marks were analysed by multivariate analysis of variance and univariate analyses of variance for each summative assessment. Numbers of fails at first attempt were analysed aggregated across all assessments initially, then separately for each assessment using χ2.
Results
Completion rates were around 90% overall and significantly higher in the graduate entry course. Failures of assessments overall were similar, but a higher proportion of graduate entry students failed the final OSLER. Mean performance on clinical assessments showed a significant overall difference, made up of lower performance on 4 of 5 knowledge-based exams (as well as higher performance on the first exam) by the graduate entry group, but similar levels of performance on all the skills-based and attitudinal assessments.
Conclusions
High completion rates are encouraging. The lower performance in some knowledge-based exams may reflect lower prior educational attainment, a substantially different demographic profile (age, gender), or an artefact of the first 2 years of a new graduate entry programme.
doi:10.1186/1472-6920-9-76
PMCID: PMC2808300  PMID: 20028543
22.  The Hamburg Selection Procedure for Dental Students – Introduction of the HAM-Nat as subject-specific test for study aptitude  
Introduction: The present study examines the question whether the selection of dental students should be based solely on average school-leaving grades (GPA) or whether it could be improved by using a subject-specific aptitude test.
Methods: The HAM-Nat Natural Sciences Test was piloted with freshmen during their first study week in 2006 and 2007. In 2009 and 2010 it was used in the dental student selection process. The sample size in the regression models varies between 32 and 55 students.
Results: Used as a supplement to the German GPA, the HAM-Nat test explained up to 12% of the variance in preclinical examination performance. We confirmed the prognostic validity of GPA reported in earlier studies in some, but not all of the individual preclinical examination results.
Conclusion: The HAM-Nat test is a reliable selection tool for dental students. Use of the HAM-Nat yielded a significant improvement in prediction of preclinical academic success in dentistry.
PMCID: PMC3839074  PMID: 24282449
student selection dentistry; prediction of study success; admission test
23.  Factors related to medical school application and acceptance in minority summer enrichment program students. 
Baylor College of Medicine has conducted a summer enrichment program for minority/disadvantaged premedical students since 1969. Follow-up data on medical school application and acceptance for participants from 1980 through 1984 were analyzed in relation to selected preprogram variables--cumulative college grade point average, total Scholastic Aptitude Test score, competitiveness of undergraduate college, sex, and ethnicity. Results of univariate and multivariate analyses indicated that: 1) females were significantly less likely to apply to medical school than males, 2) females had significantly lower mean MCAT scores (5.9 vs 7.2) even though their preprogram academic performance was comparable to that of the males, and 3) after controlling for MCAT scores, none of the preprogram variables were significant in predicting medical school acceptance. These findings suggest the need for research to explain the discrepancy between male and female MCAT performance and frequency of medical school application in summer program participants. The findings also have implications for the type of counseling provided to female participants in summer enrichment programs.
PMCID: PMC2627148  PMID: 1920520
24.  Development of a 'toolkit' to identify medical students at risk of failure to thrive on the course: an exploratory retrospective case study 
BMC Medical Education  2011;11:95.
Background
An earlier study at Nottingham suggested that 10-15% of the medical student intake was likely to fail completely or have substantial problems on the course. This is a problem for the students, the Faculty, and society as a whole. If struggling students could be identified early in the course and additional pastoral resources offered, some of this wastage might be avoided. An exploratory case study was conducted to determine whether there were common indicators in the early years, over and above academic failure, that might aid the identification of students potentially at risk.
Methods
The study group was drawn from five successive cohorts. Students who had experienced difficulties were identified in any of four ways: from Minutes of the Academic Progress Committee; by scanning examination lists at key stages (end of the first two years, and finals at the end of the clinical course); from lists of students flagged to the Postgraduate Deanery as in need of extra monitoring or support; and from progress files of those who had left the course prematurely. Relevant data were extracted from each student's course progress file into a customised database.
Results
1188 students were admitted over the five years. 162 (14%) were identified for the study, 75 of whom had failed to complete the course by October 2010. In the 87 who did graduate, a combination of markers in Years 1 and 2 identified over half of those who would subsequently have the most severe problems throughout the course. This 'toolkit' comprised failure of 3 or more examinations per year, an overall average of <50%, health or social difficulties, failure to complete Hepatitis B vaccination on time, and remarks noted about poor attitude or behaviour.
Conclusions
A simple toolkit of academic and non-academic markers could be used routinely to help identify potential strugglers at an early stage, enabling additional support and guidance to be given to these students.
doi:10.1186/1472-6920-11-95
PMCID: PMC3229499  PMID: 22098629
25.  Western medical ethics taught to junior medical students can cross cultural and linguistic boundaries 
BMC Medical Ethics  2004;5:4.
Background
Little is known about teaching medical ethics across cultural and linguistic boundaries. This study examined two successive cohorts of first year medical students in a six year undergraduate MBBS program.
Methods
The objective was to investigate whether Arabic speaking students studying medicine in an Arabic country would be able to correctly identify some of the principles of Western medical ethical reasoning. This cohort study was conducted on first year students in a six-year undergraduate program studying medicine in English, their second language at a medical school in the Arabian Gulf. The ethics teaching was based on the four-principle approach (autonomy, beneficence, non-malfeasance and justice) and delivered by a non-Muslim native English speaker with no knowledge of the Arabic language. Although the course was respectful of Arabic culture and tradition, the content excluded an analysis of Islamic medical ethics and focused on Western ethical reasoning. Following two 45-minute interactive seminars, students in groups of 3 or 4 visited a primary health care centre for one morning, sitting in with an attending physician seeing his or her patients in Arabic. Each student submitted a personal report for summative assessment detailing the ethical issues they had observed.
Results
All 62 students enrolled in these courses participated. Each student acting independently was able to correctly identify a median number of 4 different medical ethical issues (range 2–9) and correctly identify and label accurately a median of 2 different medical ethical issues (range 2–7) There were no significant correlations between their English language skills or general academic ability and the number or accuracy of ethical issues identified.
Conclusions
This study has demonstrated that these students could identify medical ethical issues based on Western constructs, despite learning in English, their second language, being in the third week of their medical school experience and with minimal instruction. This result was independent of their academic and English language skills suggesting that ethical principles as espoused in the four principal approach may be common to the students' Islamic religious beliefs, allowing them to access complex medical ethical reasoning skills at an early stage in the medical curriculum.
doi:10.1186/1472-6939-5-4
PMCID: PMC509252  PMID: 15283868

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