A national investigation on the impact of rurality on standardised clinical aptitude test performance

Rural applicants to medical school are known to be disadvantaged, given their observed poorer performance on most selection measures. This study aims to examine performance differences of rural and metropolitan applicants on all UCAT-ANZ (University Clinical Aptitude Test in Australia and New Zealand) subtests and overall, as well as explore whether increasing rurality is associated with poorer performance.

Retrospective repeated cross-sectional study of all UCAT-ANZ applicants between 2019 and 2023, stratified by rurality according to the Modified Monash Model. Six performance scores of the UCAT-ANZ were assessed: verbal reasoning, abstract reasoning, decision making, quantitative reasoning, situational judgement and aggregate cognitive score.

Rural origin applicants consistently achieved lower scores compared with the metropolitan origin applicants across all five years and most test components, with quantitative reasoning and abstract reasoning having the largest differences. Most test scores consistently decreased with each rurality level, even after accounting for key socio-economic and demographic differences. Additionally, the gap between metropolitan and rural applicants increased for decision making, quantitative reasoning, abstract reasoning and overall. The largest decrease in scores between rurality categories occurred for metropolitan and large regional centre applicants, with scores generally decreasing with each subsequent rurality category.

There remains a substantial disadvantage for rural applicants completing standardised tests for selection into medical school, and this worsens with increasing rurality. The performance gap between rural and metropolitan applicants has somewhat widened in the last five years, emphasising the need for immediate action to help address rural disadvantage within medical school selection. Failure to address this risks selection not aligning with social justice principles. Key actions include increased efforts from an earlier age to better support rural applicants, decreased reliance on these tests for selection decisions, or decreased direct competition between rural and metropolitan applicants through the use of quotas or separate tiers.