PRE-ADMISSION TESTS OF LEARNING POTENTIAL AS PREDICTORS OF
ACADEMIC SUCCESS OF FIRST-YEAR MEDICAL STUDENTS
A. A. WADEE
Vaal University of Technology, Van der Bijl Park, Gauteng, South Africa. E-mail:
Centre for Innovation in Learning and Teaching (CILT), University of Cape Town,
Private Bag, Rondebosch, 7700, South Africa. E-mail: email@example.com
PRE-ADMISSION TESTS OF LEARNING POTENTIAL AS PREDICTORS OF
ACADEMIC SUCCESS OF FIRST-YEAR MEDICAL STUDENTS
Whilst performance in the school-leaving examination may be a good predictor of
academic achievement at medical schools, it is not necessarily a perfect one. The
Health Sciences Placement Tests (HSPTs), comprising four components, were
adopted by several South African universities as a tool to understand student
preparedness. Of 127 first-year students at the University of the Witwatersrand in
2010, those from private schools performed significantly better academically than
their public school counterparts on overall HSPT performance and in the Academic
Language test, and marginally better in the Mathematics Achievement and
Mathematics Comprehension tests. Students from private schools performed better
at first-year level in the subjects of Psychology and Fundamentals of Medical and
Clinical Sciences. The Academic Language and Mathematics Comprehension tests
showed significant correlations with performance in first-year subjects, both at mid-
year and year-end assessments. The study points to the importance of the HSPTs as
an additional tool in predicting and understanding academic success at first-year
Keywords: higher education readiness; educational background; learning potential
tests; academic success
Universally, the medical fraternity has required admission of academically excellent
students to a curriculum with strong theoretical and scientific content. Medical school
admission is a continuing topic of interest in education. Intellectual challenge and the
wish to achieve are among the primary motives for choosing a career in medicine
(Johnson et al. 1998). Medical practitioners are expected to possess an
extraordinary blend of academic and personal attributes, in order to interact with
patients and other medical staff. Consequently, medical schools worldwide
constantly review their admissions processes and the criteria that classify potential
candidates as suitable for entry.
Medical school admission policies are multifaceted and incorporate selection on the
basis of academic achievement at high school or university together with the a
test/interview to assess the personal qualities of the candidate (De Clercq, Pearson
and Rolfe 2001). It has been reported that pre-admission, structured interviews may
provide useful additional information not necessarily provided by other selection
processes (Cliff and Hanslo 2009). However, studies have indicated that interviews –
though an important potential component of the admissions process – do not reliably
predict the performance of a student academically, or in the clinical setting (Basco et
al. 2008; Elam and Johnson 1992). Medical admission tests are increasingly used as
an additional source of information to help selectors differentiate between high
achievers and to compare students from different educational backgrounds (Emery
and Bell 2009; McManus et al. 2011). Edwards, Elam and Wagoner (2001) proposed
a model for selection which considered the following components:
1. The applicant pool
2. Criteria for selection
3. The admission committee
4. Selection processes and policies
As a consequence of the growing diversity of students applying to medical schools
from a pool of well-qualified applicants (Al Alwan et al. 2013) and because of the
inequalities of schools in South Africa, there is a need to make use of selection
criteria other than results obtained in the school-leaving examination. Such criteria
are designed to level the playing fields for students from various and diverse socio-
economic and educational backgrounds. A meta-analysis of student achievement
reported by McManus (2002) showed that school attainment in general successfully
predicts performance at medical school. However, in order to adjust selection as a
result of poor schooling encountered by many potentially excellent students from
educationally disadvantaged backgrounds (especially Black students), there is an
argument for lowering entry requirements. This is not an unproblematic solution:
research shows that lowering entry requirements increases the short-term risk of
students dropping out of medical school or the longer term risk of the poorer-qualified
medical entrants becoming less competent doctors (McManus 2002).. Similarly,
other meta-analytic research has clearly shown that General Cognitive Ability (GCA)
is a moderate to strong predictor of occupational achievement and relevant
performance (Bore, Munro and Powis 2009). Although there is an indisputable need
to redress demographic and socio-economic imbalances, especially as a result of the
apartheid legacy in South Africa, lowering the entry standards to medical school is
not the answer to accommodate students from previously disadvantaged
South African medical schools have recognised the need for transformation and
consider academic and non-academic factors in the selection process. Academic
criteria were mostly compiled according to the school-leaving examination pass rate
and subject choices. Owing to the changing of the school evaluation system, the
Faculty of Health Sciences at the University of the Witwatersrand, as well as other
medical schools at South African universities, have introduced additional criteria,
apart from academic performance in the penultimate and final schooling years, in the
selection of medical students.
The selection criteria need to be both reliable and valid in order to ensure successful
academic performance at university level within a medical school programme. In the
United Kingdom, the Biomedical Admissions Test (BMAT), interviews and personal
statements are designed to serve as an adjunct to examination results. This process
is intended to provide a global scoring of eligible students (Emery and Bell 2009).
South African medical schools have adopted a similar strategy by using the Health
Sciences Placement Tests (HSPTs) developed by the Alternate Admissions
Research Project (AARP – now the Centre for Educational Testing for Access and
Placement). The HSPTs have shown that performance in the first year is better
predicted by a set of tests that, in part, are similar to the scientific knowledge section
of the BMAT, particularly for students from educationally disadvantaged backgrounds
(Cliff and Hanslo, 2009; Cliff and Montero, 2010). In the United States,
undergraduate Science scores have also been shown to be strong predictors of
standardised test performance in the medical school curriculum (Basco et al. 2002).
Criteria used to select students arguably need to be effective in predicting competent
performance, both during the course and after graduation, (Kay-Lambkin, Pearson
and Rolfe 2002) but to date no single comprehensive and definitive medical student
selection model has been described (Bore, Munro and Powis 2009). Traditionally,
admissions policies have focused on the selection of applicants with high academic
scores (Kay-Lambkin, Pearson and Rolfe 2002) for the obvious reasons of the high
academic demands of a medical degree. Policies for selection of students were
traditionally based on the assumption of a strong relationship between academic
ability and success in medical school examinations.
Academic and non-academic criteria have to be applied in the selection process,
much of which has been established on intuitive grounds and without any evidence
basis (James and Chilvers 2001). It therefore becomes critical for medical schools to
validate their selection on an ongoing basis where the educational climate changes
and the attributes of graduating doctors have constantly to be considered to meet the
needs of the patient population they serve. Every medical school should identify
those objective factors which predict success on their course and incorporate them
into their selection process (James and Chilvers 2001). Doctors need specialist
knowledge and a complementary array of skills and personality traits if they are to be
professionally competent (Powis 2010), which also suggests that any competency
list for a generic medical practitioner should comprise the following:
1. Excellent academic ability
2. Good cognitive skills
3. Ability to use academic knowledge appropriately in quantitative, verbal and
Although changes in the selection policies began to take place prior to 1994 and the
intake of medical students in South Africa showed progress with regard to changing
the demographic profile (which demonstrated an improved representation of the
more disadvantaged groups in 1999 as compared to 1994), equitable representation
still remained a challenge that needed to be addressed (Cliff and Yeld 2006). In this
context, a complementary selection mechanism was introduced as part of the
process of selecting medical school students in South Africa. The Health Sciences
Placement Tests (HSPTs) – developed by the then Alternative Admission Research
Project (AARP) – were introduced at seven of the eight medical schools in South
Africa and adopted from 2003 as an additional method of gathering information for
the selection of future medical students. The HSPTs consisted of four tests, which
included generic testing of language applied to an academic context, mathematical
achievement and mathematical comprehension, and scientific reasoning. The HSPTs
were developed by interdisciplinary teams of experts over a time span of several
years and constituted the following tests (Cliff and Hanslo 2009):
• The Placement Test in English for Educational Purposes (PTEEP), which is
aimed at assessing students' ability to make meaning of texts that they are
likely to encounter in their studies and understand visually presented textual
information, by using processes such as separating superordinate from
subordinate information; applying inferential reasoning; interpreting features of
academic discourse; and understanding analogous thinking.
• The Mathematics Achievement (MACH) test, which measures the extent of a
student’s backlog in basic mathematical knowledge and skills normally
expected to have been acquired by the time the student reaches a senior
secondary school mathematics phase.
• The Mathematics Comprehension (MCOM) test, which is designed to provide
information concerning the student’s potential to learn new mathematical
knowledge and skills.
• The Scientific Reasoning Test (SRT), which is aimed at assessing the
student's capacity to engage in the type of logical, evidence-based thinking
typically required of students in higher education.
Given the historical context mentioned, the tests were designed to obtain information
about the potential of students to cope with the typical academic and cognitive
demands of higher education. Additionally, the goal of the HSPTs was to enable
talented students whose education had been particularly compromised by unequal
schooling, to demonstrate the extent to which they would be able to cope in higher
education contexts where there would be high levels of academic and non-academic
support and mentoring. These tests were regarded as a diagnostic benchmark of
students' entry-level performance (AARP, 2004), a benchmark which could then be
incorporated into the selection and curriculum placement of students.
Studies have shown correlations between selection test scores and performance
where aptitude selection instruments that assess science, mathematics and linguistic
capabilities of selected candidates were significantly predictive of in-course
performance of students in colleges in Saudi Arabia (Al Alwan et al. 2013).
Internationally, there exist mixed results regarding formal measures of undergraduate
institution selection but they still remain useful and important components to
predicting student performances. Biomedical tests have to be valid and reliable
predictive indicators of student eligibility and success and aspects such as verbal
and numerical reasoning have been strong predictors of student success (Emery and
Bell 2009). Ultimately, communication and interpersonal skills have to be balanced
against academic and scientific ability and this still remains a major challenge for
medical schools worldwide.
THE CONTEXT OF THE CURRENT STUDY
Generally in South African medical school selection processes, academic pre-
admission criteria include the prospective student’s final secondary school mark, for
example, a composite grading of all final-year schooling scores, as well as the scores
on a set of pre-admission tests. Although previous academic performance is a good
predictor of success on the medical programme (Ferguson, James and Madeley
2002; Lumb and Vail 2004), it is not a perfect one. For example, one study has
shown that it accounted for 23% of the variance in performance in undergraduate
medical training and only 6% in post-graduate competency (Ferguson, James and
The aim of the current study was to investigate the degree of association between
the scores on the specific test components of the HSPTs and the scores on the in-
course mid-year and final examinations for students in their first year of study
towards a medical degree. First-year academic performance has historically been
shown to be a critical filter of students entering medical school (Ruscingo, Pinto Zipp
and Olson 2010). In terms of the tests, a composite score provides an average of the
four tests that make up the HSPTs. For the purposes of this study, the individual
component scores were teased out of the test and these analysed against the first-
year subjects included in this study in order to identify specific predictor domains of
student success in the first year. Additionally, attempts were made to control for
variation in pre-admission test and academic performance scores by demographic
variables such as gender, and student school background, since these variables are
known historically to be associated with differences in academic performance.
The medical curriculum at the University of the Witwatersrand spans a minimum
period of six years, the first two of which could be considered pre-clinical years
comprising basic sciences, anatomy and physiology subjects. A retrospective study
was performed where in-course performance for the basic and human sciences was
assessed in conjunction with the pre-admission test results of the students who had
been admitted for the 2010 intake.
Four pre-admission predictors of performance were examined and considered for
(* Defined above)
These scores and a composite HSPT score were assessed in conjunction with the
mid-year and final first-year results in the following subjects:
4. Fundamentals of Medical and Clinical Sciences (SCMD)
The component results for pre-admission and corresponding first-year results were
provided by the university with the permission of the Dean of the Faculty of Health
Sciences. Variables analysed included student numbers, the mean scores of each
component test and a composite as well as the class mean values for the first-year
subjects chosen for scrutiny.
Database management and statistical analyses were performed with SAS software,
version 9.1 (SAS Institute Inc., Cary, NC, USA). Results from each component of the
Composite Index are reported as mean ±SD. Unadjusted means were compared by
t-test or Wilcoxon-Mann Whitney tests when appropriate. Spearman Correlation
coefficients were calculated between the pre-admission test components and the
first-year subjects unadjusted and after gender adjustments. Stepwise multiple linear
regression analysis was performed to assess independent relations between pre-
admission test components and the first-year subjects marks with appropriate
adjustors. A p-value of <0.05 was considered statistically significant.
One hundred and twenty seven students were accepted to medical school at the
University of the Witwatersrand for 2010 (Table 1).
TABLE 1 HERE
The majority were females (62%) and of Black ethnicity (42.5%); 33% were White;
15% Indian; and 9.5% Coloured. Females and males had similar scores for the
medical pre-admission tests (Composite Index (CI), PTEEP, MACH, MCOM and
SRT) with p>0.05. Students from private schools performed higher in all tests
besides the SRT compared to those from public schools (Table1), suggesting that
school background factors continue to impact on the academic performance of entry-
level medical school students.
Table 2 shows the results of the June and November examinations.
TABLE 2 HERE
No differences between public and private schools were found in the June
examinations. In contrast in the November examination, students from private
schools achieved higher marks than students admitted from public schools in the
subjects of SCMD and Psychology (p<0.05). After adjusting for gender and school
background the marks for Chemistry, SCMD and Sociology increased in November
examinations (p<0.001). However, in Biology a small decrease in the marks was
Strong positive correlations were noted between the Composite Index and the marks
obtained by the students in their June and November examinations (Spearman
correlation coefficients (rs) between 0.42 and 0.79, with p<0.0001). Furthermore
similar correlations coefficients were achieved after adjusting for school background
TABLE 3 HERE
Table 4 depicts student performance according to each subject undertaken using the
pre-admissions test (PTEEP, MACH, MCOM and SRT) and adjusting for gender and
TABLE 4 HERE
Higher marks of mid-term and year-end examinations were explained by better
results in the MCOM tests for the different subjects (partial r2= 0.20 to 0.25,
p<0.0001) and for PTEEP (partial r2= 0.04 to 0.25, p< 0.05) in June. Similar findings
were seen in November as well (Table 4).
The combined pre-admission test (CI) appeared to be the most important predictor of
the mid-year and final year marks of the majority of the subjects. For the June
examinations, the CI explained 32%, 20% and 32% of the variance in the marks
obtained by the medical students in Biology, Chemistry and Psychology respectively
(p<0.0001). In addition, at the year-end examinations the Composite Index predicted
the scores achieved in Biology, Physics, Sociology and SCMD and Psychology
(p<0.0001), but not Chemistry. MCOM exhibited an independent association with
Biology November marks (partial r2 of 0.02, p=0.03) together with CI. Physics marks
in mid-term instead accounted for 20% (p<0.0001) of the variance in the MCOM
scores only. In addition, MCOM scores predicted Biology, SCMD examinations
results for November (p=0.03) as well. The Academic Language test (PTEEP)
scores were the sole predictor of the Sociology marks (partial r2=0.22, p<0.0001) in
June and explained only 2% of the increase in the Psychology scores (p=0.03).
The present study attempted an investigation of a single overarching question: to
what extent are scores on the HSPTs as individual tests and as a combined,
composite measure, associated with academic performance of first-year students in
key medical school courses at mid-year and year-end? This overarching question
was approached from four angles: (1) an investigation of the extent to which
differences in key demographic variables (gender and school background) were
associated with differences in mean levels of achievement on pre-admissions tests
and in key first-year courses; (2) the extent to which these demographic differences
(if any) were still visible in academic performance at the end of the first year of study;
(3) an investigation of correlations – adjusted for differences in school background –
between a composite score on the pre-admissions tests and academic performance
at mid-year and year-end; and (4) regression analyses – adjusted for gender and
school background variables – to determine the contributions of pre-admissions tests
individually and as a composite towards variation in academic performance in key
courses at mid-year and at year-end.
The results of the present study point to the importance of selection criteria using the
HSPTs as an additional tool in predicting academic success in health sciences at the
University of the Witwatersrand. Our study initially compared the performance of
students admitted from public versus private schools in their achievements on the
HSPTs. The results indicate no gender difference in their performance across the
various assessments. However, when the analysis was performed on admitted
students from public and private schools, students from private schools performed
significantly better than their public school counterparts in the assessments on the
academic language proficiency (PTEEP) test and their overall composite scores
were also significantly higher (p<0.0001; Table 1). Whilst the trend of better
performance was still with students from private schools in the MACH and MCOM
assessments, these did not reach statistical significance.
These findings confirm and augment those reported by Cliff and Hanslo (2009) in
suggesting that pre-admission tests and the PTEEP as a test of academic language
proficiency and academic literacy in particular, have predictive value in underscoring
an ‘advantage’ on entry to higher education that students from private schools have
over students from public schools. The effects of language and academic literacy on
student performance at university are well-documented. (Higgins-Opitz and Tufts
2014; Higgins-Opitz et al. 2014; Fleisch, Schöer and Cliff 2015). Furthermore,
studies have also shown that school-leavers embarking on university studies are
generally inadequately prepared to cope with the language-of-instruction demands of
studies in higher education (Ramukumba and Gravett 2004; Cliff 2014 and 2015).
The results of the present study support the notion of using scores, such as those
achieved on the PTEEP, as indicators of likelihood of succeeding at university.
Further evidence in support of using PTEEP as an additional tool for admission
purposes is provided by the recent work of Mashige, Ramprasad and Venkatash
(2014) who demonstrated a weak correlation between matric English scores and
first-year performance in all subjects.
The present study, and others referred to in the previous paragraph, also add weight
to the importance of focusing on literacy as part of the disciplinary curriculum.
Performance on tests such as the PTEEP and the MCOM are strongly influenced by
the language proficiency and literacy-laden nature of the tests themselves, and the
academic contexts that they simulate. The present study indicates that ‘conventional’
curriculum may not necessarily be sufficient to address the language and literacy
needs of medical school students, especially those from English Second Language
backgrounds, if these students are to be enabled to ‘overturn’ anticipated
relationships between poor entry-level test performance and academic
underperformance during and at the end of first-year studies.
In addition, data from Table 2 suggest that residual effects of the ‘advantage’ private
school background students have over public school background students in terms of
their readiness to cope with the demands of higher education study remain visible
right through the first year of study. Students from private schools also performed
better than their public school counterparts in SCMD and Psychology. The points
made in the previous paragraph about the need to address language and literacy
demands alongside conventional curriculum demands remain apposite.
Finally, we return to the argument about the use of tests such as the HSPTs as an
additional tool in the selection of medical school students (and, by implication,
students for other academic programmes). We believe the findings of this study
emphasise the complementary value of the HSPTs in identifying and understanding
variation in academic readiness of medical school students that is not necessarily
visible on the basis of school-leaving results alone. Many applicants to medical
schools at the University of the Witwatersrand (and other South African medical
schools and equally high-demand academic programmes) obtain equally outstanding
school-leaving examination results, which makes it extremely difficult to make
selections decisions amongst these applicants who exhibit so little evidence of
academic variation in their school-level academic achievement. Furthermore – as
crtiterion-referenced assessments with the assessment ‘target’ being readiness to
cope with first-year academic literacy, mathematical thinking and scientific reasoning
demands in the medium-of-instruction – the HSPTs have value in identifying the
ability of applicants to cope with their study programmes that is not visible in the
school-leaving examination results. Increasingly (as pointed out earlier in this paper),
school-leaving examination results have been difficult to interpret: the diverse
educational backgrounds of applicants make it difficult to establish the meaning of
school-leaving examination scores and the interpretation of what these scores tell us
about what applicants know and can do. The constructs assessed by the HSPTs
produce additional academic readiness information against which the school-leaving
examination results can be interpreted – and on the basis of which selection
decisions can be made.
We believe that the present study also carries implications for the selection of
students from educationally advantaged (well-resourced) and educationally
disadvantaged school backgrounds. For students from educationally advantaged
backgrounds, we believe results from tests such as the HSPTs by and large confirm
the beneficial effects of well-resourced schooling – but the results remain useful at
the level of individual applicants about whom selection decisions need to be made.
Nonethless, HSPT results still provide important information to selection committees
about the academic readiness (and literacies) of applicants from advantaged
backgrounds. For students from educationally disadvantaged backgrounds, HSPT
scores provide alternate academic readiness information to school-leaving
examination results in many cases (consonant with the findings in the Cliff and
Hanslo, 2009, study), particularly in relation to the ability of these students to cope
with the medium-of-instruction demands of tertiary study. For students from
disadvantaged backgrounds, the tests provide important information about the extent
to which these students will cope with their studies in, for example, an English
medium-of-instruction teaching environment and about the extent and kind of
academic support and curriculum responsiveness that might be indicated if such
students are to be successful. From a selection point of view, the HSPTs act as
mechanisms in this instance for making judgments about the level of academic
support such will require once selected. Findings from this study confirm that – in the
presence of conventional curriculum provision (such as that provided by the courses
that formed the focus of this study) – the effects of (disadvantaged) educational
background remain visible through the first year of study. The use of HSPT
information provides a framework for the development of explicit or additional support
aimed at addressing the needs of students from disadvantaged backgrounds.
In a South African context, demographic factors such as school background or
population group continue to play an important part in understanding talent and
achievement. Initially, an unbiased and unadjusted study was performed which did
not consider race or gender. Against the diverse educational and socio-economic
background which South African tertiary institutions face, the same data was further
adjusted to incorporate the effect of race and gender on the same results. This study
was also limited to the student pool at the University of the Witwatersrand as well as
pertaining to the curricula of the final high school year and first-year of university of
2009 and 2010 respectively which become relevant when studying the same
parameters over a longer time span when the curricula changed as desired by
All statistical analyses were undertaken by Professor Elana Libhauber of the
University of the Witwatersrand, who is gratefully acknowledged.
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Table 1: Composite index and PTEEP, MACH, MCOM and SRT scores on
HSPTs for the 2010 intake per school type (public and private)
NUMBER OF STUDENTS, (%)
Table 2: Subject results for mid-year and final year 2010 per school type
FUNDAMENTALS OF MEDICAL AND CLINICAL
FUNDAMENTALS OF MEDICAL AND CLINICAL
PSYCHOLOGY (year-end only available)
Data are presented as mean ± SD; ^p<0.05 between public and private schools!
Table 3: Correlations of the Composite Index with mid-year and final year subject
Spearman r adjusted
for school background
Fundamentals of Medical and Clinical
Table 4: Stepwise regression analysis for mid-year and final year subject
Results of subjects
ß coefficient ±SEM
Biology - June
Biology - November
Physics - June
2. MCOM: 0.48±0.09
Physics - November
Chemistry - June
Chemistry - November
Sociology - June
Sociology - November
Psychology - June
2. Composite index:
MCOM : 0.18±0.04
2. Composite index:
Medical and Clinical
1. Individual tests scores (PTEEP, MCOM, MACH and SRT), gender and schools
were included in the model for each subject
2. Individual tests scores (PTEEP, MCOM, MACH and SRT), gender and schools
with the addition of Composite Index scores were included in the model for each