What is the effect of secondary (high) schooling on subsequent medical school performance? A national, UK-based, cohort study

Abstract

Objectives: University academic achievement may be inversely related to the performance of the secondary (high) school an entrant attended. Indeed, some medical schools already offer 'grade discounts' to applicants from less well-performing schools. However, evidence to guide such policies is lacking. In this study, we analyse a national dataset in order to understand the relationship between the two main predictors of medical school admission in the UK (prior educational attainment (PEA) and performance on the United Kingdom Clinical Aptitude Test (UKCAT)) and subsequent undergraduate knowledge and skills-related outcomes analysed separately.

Methods: The study was based on national selection data and linked medical school outcomes for knowledge and skills-based tests during the first five years of medical school. UKCAT scores and PEA grades were available for 2107 students enrolled at 18 medical schools. Models were developed to investigate the potential mediating role played by a student's previous secondary school's performance. Multilevel models were created to explore the influence of students' secondary schools on undergraduate achievement in medical school.

Results: The ability of the UKCAT scores to predict undergraduate academic performance was significantly mediated by PEA in all five years of medical school. Undergraduate achievement was inversely related to secondary school-level performance. This effect waned over time and was less marked for skills, compared with undergraduate knowledge-based outcomes. Thus, the predictive value of secondary school grades was generally dependent on the secondary school in which they were obtained.

Conclusions: The UKCAT scores added some value, above and beyond secondary school achievement, in predicting undergraduate performance, especially in the later years of study. Importantly, the findings suggest that the academic entry criteria should be relaxed for candidates applying from the least well performing secondary schools. In the UK, this would translate into a decrease of approximately one to two A-level grades.

Figure 1

Flowchart of data available for the outcomes for each of the five academic years of medical school training. UKCAT, United Kingdom Clinical Aptitude Test.

Figure 2

Illustration of the conceptual model for the single level mediation effect of previous educational attainment on the association between total UKCAT scores and undergraduate medical school knowledge and skills-based examinations. UKCAT, United Kingdom Clinical Aptitude Test.

Figure 3

Proportion of the predictive power of the UKCAT scores for undergraduate knowledge and skills-based examination outcomes explained by PEA in medical school. The proportion is computed as a quotient of the indirect effect of the UKCAT performance through PEA divided by the total effect of UKCAT performance. The black dotted line denotes the threshold at 43% selected so as to contrast the trend between the ‘preclinical’ (first two) years and the ‘clinical’ years (three to five) of medical school undergraduate training. PEA, prior educational attainment; UKCAT, United Kingdom Clinical Aptitude Test.

Figure 4

Effect of average school level performance by reported grades on undergraduate medical school knowledge-based examinations (as a standardised z-score) for all secondary schools in England in 2008. The second decile (average school level performance of 200.2) and eighth decile (average school level performance of 251.9) are denoted by the purple and brown vertical lines, respectively. The horizontal black dotted lines are arbitrary points chosen to indicate the equivalent level of performance between those entrants from secondary schools at the lower decile of performance and those at the upper decile of performance.

Figure 5

Effect of average school level performance by reported grades on undergraduate medical school skills-based examinations (as a standardised z-score) for all secondary schools in England in 2008. The second decile (average school level performance of 200.2) and eighth decile (average school level performance of 251.9) are denoted by the purple and brown vertical lines, respectively. The horizontal black dotted lines are arbitrary points chosen to indicate the equivalent level of performance between those entrants from secondary schools at the lower decile of performance and those at the upper decile of performance.