Should the HPAT exam continue to be used as a means of evaluating medical students?

Dean Wright 

University College Dublin 

dean.wright@ucdconnect.ie

Now into its eighth year of operation the Health Professions Admission Test (or HPAT) remains a heated topic of debate. Introduced in Ireland in 2009, its prime goal was to dilute the effects of the ‘points race’ where previous students required an almost perfect Leaving Certificate in order to gain entry to medical school. The HPAT, now taken in conjunction the Leaving Certificate exams, aimed to broaden nationwide access to Medicine by testing non-academic skill sets. It accompanied a revised system where students are now required to meet both the minimum CAO requirements and the Leaving Certificate points requirements for Medicine in one sitting. This eliminated a student’s ability to select ‘easy’ subjects in a subsequent exam period and use a combination of subjects from multiple exam years to gain entry into a medical course in Ireland. This was a welcomed amendment to a flawed system yet many questioned the validity of the introduction of what seemed to be a standardised aptitude test. According to the promotors of the HPAT it is an exam that cannot be prepared for. It was intended to create an environment where the more suitable candidates score higher and the best potential doctors are evaluated and identified. ACER, the designers of the HPAT, claimed intense study would not improve a student’s score. However the existence of expensive HPAT preparatory courses (which cost, on average, a few hundred euro) undermines this claim. Surely a test cannot be studied for if it contains no learnable content?

A review by five Irish medical faculties in 2011 found that 80% of students who repeated the HPAT improved their score. Additional low-cost practice test materials were also subsequently made available by ACER in response to the report. It also found that 40 per cent of successful applicants got a place in medical school with the help of an improved HPAT score1. In 2010 in particular, 111 of 434 students who received places not only repeated the HPAT but were also already registered with another third-level course at time of acceptance. This trend resulted in a high drop-out rate in some medicine-associated courses such as Biomedical Science at a substantial cost to the exchequer. More recently a 2014 investigation into similarities between official exam paper questions and preparatory exam questions supplied by a HPAT preparation company led to seven questions being removed from that year’s scoring process. This suggests that instead of ‘levelling the playing field’ the HPAT has become a barrier against students who come from a more disadvantaged background. In fact, less than 4% of applicants to Irish Medical degree programmes come from disadvantaged backgrounds.

The basic relevance of the test has also been questioned. Quinn et al 20102 found that, based on their performance in a mock HPAT test, several currently practicing consultants would have been excluded from entry into a medicine course. This further undermines the effectiveness of the HPAT to identify those most suitable for a medical career.

The solution?
Many want the HPAT to be abandoned altogether at undergraduate level. Dr Tom O’Rourke, in a letter to the Irish Times in 2016 argued that the selection of better doctors is more appropriate at a later stage in the medical career pathway and suggested changing the ‘debate from choosing correctly at the time of entry to choosing correctly at postgraduate level’. The Quinn et al study made a similar observation. A less radical, but my no means ideal solution would be to allocate a high fixed percentage of all available  places to first-sit students. This would weaken the influence of preparatory courses on entry into Irish undergraduate medicine courses. Another option might be to emulate some North American systems and conduct sets of mini-interview as a screening process. In this way we could examine non-cognitive skills such as professionalism, interpersonal skills, and ethical/moral judgement.

The HPAT, for all its flaws, is a step forward from the old system. It places a new emphasis on problem solving, critical thinking and interpersonal skills, all of which are important aspects of medical practice. It does not, however, properly identify those most suitable for a career in medicine. Its true role is as a hurdle within a bottle-necked system and yet another obstacle for those with a passion for medicine to overcome.

In a time where the public’s expectations of standards of healthcare are increasing, it is important that the evolution of our selection criteria keeps up the pace.

References

1. O’Flynn, D.S., Mills, D.A. and Fitzgerald, D.T. (2012) HPAT-report-July-2012. Available at: http://1.http://www.iua.ie/wp-content/uploads/2013/06/HPAT-report-July2012.pdf (Accessed: 31 January 2017)

2. Quinn A, Corrigan MA, Broderick J, McEntee G, Hill ADK. A Comparison of Performances of Consultant Surgeons, NCHDs and Medical Students in a Modified HPAT Examination. IMJ 2010 103:6