The HPAT has turned out to be a failure. Back to the Leaving Cert

If being able to assess information and make important decisions in a timely fashion in a pressurised environment is not preparation for a career in medicine, what is?

Admission to medical courses is determined by combining a candidate’s HPAT and Leaving Certificate results.

Comedian George Burns observed: “The key to success is sincerity. If you can fake that, you’ve got it made.”

Despite living until he was 100 years old, Burns never attempted to enrol in medical school in Ireland. But, with that attitude, he would have aced the Health Professions Admissions Test (HPAT).

The HPAT — pronounced H-pat — was introduced in 2009 after the Fottrell report recommended that medical school entry should not be based purely on academic grades.

The ambition was to dilute the points race by identifying students with other non-academic skills necessary for medicine and broaden medical school entry to a wider socioeconomic group.

The HPAT is two-and-a-half-hour multiple choice test with three sections on “logical reasoning and problem solving”, “inter-personal understanding”, and “non-verbal reasoning”.

Admission to medical courses is determined by combining a candidate’s HPAT and Leaving Certificate results.

It was recently announced that, from 2027, two important reforms will be made. Firstly, the unfair practice of downgrading a student’s Leaving Certificate points will be removed. Currently, all points over 550 are “moderated” — a polite way of describing a reduction in their value by 80% — so that each additional five points becomes one point. For example, an outstanding student who has worked incredibly hard for three years to secure the maximum 625 Leaving Certificate points sees them magically reduced to 565 points the moment they apply for medicine.

The second change involves a more welcome devaluation, with the HPAT being marked out of a maximum 150 points rather than the existing 300.

Both changes are welcome, but they do not go remotely far enough. Reducing the value of the HPAT by half indicates that medical schools have lost confidence in it, so why not simply scrap it?

Exam pressure

The Irish Universities Association acknowledges “these changes mean that entry to medicine will refocus on Leaving Certificate achievement, which has proven to be a stronger predictor of student completion than HPAT”.

Why then do students need the added pressure of sitting another exam in a Leaving Certificate year already filled with stressful exams? There are only about 500 undergraduate medical school places available for the 3,000 students who annually sign up for the HPAT. For the vast majority of students, their HPAT performance is ultimately a meaningless waste of both time and money.

The HPAT will be taken by students this month just before they sit their “mock” exams and, in some cases, a portion of their actual Leaving Cert — such as language orals or music recitals. The students who choose to sit the HPAT are surely adversely affected by this distraction. How many students have missed out on their preferred second-choice career through this unwise division of labour? Conversely, cautious students worried that sitting the HPAT might disrupt their preparations for the Leaving Cert may decide to skip the HPAT — effectively abandoning their dream career in medicine before even taking their exams.

But can any test accurately identify suitable doctors? Modern medicine covers such a wide range of specialities that it is hard to see any test of “interpersonal understanding” adequately assessing the suitability of students to pursue each of them.

Excellent interpersonal skills might well be crucial for a neurosurgeon or oncologist, but these attributes are of less obvious value to a pathologist.

Research on this topic has found a student’s HPAT score did not correlate with validated measures of “physician empathy”.

If the HPAT really is essential, then why is it not required of international students wishing to study medicine in Ireland? Persistent underfunding of Irish third-level education creates an obvious temptation to reserve more places for international students, with non-EU undergraduate fees for medicine costing up to €61,000 per annum in contrast with the €2,500 paid by Irish and EU students. Why is a similar aptitude test not required for related degrees — such as veterinary medicine or nursing — in which places can be secured by high-achieving students with a complete phobia of animals or aversion to humans?

Cottage industry of preparation courses

Medicine has long been accused of being elitist — with only 3% of medical students coming from a disadvantaged background, compared to 11% overall — and the HPAT was seen as a way of improving this by widening admissions.

In fact, it has had the exact opposite effect.

For less-affluent students, the HPAT fee of €164 adds an obstacle to their path rather than removing one.

Worse still, despite the organisers’ claims that the HPAT cannot be studied for, a cottage industry of preparation courses has sprung up.

By paying up to €1,700, candidates are coached on the “correct” answer to possible questions — enabling them to display skills they might not actually possess. If the HPAT really is preparation proof, then the performance of students taking it for a second time should remain unchanged.

However, medical schools have found that most students who repeat the HPAT improve their score and end up enrolling significant numbers of students who have sat it multiple times.

If the Government is serious about finding those best suited to a medical career, then a preferable option would be to award bonus CAO points to candidates taking Leaving Cert subjects such as chemistry, physics, and biology, which are of obvious relevance.

A more radical approach would be to make medicine a fully postgraduate professional qualification, similar to North America, so entrants are in a better position to decide where their true vocation and skills lie.

The best option might be for our deans of medicine to channel their inner Michael J Fox and go “back to the future”.

Sitting the Leaving Cert in the traditional manner requires students to assess information and make important decisions in a timely fashion in a pressurised environment. If that is not a good preparation for a career in medicine, it is hard to know what is.

James McDermott is a barrister and assistant professor at University College Dublin’s Sutherland School of Law

Matthew Sadlier is an associate professor at UCD and a consultant psychiatrist