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1.  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
2.  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
3.  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
4.  Predictive validity of the UK clinical aptitude test in the final years of medical school: a prospective cohort study 
BMC Medical Education  2014;14:88.
Background
The UK Clinical Aptitude Test (UKCAT) was designed to address issues identified with traditional methods of selection. This study aims to examine the predictive validity of the UKCAT and compare this to traditional selection methods in the senior years of medical school. This was a follow-up study of two cohorts of students from two medical schools who had previously taken part in a study examining the predictive validity of the UKCAT in first year.
Methods
The sample consisted of 4th and 5th Year students who commenced their studies at the University of Aberdeen or University of Dundee medical schools in 2007. Data collected were: demographics (gender and age group), UKCAT scores; Universities and Colleges Admissions Service (UCAS) form scores; admission interview scores; Year 4 and 5 degree examination scores. Pearson’s correlations were used to examine the relationships between admissions variables, examination scores, gender and age group, and to select variables for multiple linear regression analysis to predict examination scores.
Results
Ninety-nine and 89 students at Aberdeen medical school from Years 4 and 5 respectively, and 51 Year 4 students in Dundee, were included in the analysis. Neither UCAS form nor interview scores were statistically significant predictors of examination performance. Conversely, the UKCAT yielded statistically significant validity coefficients between .24 and .36 in four of five assessments investigated. Multiple regression analysis showed the UKCAT made a statistically significant unique contribution to variance in examination performance in the senior years.
Conclusions
Results suggest the UKCAT appears to predict performance better in the later years of medical school compared to earlier years and provides modest supportive evidence for the UKCAT’s role in student selection within these institutions. Further research is needed to assess the predictive validity of the UKCAT against professional and behavioural outcomes as the cohort commences working life.
doi:10.1186/1472-6920-14-88
PMCID: PMC4008381  PMID: 24762134
UKCAT; Predictive validity; Psychometric; Assessment; Selection; Admissions; Aptitude
5.  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
6.  Predictive power of UKCAT and other pre-admission measures for performance in a medical school in Glasgow: a cohort study 
BMC Medical Education  2014;14:116.
Background
The UK Clinical Aptitude Test (UKCAT) and its four subtests are currently used by 24 Medical and Dental Schools in the UK for admissions. This longitudinal study examines the predictive validity of UKCAT for final performance in the undergraduate medical degree programme at one Medical School and compares this with the predictive validity of the selection measures available pre-UKCAT.
Methods
This was a retrospective observational study of one cohort of students, admitted to Glasgow Medical School in 2007. We examined the associations which UKCAT scores, school science grades and pre-admissions interview scores had with performance indicators, particularly final composite scores that determine students’ postgraduate training opportunities and overall ranking (Educational Performance Measure - EPM, and Honours and Commendation – H&C). Analyses were conducted both with and without adjustment for potential socio-demographic confounders (gender, age, ethnicity and area deprivation).
Results
Despite its predictive value declining as students progress through the course, UKCAT was associated with the final composite scores. In mutually adjusted analyses (also adjusted for socio-demographic confounders), only UKCAT total showed independent relationships with both EPM (p = 0.005) and H&C (p = 0.004), school science achievements predicted EPM (p = 0.009), and pre-admissions interview score predicted neither. UKCAT showed less socio-demographic variation than did TSS.
Conclusion
UKCAT has a modest predictive power for overall course performance at the University of Glasgow Medical School over and above that of school science achievements or pre-admission interview score and we conclude that UKCAT is the most useful predictor of final ranking.
doi:10.1186/1472-6920-14-116
PMCID: PMC4063234  PMID: 24919950
UKCAT; Predictive validity; Widening participation; Socio-economic indicators; Admissions interview; School HE participation rate
7.  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
8.  The value of the UK Clinical Aptitude Test in predicting pre-clinical performance: a prospective cohort study at Nottingham Medical School 
BMC Medical Education  2010;10:55.
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 (Quantitative Reasoning, Verbal Reasoning, Abstract Reasoning, and Decision Analysis), and the results are available to students and admissions panels in advance of the selection process. As yet the predictive validity of the test against course performance is largely unknown.
The study objective was to determine whether UKCAT scores predict performance during the first two years of the 5-year undergraduate medical course at Nottingham.
Methods
We studied a single cohort of students, who entered Nottingham Medical School in October 2007 and had taken the UKCAT. We used linear regression analysis to identify independent predictors of marks for different parts of the 2-year preclinical course.
Results
Data were available for 204/260 (78%) of the entry cohort. The UKCAT total score had little predictive value. Quantitative Reasoning was a significant independent predictor of course marks in Theme A ('The Cell'), (p = 0.005), and Verbal Reasoning predicted Theme C ('The Community') (p < 0.001), but otherwise the effects were slight or non-existent.
Conclusion
This limited study from a single entry cohort at one medical school suggests that the predictive value of the UKCAT, particularly the total score, is low. Section scores may predict success in specific types of course assessment.
The ultimate test of validity will not be available for some years, when current cohorts of students graduate. However, if this test of mental ability does not predict preclinical performance, it is arguably less likely to predict the outcome in the clinical years. Further research from medical schools with different types of curriculum and assessment is needed, with longitudinal studies throughout the course.
doi:10.1186/1472-6920-10-55
PMCID: PMC2922293  PMID: 20667093
9.  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
10.  Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study 
BMJ : British Medical Journal  1998;317(7166):1111-1117.
Objective To assess the relation between a range of measures and the likelihood of applicants to medical schools in the United Kingdom being offered a place overall and at each medical school, with particular emphasis on ethnic minority applicants.
Design Data provided by the Universities and Colleges Admissions Service on 92 676 applications to medical schools from 18 943 candidates for admission in 1996 and 1997. Statistical analysis was by multiple logistic regression.
Main outcome measures Receipt of a conditional or unconditional offer of a place at medical school.
Results Eighteen separate measures were independently associated with the overall likelihood of receiving an offer. Applicants from ethnic minority groups were disadvantaged, as were male applicants, applicants applying late in the selection season, applicants making non-medical (so called insurance) choices, applicants requesting deferred entry (so called gap year), and applicants at further or higher education or sixth form colleges. Analysis at individual medical schools showed different patterns of measures that predicted offers. Not all schools disadvantaged applicants from ethnic minority groups and the effect was stable across the two years, suggesting structural differences in the process of selection. The degree of disadvantage did not relate to the proportion of applicants from ethnic minority groups.
Conclusions The data released by the Council of Heads of Medical Schools allow a detailed analysis of the selection process at individual medical schools. The results suggest several areas in which some candidates are disadvantaged, in particular those from ethnic minority groups. Similar data in the future will allow monitoring of changes in selection processes.
Key messagesThe Council of Heads of Medical Schools has made publicly available, on the website of the Universities and Colleges Admissions Service, detailed data on individual applications for medical school in 1996 and 1997These data allow analysis of factors influencing selection at individual medical schools in the United Kingdom, although some important measures such as GCSE grades, estimated A level grades, and assessments of personal attributes are not availableIn 1996-7 certain groups, in particular ethnic minority groups and male applicants, were disadvantaged during selectionThe disadvantage of applicants from ethnic minority groups seems stable across years, with some schools consistently showing no evidence of disadvantageProvision of similar data in the future will allow continued monitoring of selection and of the proposals for change made by the council
PMCID: PMC28692  PMID: 9784446
11.  Medical school applicants from ethnic minority groups: identifying if and when they are disadvantaged. 
BMJ : British Medical Journal  1995;310(6978):496-500.
OBJECTIVE--To assess whether people from ethnic minority groups are less likely to be accepted at British medical schools, and to explore the mechanisms of disadvantage. DESIGN--Prospective study of a national cohort of medical school applicants. SETTING--All 28 medical schools in the United Kingdom. SUBJECTS--6901 subjects who had applied through the Universities' Central Council on Admissions in 1990 to study medicine. MAIN OUTCOME MEASURES--Offers and acceptance at medical school by ethnic group. RESULTS--Applicants from ethnic minority groups constituted 26.3% of those applying to medical school. They were less likely to be accepted, partly because they were less well qualified and applied later. Nevertheless, taking educational and some other predictors into account, applicants from ethnic minority groups were 1.46 times (95% confidence interval 1.19 to 1.74) less likely to be accepted. Having a European surname predicted acceptance better than ethnic origin itself, implying direct discrimination rather than disadvantage secondary to other possible differences between white and non-white applicants. Applicants from ethnic minority groups fared significantly less well in 12 of the 28 British medical schools. Analysis of the selection process suggests that medical schools make fewer offers to such applicants than to others with equivalent estimated A level grades. CONCLUSIONS--People from ethnic minority groups applying to medical school are disadvantaged, principally because ethnic origin is assessed from a candidate's surname; the disadvantage has diminished since 1986. For subjects applying before A level the mechanism is that less credit is given to referees' estimates of A level grades. Selection would be fairer if (a) application forms were anonymous; (b) forms did not include estimates of A level grades; and (c) selection took place after A level results are known.
PMCID: PMC2548873  PMID: 7888888
12.  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
13.  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
14.  The educational background and qualifications of UK medical students from ethnic minorities 
Background
UK medical students and doctors from ethnic minorities underperform in undergraduate and postgraduate examinations. Although it is assumed that white (W) and non-white (NW) students enter medical school with similar qualifications, neither the qualifications of NW students, nor their educational background have been looked at in detail. This study uses two large-scale databases to examine the educational attainment of W and NW students.
Methods
Attainment at GCSE and A level, and selection for medical school in relation to ethnicity, were analysed in two separate databases. The 10th cohort of the Youth Cohort Study provided data on 13,698 students taking GCSEs in 1999 in England and Wales, and their subsequent progression to A level. UCAS provided data for 1,484,650 applicants applying for admission to UK universities and colleges in 2003, 2004 and 2005, of whom 52,557 applied to medical school, and 23,443 were accepted.
Results
NW students achieve lower grades at GCSE overall, although achievement at the highest grades was similar to that of W students. NW students have higher educational aspirations, being more likely to go on to take A levels, especially in science and particularly chemistry, despite relatively lower achievement at GCSE. As a result, NW students perform less well at A level than W students, and hence NW students applying to university also have lower A-level grades than W students, both generally, and for medical school applicants. NW medical school entrants have lower A level grades than W entrants, with an effect size of about -0.10.
Conclusion
The effect size for the difference between white and non-white medical school entrants is about B0.10, which would mean that for a typical medical school examination there might be about 5 NW failures for each 4 W failures. However, this effect can only explain a portion of the overall effect size found in undergraduate and postgraduate examinations of about -0.32.
doi:10.1186/1472-6920-8-21
PMCID: PMC2359745  PMID: 18416818
15.  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
16.  Online Schools and Children With Special Health and Educational Needs: Comparison With Performance in Traditional Schools 
Background
In the United States, primary and secondary online schools are institutions that deliver online curricula for children enrolled in kindergarten through 12th grade (K-12). These institutions commonly provide opportunities for online instruction in conjunction with local schools for students who may need remediation, have advanced needs, encounter unqualified local instructors, or experience scheduling conflicts. Internet-based online schooling may potentially help children from populations known to have educational and health disadvantages, such as those from certain racial or ethnic backgrounds, those of low socioeconomic status, and children with special health care needs (CSHCN).
Objective
To describe the basic and applied demographics of US online-school users and to compare student achievement in traditional versus online schooling environments.
Methods
We performed a brief parental survey in three states examining basic demographics and educational history of the child and parents, the child’s health status as measured by the CSHCN Screener, and their experiences and educational achievement with online schools and class(es). Results were compared with state public-school demographics and statistical analyses controlled for state-specific independence.
Results
We analyzed responses from 1971 parents with a response rate of 14.7% (1971/13,384). Parents of online-school participants were more likely to report having a bachelor’s degree or higher than were parents of students statewide in traditional schools, and more of their children were white and female. Most notably, the prevalence of CSHCN was high (476/1971, 24.6%) in online schooling. Children who were male, black, or had special health care needs reported significantly lower grades in both traditional and online schools. However, when we controlled for age, gender, race, and parental education, parents of CSHCN or black children reported significantly lower grades in online than in traditional schooling (adjusted odds ratio [aOR] 1.45, 95% confidence interval [CI] 1.29–1.62 for CSHCN, P < .001; aOR 2.73, 95% CI 2.11–3.53 for black children, P < .001.) In contrast, parents with a bachelor’s degree or higher reported significantly higher online-school grades than traditional-school grades for their children (aOR 1.45, 95% CI 1.15–1.82, P < .001).
Conclusions
The demographics of children attending online schools do not mirror those of the state-specific school populations. CSHCN seem to opt into online schools at a higher rate. While parents report equivalent educational achievement in online and traditional classrooms, controlling for known achievement risks suggests that CSHCN and black children have lower performance in online than in traditional schools. Given the millions of students now in online schools, future studies must test whether direct assistance in online schools, such as taking individualized education plans into consideration, will narrow known disparities in educational success. Only then can online schools emerge as a true educational alternative for at-risk populations.
doi:10.2196/jmir.1947
PMCID: PMC3384422  PMID: 22547538
Virtual schooling; schools; K-12; children with special health care needs; online learning; education, adolescent health services, special education
17.  Rural medical students at urban medical schools: Too few and far between? 
Open Medicine  2007;1(1):e13-e17.
Background
Rural regions of industrialized nations are experiencing a crisis in health care access, reflecting a high disease burden and a low physician supply. The maldistribution of physicians stems partly from the low rate of entry into medical school of applicants from rural backgrounds.
Methods
We analyzed applicants to the University of Toronto medical school in 2005 (n = 2052) to test for possible institutional bias against rural applicants and possible applicant bias against the institution. The designation of rurality was assigned using the Statistics Canada classification of residential postal codes to detect residence in communities with a population of fewer than 10,000 people.
Results
Consistent with past reports, rural applicants were under-represented (n = 93, 4.5% of applicants relative to 20% of baseline population). Rural applicants, on average, were equally competitive with urban applicants as measured by grades, test scores, and interviews. Rural applicants were just as likely as urban applicants to be offered admission (17% vs 14%, p = 0.43), indicating no large bias from the institution. Rural applicants, however, were more than twice as likely to decline the admission offer (69% vs 24%, p < 0.001), indicating a large bias against the institution. This discrepancy was not explained by financial disparity and was not confined to those applicants most likely to receive invitations to other schools.
Conclusions
Programs to increase physician supply in rural areas need to address students' concealed preferences that are established before enrolment. Medical schools, in particular, need to encourage more rural students to apply and to persuade those offered admission to accept.
PMCID: PMC2801916  PMID: 20101285
18.  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
19.  Canadian Applicants to Medical Schools in Canada for 1965-66 
An examination of applicants to Canadian medical schools for 1965-66 revealed that 4660 applications were received by the 12 schools for approximately 900 places available; 2852 of these were from Canadians, but because many applicants applied to more than one school, these 2852 applications represented only 1767 individuals. Evaluations made by the schools concerning the acceptability of these applicants showed that only 36 persons rated as “acceptable” by one or more schools failed to gain admission to any Canadian school for 1965-66. Furthermore, 66 “marginal” applicants were accepted, as were 130 multiple applicants who were rated as “acceptable” by one school but “marginal” and/or “unacceptable” by one or more other schools. Of the 464 multiple applicants, only 40% received the same evaluation from all schools to which they applied. If those multiple applicants who were rated as acceptable by all schools to which they applied are added to single applicants rated as acceptable, the pool of these clearly acceptable candidates (40% of all Canadian applicants) is sufficient only to fill 78% of places available. It was thus concluded that it is erroneous to speak of a surplus of well-qualified Canadian applicants at the present time.
PMCID: PMC1935450  PMID: 5908424
20.  Wrong schools or wrong students? The potential role of medical education in regional imbalances of the health workforce in the United Republic of Tanzania 
Background
The United Republic of Tanzania, like many other countries in sub-Saharan Africa, faces a human resources crisis in its health sector, with a small and inequitably distributed health workforce. Rural areas and other poor regions are characterised by a high burden of disease compared to other regions of the country. At the same time, these areas are poorly supplied with human resources compared to urban areas, a reflection of the situation in the whole of Sub-Saharan Africa, where 1.3% of the world's health workforce shoulders 25% of the world's burden of disease. Medical schools select candidates for training and form these candidates' professional morale. It is therefore likely that medical schools can play an important role in the problem of geographical imbalance of doctors in the United Republic of Tanzania.
Methods
This paper reviews available research evidence that links medical students' characteristics with human resource imbalances and the contribution of medical schools in perpetuating an inequitable distribution of the health workforce.
Existing literature on the determinants of the geographical imbalance of clinicians, with a special focus on the role of medical schools, is reviewed. In addition, structured questionnaires collecting data on demographics, rural experience, working preferences and motivational aspects were administered to 130 fifth-year medical students at the medical faculties of MUCHS (University of Dar es Salaam), HKMU (Dar es Salaam) and KCMC (Tumaini University, Moshi campus) in the United Republic of Tanzania. The 130 students represented 95.6% of the Tanzanian finalists in 2005. Finally, we apply probit regressions in STATA to analyse the cross-sectional data coming from the aforementioned survey.
Results
The lack of a primary interest in medicine among medical school entrants, biases in recruitment, the absence of rural related clinical curricula in medical schools, and a preference for specialisation not available in rural areas are among the main obstacles for building a motivated health workforce which can help correct the inequitable distribution of doctors in the United Republic of Tanzania.
Conclusion
This study suggests that there is a need to re-examine medical school admission policies and practices.
doi:10.1186/1478-4491-8-3
PMCID: PMC2837610  PMID: 20187942
21.  A survey and analysis of student academic support programs in medical schools focus: underrepresented minority students. 
This article describes an investigation that compiled information regarding academic support for medical students at 120 US medical schools. Specifically, the purpose of the study was to identify programs for underrepresented minority medical students and to review prospective applicant materials for photographic evidence that underrepresented minorities are involved in medical education. Eighty-three responses were returned and analyzed. Academic support services described most frequently were prematriculation, tutoring, and counseling and advising. Forty-one of the 83 schools indicated they offer prematriculation programs, 28 of which were required of under-represented minority freshmen entrants. Fifteen described offerings for undergraduate students and six for both undergraduate and secondary school students. Materials from the University of Iowa, the University of Medicine and Dentistry of New Jersey, and Stanford University revealed a variety of services and the largest numbers of photographs of under-represented minorities. These institutions are also among the leaders in underrepresented minority enrollment. Effective communication of academic support and minority presence appear to be contributory factors in enhancing diversity in medical education. Further investigation of academic support, evaluation of support services by participants, and dialogue about effective components of quality academic support are logical next steps to achieve the Association of American Medical College's goal of 3000 by 2000.
PMCID: PMC2607663  PMID: 8046766
22.  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
23.  Increasing the pool of qualified minority medical school applicants: premedical training at historically black colleges and universities. 
Public Health Reports  1994;109(1):77-85.
Historically black colleges and universities have educated significant numbers of black students preparing for careers in medicine. These institutions have the potential to make even greater contributions to the pool of black medical school applicants and ultimately to the supply of black physicians. The Division of Disadvantaged Assistance, Bureau of Health Professions, Health Resources and Services Administration within the Public Health Service, commissioned a study of the curriculums and other factors related to premedical education. The study was conducted at the historically black colleges and universities that graduate a large number of students who gain admission to medical school, and the historically black colleges and universities whose students are less successful in gaining admission to medical school. Nine historically black colleges and universities participated in a self-assessment of their undergraduate premedical curriculums. The findings from schools with higher acceptance rates were compared with those of schools with lower acceptance rates to identify factors contributing to the production of significant numbers of successful medical school applicants. Comparisons of data on these schools revealed several important factors that may be related to differences in acceptance rates: Those schools that devoted greater effort to premedical training (for example, advising students about how to prepare for medical school, curriculum development, maintaining premedical or pre-health professions offices and clubs--the staff of these offices provide students with information on medical or other health professions schools--to identify and recruit students) tended to have higher acceptance rates.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1402245  PMID: 8303019
24.  Guidelines, Editors, Pharma And The Biological Paradigm Shift 
Mens Sana Monographs  2007;5(1):27-30.
Private investment in biomedical research has increased over the last few decades. At most places it has been welcomed as the next best thing to technology itself. Much of the intellectual talent from academic institutions is getting absorbed in lucrative positions in industry. Applied research finds willing collaborators in venture capital funded industry, so a symbiotic growth is ensured for both.
There are significant costs involved too. As academia interacts with industry, major areas of conflict of interest especially applicable to biomedical research have arisen. They are related to disputes over patents and royalty, hostile encounters between academia and industry, as also between public and private enterprise, legal tangles, research misconduct of various types, antagonistic press and patient-advocate lobbies and a general atmosphere in which commercial interest get precedence over patient welfare.
Pharma image stinks because of a number of errors of omission and commission. A recent example is suppression of negative findings about Bayer's Trasylol (Aprotinin) and the marketing maneuvers of Eli Lilly's Xigris (rhAPC). Whenever there is a conflict between patient vulnerability and profit motives, pharma often tends to tilt towards the latter. Moreover there are documents that bring to light how companies frequently cross the line between patient welfare and profit seeking behaviour.
A voluntary moratorium over pharma spending to pamper drug prescribers is necessary. A code of conduct adopted recently by OPPI in India to limit pharma company expenses over junkets and trinkets is a welcome step.
Clinical practice guidelines (CPG) are considered important as they guide the diagnostic/therapeutic regimen of a large number of medical professionals and hospitals and provide recommendations on drugs, their dosages and criteria for selection. Along with clinical trials, they are another area of growing influence by the pharmaceutical industry. For example, in a relatively recent survey of 2002, it was found that about 60% of 192 authors of clinical practice guidelines reported they had financial connections with the companies whose drugs were under consideration. There is a strong case for making CPGs based not just on effectivity but cost effectivity. The various ramifications of this need to be spelt out. Work of bodies like the Appraisal of Guidelines Research and Evaluation (AGREE) Collaboration and Guidelines Advisory Committee (GAC) are also worth a close look.
Even the actions of Foundations that work for disease amelioration have come under scrutiny. The process of setting up ‘Best Practices’ Guidelines for interactions between the pharmaceutical industry and clinicians has already begun and can have important consequences for patient care. Similarly, Good Publication Practice (GPP) for pharmaceutical companies have also been set up aimed at improving the behaviour of drug companies while reporting drug trials
The rapidly increasing trend toward influence and control by industry has become a concern for many. It is of such importance that the Association of American Medical Colleges has issued two relatively new documents - one, in 2001, on how to deal with individual conflicts of interest; and the other, in 2002, on how to deal with institutional conflicts of interest in the conduct of clinical research. Academic Medical Centers (AMCs), as also medical education and research institutions at other places, have to adopt means that minimize their conflicts of interest.
Both medical associations and research journal editors are getting concerned with individual and institutional conflicts of interest in the conduct of clinical research and documents are now available which address these issues. The 2001 ICMJE revision calls for full disclosure of the sponsor's role in research, as well as assurance that the investigators are independent of the sponsor, are fully accountable for the design and conduct of the trial, have independent access to all trial data and control all editorial and publication decisions. However the findings of a 2002 study suggest that academic institutions routinely participate in clinical research that does not adhere to ICMJE standards of accountability, access to data and control of publication.
There is an inevitable slant to produce not necessarily useful but marketable products which ensure the profitability of industry and research grants outflow to academia. Industry supports new, not traditional, therapies, irrespective of what is effective. Whatever traditional therapy is supported is most probably because the company concerned has a product with a big stake there, which has remained a ‘gold standard’ or which that player thinks has still some ‘juice’ left.
Industry sponsorship is mainly for potential medications, not for trying to determine whether there may be non-pharmacological interventions that may be equally good, if not better. In the paradigm shift towards biological psychiatry, the role of industry sponsorship is not overt but probably more pervasive than many have realised, or the right thinking may consider good, for the health of the branch in the long run.
An issue of major concern is protection of the interests of research subjects. Patients agree to become research subjects not only for personal medical benefit but, as an extension, to benefit the rest of the patient population and also advance medical research.
We all accept that industry profits have to be made, and investment in research and development by the pharma industry is massive. However, we must also accept there is a fundamental difference between marketing strategies for other entities and those for drugs.
The ultimate barometer is patient welfare and no drug that compromises it can stand the test of time. So, how does it make even commercial sense in the long term to market substandard products? The greatest mistake long-term players in industry may make is try to adopt the shady techniques of the upstart new entrant. Secrecy of marketing/sales tactics, of the process of manufacture, of other strategies and plans of business expansion, of strategies to tackle competition are fine business tactics. But it is critical that secrecy as a tactic not extend to reporting of research findings, especially those contrary to one's product.
Pharma has no option but to make a quality product, do comprehensive adverse reaction profiles, and market it only if it passes both tests.
Why does pharma adopt questionable tactics? The reasons are essentially two:
What with all the constraints, a drug comes to the pharmacy after huge investments. There are crippling overheads and infrastructure costs to be recovered. And there are massive profit margins to be maintained. If these were to be dependent only on genuine drug discoveries, that would be taking too great a risk.Industry players have to strike the right balance between profit making and credibility. In profit making, the marketing champions play their role. In credibility ratings, researchers and paid spokes-persons play their role. All is hunky dory till marketing is based on credibility. When there is nothing available to make for credibility, something is projected as one and marketing carried out, in the calculated hope that profits can accrue, since profit making must continue endlessly. That is what makes pharma adopt even questionable means to make profits.
Essentially, there are four types of drugs. First, drugs that work and have minimal side-effects; second, drugs which work but have serious side-effects; third, drugs that do not work and have minimal side-effects; and fourth, drugs which work minimally but have serious side-effects. It is the second and fourth types that create major hassles for industry. Often, industry may try to project the fourth type as the second to escape censure.
The major cat and mouse game being played by conscientious researchers is in exposing the third and fourth for what they are and not allowing industry to palm them off as the first and second type respectively. The other major game is in preventing the second type from being projected as the first. The third type are essentially harmless, so they attract censure all right and some merriment at the antics to market them. But they escape anything more than a light rap on the knuckles, except when they are projected as the first type.
What is necessary for industry captains and long-term players is to realise:
Their major propelling force can only be producing the first type. 2. They accept the second type only till they can lay their hands on the first. 3. The third type can be occasionally played around with to shore up profits, but never by projecting them as the first type. 4. The fourth type are the laggards, real threat to credibility and therefore do not deserve any market hype or promotion.
In finding out why most pharma indulges in questionable tactics, we are lead to some interesting solutions to prevent such tactics with the least amount of hassles for all concerned, even as both profits and credibility are kept intact.
doi:10.4103/0973-1229.32176
PMCID: PMC3192391  PMID: 22058616
Academia; Pharmaceutical Industry; Clinical Practice Guidelines; Best Practice Guidelines; Academic Medical Centers; Medical Associations; Research Journals; Clinical Research; Public Welfare; Pharma Image; Corporate Welfare; Biological Psychiatry; Law Suits Against Industry
25.  International students in United States’ medical schools: does the medical community know they exist? 
Medical Education Online  2012;17:10.3402/meo.v17i0.15748.
Background
Matriculation of international students to United States’ (US) medical schools has not mirrored the remarkable influx of these students to other US institutions of higher education.
Methods
While these students’ numbers are on the rise, the visibility for their unique issues remains largely ignored in the medical literature.
Results
These students are disadvantaged in the medical school admissions process due to financial and immigration-related concerns, and academic standards for admittance also continue to be significantly higher compared with their US-citizen peers. Furthermore, it is simply beyond the mission of many medical schools – both public and private – to support international students’ education, especially since federal, state-allocated or institutional funds are limited and these institutions have a commitment to fulfill the healthcare education needs of qualified domestic candidates. In spite of these obstacles, a select group of international students do gain admission to US medical schools and, upon graduation, are credentialed equally as their US-citizen counterparts by the Accreditation Council for Graduate Medical Education (ACGME). However, owing to their foreign citizenship, these students have visa requirements for post-graduate training that may adversely impact their candidacy for residency placement.
Conclusion
By raising such issues, this article aims to increase the awareness of considerations pertinent to this unique population of medical students. The argument is also made to support continued recruitment of international students to US medical schools in spite of these impediments. In our experience, these students are not only qualified to tackle the rigors of a US medical education, but also enrich the cultural diversity of the medical student body. Moreover, these graduates could effectively complement the efforts to augment US physician workforce diversity while contributing to healthcare disparity eradication, minority health issues, and service in medically underserved areas.
doi:10.3402/meo.v17i0.15748
PMCID: PMC3368516  PMID: 22679360
international students; medical school admission; diversity; minority; recruitment

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