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What is the effect of secondary (high) schooling on subsequent medical school performance? A national, UK-based, cohort study
  1. Lazaro M Mwandigha1,
  2. Paul A Tiffin1,
  3. Lewis W Paton1,
  4. Adetayo S Kasim2,
  5. Jan R Böhnke1,3
  1. 1 Department of Health Sciences, University of York, Heslington, UK
  2. 2 Wolfson Research Institute for Health and Wellbeing, Durham University, Stockton-on-Tees, UK
  3. 3 Dundee Centre for Health and Related Research, School of Nursing and Health Sciences, University of Dundee, Dundee, UK
  1. Correspondence to Dr Paul A Tiffin; paul.tiffin{at}


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.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See:

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  • Contributors All authors made substantial contribution to this study. LMM conducted the statistical analyses and contributed to the writing of the article. PAT and ASK led the conception, design, supervision of the statistical analyses, interpretation of the results and contributed to the writing of the article. JRB was involved with supervision of the statistical analysis and handling of missing data, interpretation of the results, revising and writing of the manuscript. LWP was involved in the interpretation of the results, revising, writing and critical appraisal of the manuscript. All authors have approved the final version of the article submitted.

  • Funding LMM is supported in his PhD, of which this study is a component, via funding from the UKCAT Board. In addition, Hull York Medical School financially contributed to the student fees for LMM. PAT is currently supported in his research by a National Institute for Healthcare Research (NIHR) Career Development Fellowship. PAT is also lead for the DREAMS Network, an international collaboration on selection into the professions, of which LMM, JRB and LWP are also members, which is funded by a Worldwide University Network (WUN) Research Development Fund award. This paper presents independent research part-funded by the National Institute for Health Research (NIHR).

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests LMM is supported in his PhD project via funding from the UKCAT Board and has received travel expenses incurred for attending a UKCAT Research Group meeting. PAT has previously received research funding from the Economic and Social Research Council (ESRC), the Engineering and Physical Sciences Council (EPSRC), the Department of Health for England, the UKCAT Board and the General Medical Council (GMC). In addition, PAT has previously performed consultancy work on behalf of his employing University for the UKCAT Board and Work Psychology Group and has received travel and subsistence expenses for attendance at the UKCAT Research Group.

  • Patient consent Not required.

  • Ethics approval No human subjects were tested for this study, therefore no ethical approval was necessary. The anonymised raw data used in these analyses were made available by the UK Medical Education Database ( following approval of an application. From the data, no piece of information can be used to identify a secondary school, medical school or individual. As such, the identity of the participants is fully protected. All participants consented to the collection of the data for research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement This study involved the analyses of anonymised secondary data of medical school entrants. Access to the data may be obtained from the UK Medical Education Database ( following approval of an application.