Creative Education
2013. Vol.4, No.6A, 15-19
Published Online June 2013 in SciRes (
Copyright © 2013 SciRes. 15
Validity Evidence for Assessments on a UK Graduate Entry
Medical Course
Celia A. Taylor, Remi Zvauya
School of Clinical and Experimental Medicine, University of Birmingham, Edgbaston, UK
Received February 21st, 2013; revised March 23rd, 2013; accepted March 30th, 2013
Copyright © 2013 Celia A. Taylor, Remi Zvauya. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Graduate entry medical courses (GEC) have been introduced into the UK to increase the supply of doctors
and to widen participation. In addition to evaluation against these outcomes, the educational process
should also be evaluated. One aspect of process is assessment and different types of validity evidence for
the assessments used should be provided. This paper provides validity evidence for the assessments on a
UK GEC, focusing on the 2010/11 assessment diet. The types of validity evidence provided are content,
internal structure, relationship with other variables and consequences. Students’ GEC assessment results
are used to determine whether or not students should progress to Year 3 on the traditional course. 66% of
the learning outcome/body system combinations in the assessment specification for Years 1 & 2 of the
traditional course were assessed in one assessment diet. Short answer questions performed “best” in terms
of difficulty and discrimination. The reliability of three modules was just outside the recommended range
of 0.7 to 0.9. GEC performance is at least as good a predictor of final year performance as Year 1/2 per-
formance on the traditional course. Across the six written modules for 2010/11, 12 scores (5%) were in
the borderline range. Judgement regarding the validity of interpretations made from GEC assessment re-
sults is left to the reader since such judgements should not be made by those providing the validity evi-
dence. Similar studies should aim to use benchmarks to enable results to be more objectively evaluated.
Keywords: Graduate Entry Medicine; Assessment; Validity
While in the USA and Canada most medical students have
already completed an undergraduate degree before beginning
their medical training, the majority of entrants to medical
school in the UK and in many other countries are school leavers
aged 18 - 19. Following a similar initiative in Australia, since
2000 15 UK medical schools have introduced four-year gradu-
ate entry courses (GEC). As part of a larger expansion of UK
medical schools, there were two main reasons for the introduc-
tion of GEC: the need to quickly increase the supply of doctors
and to attract students from a broader range of social back-
grounds (Department of Health, 2004).
Evaluation of Gradua te Entry Courses
Given the relatively recent introduction of GEC in the UK, it
is important to evaluate the impact of such courses. In terms of
student ‘inputs’, evidence from both Australia and the UK sug-
gests that GEC have had little impact in increasing diversity
(Powis et al., 2004; Mathers et al., 2011). In terms of under-
graduate outcomes, a number of recent articles have shown that
graduates from UK GEC perform at least as well as students on
five year traditional courses (TC) by the time they graduate
(Calvert et al., 2009; Manning & Garrud, 2009; Price & Wright,
2010; Shehmar et al., 2010). There is some evidence from Aus-
tralia that GEC students are at least as well prepared for their
first jobs as TC students (Dean et al., 2003), but longer-term
evidence regarding postgraduate performance outcomes is not
yet available.
As well as considering inputs and outcomes, it is also impor-
tant to evaluate the educational process of the GEC themselves.
One critical aspect of process, for which there is little published
evidence, is assessment validity. Validity is a key requirement
in the General Medical Council’s (GMC) document Tomor-
rows Doctors (GMC, 2009) and is one of the components of
assessment utility identified by Van der Vleuten (Van der
Vleuten, 1996). As described by Shaw and colleagues, “validity
is concerned with the appropriateness or correctness of infer-
ences, decisions or descriptions made about individuals, groups,
or institutions from test results” (Shaw et al., 2012: p. 162).
Validity is particularly important to ensure against two types of
error, both of which have implications for students, medical
schools and patients: false negatives (failing a competent stu-
dent) and false positives (passing an incompetent student).
Based on the 1999 edition of the Standards for Educational
and Psychological Testing (American Educational Research
Association et al., 1999), Downing highlights that validity is
now considered a unified concept and that evidence should be
provided on five different aspects: content, response process,
internal structure, relationship with other variables and conse-
quences (Downing, 2003).
There are only three examples of a unified approach being
applied to assessments in medical education. Two of these stud-
ies focus on a single assessment (Objective Structured Clinical
Examinations and Mini Clinical Evaluation Exercise) and are
based on data from small samples of postgraduate trainees
(Varkey et al., 2008; Hatala et al., 2006). The third study com-
pares the validity evidence for different types of assessments
for an undergraduate internal medicine rotation (Auewarakul et
al., 2005). Only one paper (Varkey et al., 2008) specifies objec-
tive benchmarks, for inter-rater reliability and internal consis-
tency. Aurwarakul and colleagues provide subjective ratings for
each aspect of validity and use these to compare the different
types of assessment (Auewarakul et al., 2005). However, given
the difficulties of providing evidence for all aspects of validity,
it is crucial that those providing subjective ratings do not also
make global judgements regarding the appropriateness of the
interpretation of scores from those assessments.
This paper adds to the evidence base by providing validity
evidence for the GEC assessments at one UK medical school,
focusing on the sources of evidence for which objective evi-
dence can be generated and, where possible, compared to
benchmarks. Figure 1 shows how we have approached the
provision of a “chain of evidence” (Downing, 2003), which can
be used to support (or otherwise) our use of students’ scores in
distinguishing competence from incompetence. The term “chain”
suggests a hierarchical structure, but the inter-relationships
between the different sources of validity evidence led us to base
our structure on a Venn diagram.
The Birmingham GEC and Assessments
The University of Birmingham runs a four-year GEC which
admits graduates with a first class life sciences degree. The first
year of the GEC is delivered using problem-based learning
(PBL) using a series of integrated clinical cases. There are
seven modular assessments: the six case-based modules are
assessed using written exams comprising single best answer
Figure 1.
Structure for the provision of validity evidence.
Content: Is the content of the assessment aligned
with how competence is defined? Internal Struc-
ture: Do the items used ensure competent stu-
dents’ scores exceed those of incompetent stu-
dents? Are students’ scores an accurate reflection
of those that would be attained on a different
sample of items? Relationship with other vari-
ables: Do increasing scores reflect an increase in
student ability? Consequences: Would the same
pass/fail decision be made if the assessment were
repeated with a different sample of items?
multiple choice questions (MCQs), anatomy spotter extended
matching questions (SPOs) and short answer questions (SAQs).
The seventh module is Clinical Competencies which draws on
students’ learning across the year, including their time in Gen-
eral Practice (GP). The assessment for this module comprises a
“live” exam, which prior to 2006/07 consisted of a communica-
tion element based on a simulated GP consultation and a cogni-
tive element based on a viva in which the examiner examined
each student for ten minutes using structured questions based
on the content of the six case-based modules. However, it was
recognized that the cognitive part of the assessment was as-
sessing integration of knowledge already being assessed in the
written exams, while there was insufficient assessment of the
process of PBL. A new cognitive assessment was introduced
from 2006/07, using a simplified version of the triple jump
(Smith, 1993). In the new assessment, students spend ten min-
utes reading an unseen clinical case scenario and produce a
written list of ten learning objectives (LOs) appropriate for the
case from the perspective of a GEC PBL student. The student
then has ten minutes to present their LOs to an examiner, who
explores the student’s reasons for selecting the particular LOs
and the breadth and depth of their understanding of the issues in
the clinical scenario, including the ways in which they might
approach their future learning needs.
Students who pass all seven GEC modules join Year 3 of the
TC and begin their clinical training. Students failing one or
more modules (without extenuating circumstances) are entitled
to one re-sit attempt. Failure at re-sit means that a student
would be required to withdraw from the course.
Provision of Validity Evidence
RZ blueprinted each of the 535 written exam questions for
the 2010/11 GEC assessment diet (270 MCQs, 175 SPO and 90
SAQs) to a learning outcome (based on the GMC’s “outcomes
for graduates” in Tomorrows Doctors (GMC, 2009)) and body
system (or noted it as “generic”). We then calculated the num-
ber of questions of each type in each of the 87 “relevant” cells
of the blueprint matrix. A learning outcome/body system com-
bination was considered irrelevant if the learning outcome
could not be assessed at body system level but would be as-
sessed generically instead. We then compared the completed
blueprint to the assessment specification developed for Years 1
& 2 of the TC. The assessment specification details the learning
outcome and body system combinations from which the ques-
tions in the Year 1 & 2 written assessments are sampled each
year, which was developed in conjunction with module leads in
February 2011. Of the 87 learning outcome/body system com-
binations in the assessment specification for Years 1 & 2 of the
TC, 57 (66%) were assessed in the GEC written exams in
2010/11 (details available on request).
Internal Structure
To evaluate the internal structure of the GEC assessments we
examined item facility (percentage of students answering cor-
rectly) and discrimination (item-rest correlation) for the differ-
ent question types (MCQ, SPO and SAQ) and reliability at
module level for the six written GEC modules for the 2010/11
diet. The optimal item difficulty and discrimination depend on
the purpose of the assessment, but we used an optimal facility
Copyright © 2013 SciRes.
Copyright © 2013 SciRes. 17
range of 20% - 80% and a minimum discrimination value of 0.2.
We evaluated reliability at module level using Cronbach’s al-
pha, with a benchmark coefficient between 0.7 and 0.9 (Streiner
& Norman, 2003).
The percentage of each type of question meeting the item fa-
cility and discrimination targets and the reliability of the written
assessment as a whole for each module is shown in Table 1.
Across the six modules, SAQs perform “best” in terms of both
facility and discrimination, which would be expected given the
scoring process for SAQs (each marked out of ten) compared to
MCQs and SPOs (which have one mark each). Three of the six
reliability coefficients are in the recommended range of 0.7 to
0.9, with the other three just below this.
Relationship with Other Variables
We analyzed anonymous performance data for all 331 stu-
dents who began the GEC course between 2003 and 2010 and
for all 687 students who completed the TC in 2010 or 2011. As
appropriate, the following data were obtained for each student,
with first sit, standard-set marks used:
Year of entry;
GEC written score (mean across all six modules), live exam
score and weighted average score;
Year 1 & 2 weighted average score;
Final year weighted average score.
Weighted average scores are used to aggregate student per-
formance across the MBChB and identify which students are
eligible for the award of MBChB with Honours. The weight
used for each assessment is determined by the module credit
value although the weights on modules in the last three years
and on all clinical modules are increased by 25%. The GEC
dataset was split into two groups based on the type of live exam
undertaken: Knowledge (those matriculating in 2003-5) and
Process (2006-10).
We calculated convergent/divergent correlations between
GEC written and live scores. Given the change in focus of the
assessment, we would expect a higher positive correlation when
the live exam was assessing knowledge compared to when it
was assessing process. We also compared the correlations be-
tween weighted average GEC/TC Years 1 & 2 performance and
final year performance for students graduating in 2010 and
2011. As the data were normally distributed, we used Pearson
correlation coefficients to evaluate these relationships. Correla-
tion coefficients from the different groups (Knowledge vs.
Process and GEC vs. TC) were compared using Fisher’s r-to-z
transformation (Lowry, 2012). P-values < 0.05 were considered
statistically significant. Where appropriate, the Bonferroni ad-
justment was used to correct p-values for multiple comparisons.
Figure 2 shows the relationship between GEC written and
live scores for the Knowledge and Process groups. There is a
stronger positive correlation between written and live scores for
the Knowledge group (r = 0.67) when compared to the Process
group (r = 0.18): z = 5.42, p < 0.001, suggesting that different
skills are being assessed in the new live exam.
Table 2 shows the Pearson correlation coefficients between
GEC/Year 1 & 2 and final year weighted averages for the co-
horts of students graduating in 2010 and 2011. All four indi-
vidual correlation coefficients are statistically significant at p <
0.001. The correlations for GEC are higher than for the TC, but
not statistically significantly so, suggesting that GEC perform-
ance is at least as good a predictor of final year performance as
TC Year 1 & 2 performance.
We assessed pass mark reliability for each written module in
the 2010/11 assessment diet by calculating the percentage of
the cohort in each of four groups: clear fail, borderline fail,
borderline pass and clear pass. The “regression-based” approach
was used to assess pass mark reliability, which uses students’
estimated true scores (ETS) and controls for regression to the
Table 1.
Internal structure by module.
Questions Facility
(% Questions) Discrimination IR Corr
(% Questions) Overall Reliability
<20% “Hard ” 20% - 80%>80% “Easy ” >0.2
MCQ 45
SPO 30
SAQ 15
MCQ 45
SPO 30
SAQ 15
MCQ 45
SPO 30
SAQ 15
MCQ 45
SPO 30
SAQ 15
MCQ 45
SPO 30
SAQ 15
MCQ 45
SPO 25
SAQ 15
ote: percentages may not sum to 100% due to rounding. Facility for the SAQs is based on the total question score (out of a possible 10 marks).
Figure 2.
Relationship between GEC written and live exam scores, by type of
live exam (knowledge or process).
Table 2.
Correlations between GEC/Year 1 & 2 and final year weighted
Year TC Year
1 & 2 GEC Comparison of
Correlation Coefficients
r = 0.62
(n = 363)
p < 0.001
r = 0.65
(n = 38)
p < 0.001
Z = 0.64
p = 1.000
r = 0.55
(n = 324)
p < 0.001
r = 0.78
(n = 39)
p < 0.001
Z = 2.46
p = 0.083
Note: p-values have been corrected for multiple comparisons using the Bonferroni
mean (Harvill, 1991). Borderline boundaries were one standard
error of the estimate (SEE) above and below the pass mark.
Figure 3 shows the percentage of students in each of the four
outcome categories by module. The percentage of students
classified as “borderline” ranges from 0% to 15% across the six
Evaluation of Validity Evidence
The assessments for which we have provided validity evi-
dence are used to determine whether students should progress
into Year 3 of the TC: while students have to pass other as-
sessments before graduating, it is important that GEC pass/fail
decisions are both accurate and fair. Interpreting the results
presented in this paper to determine the appropriateness of
these decisions is left to the reader. This is because provision of
the evidence must be independent of interpretation of the evi-
dence in order to avoid bias.
We were unable to find any studies using blueprints to assess
content validity; and neither could we find any published re-
ports of pass mark reliability in the literature. The former may
be due to controversy regarding whether or not blueprints
should be published (McLaughlin et al., 2005) and the latter to
concerns about students using the data as a basis to appeal fail
decisions. Because all 2010/11 GEC students failing their first
attempt at a module passed their re-sit, no false negative deci-
sions were made. While the re-sitting students may have just
passed their first attempt if the exam was held on a different
Figure 3.
Pass mark reliability, by module. SEE: Standard error of the estimate.
day with different questions, erring on the side of caution helps
ensure medical schools do not graduate incompetent students.
We have not been able to evaluate whether the GEC pass marks
were set at the right level, since this would require Year 3 score
data for students who had both passed and failed the GEC as-
Notwithstanding these concerns, we believe multiple sources
of validity evidence data should be published, particularly
where benchmarks are available against which such data can be
evaluated. Such data can be used as a starting point for qualita-
tive work to explain differences in validity evidence across
assessments (and across educational institutions) and therefore
to identify ways in which assessments can be improved. An
example from the data reported here, which also highlights the
inter-relationships between the different sources of validity
evidence, is the need to compare the characteristics of the writ-
ten questions meeting the facility and discrimination targets
with those that do not, and to revise the poorly-performing
questions appropriately.
This review should improve the reliability (internal consis-
tency) of the assessments, but this must be achieved without
reducing the spread of learning outcomes being assessed (i.e.
by jeopardizing content validity).
We have also shown how validity evidence can be used to
evaluate changes in the assessment process; the importance of
which is highlighted by Cook and Beckman (Cook & Beckman,
2006). The change in focus of the live exam from knowledge to
process appears to have had the desired effect of having the live
exam assess different skills to the written exam. The new exam
included assessment of communication skills, dealing with
uncertainty, synthesis of new information and writing learning
objectives; all essential skills during the students’ clinical years
and beyond. It is vital that these skills are nurtured early on and
that students who may struggle to manage their own learning in
the clinical years can be identified and supported.
Providing validity evidence is rarely straightforward: while
we have shown that GEC performance is an excellent predictor
of final year performance, the ‘ultimate’ outcome is postgradu-
ate performance, for which final year performance is a reason-
able, but not excellent, predictor (Hamdy et al., 2006). In addi-
tion, we have not been able to provide objective evidence on all
aspects of validity identified by Downing (Downing, 2003) and
it is important to remember that validity is only one component
of assessment utility (Van der Vleuten, 1996). Our results only
relate to inferences made on the basis of the particular diet(s) of
Copyright © 2013 SciRes.
assessments considered and cannot be generalized to the as-
sessments themselves. Nevertheless, we would encourage oth-
ers to undertake similar work, so that more generalizable les-
sons can be learned.
The authors wish to thank Angela Priestman, Trudy Knight,
Camelia Arsene, Christine Wright and Mary Stevenson for their
suggestions on drafts of this paper.
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