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The hidden costs of ‘free’ education

Unless there is significant change, studying medicine will continue to be a path only available to middle-class students

Studying medicine is a middle-class activity. It has always been this way. I have noticed recently while researching pioneering female doctors of the early 20th Century that most of them came from well-to-do, mostly Protestant families, with fathers who were clergymen or bank managers or engineers. Middling men. Not upper-class, not dripping in property and titles, but certainly not short of a few bob, and keen for their offspring to progress up the social ladder.

When Donogh O’Malley introduced ‘free’ education in 1966, it was anticipated that the opportunity for educating and bettering oneself was now up to the individual, accessible to anyone who worked hard and knuckled down. (Incidentally, O’Malley was married to Dr Hilda Moriarty, one of those aforementioned pioneering female doctors). The gates of the universities would be flung open and there would be equal access for the Frank McCourts and the Vere Wynne-Joneses alike. Anyone who applied themselves could apply.

Of course, it soon became clear that ‘free’ education wasn’t that free at all. There were still books to buy and uniforms to source (and they must come from the exclusive uniform shop with the exclusive uniform crests and for the exclusive uniform 300 per cent profit margin price). There are ‘voluntary contributions’, which are about as voluntary as an invitation from a Mafia boss to shine his shoes. Arts and crafts materials, photocopying charges, the fiver for the bus to the Sciath na Scol final, the donation for Sister Agnes’s retirement sandwiches. It all adds up, and that’s just in junior infants. It’s a long and expensive road from there to university.

And when your child is filling in the all-important, life-defining, ‘don’t-mess-this-up-or-you’re-doomed’ CAO form, they may not yet realise that the decision they are making is not simply an academic one, it is an economic one too. A parent might be delighted to hear that little Emily has decided to be a doctor, until they realise the price they will have to pay before she ever gets her hands on an overpriced Littmann. Secondary schools in areas of deprivation are still far less likely to have students progressing to third-level education of any kind, and when it comes to courses such as medicine, the figures for entrants from these schools are tiny (a recent HEA report showed that UCC, UCD and RCSI have fewer than 5 per cent of students from these areas). There are many reasons for this, but fundamentally it comes down to class and privilege, and the cosy social protection that those things provide. Expectations are lowered in schools in disadvantaged areas, which is of course a self-fulfilling cycle.

A young woman who was attending a DEIS school told her guidance counsellor that she was considering applying for medicine. The counsellor looked at her up and down and said “ah no, I don’t think so”. The young woman was undeterred, however, and started looking into the course herself, and how she might apply. None of her family members had been to university, so she wasn’t quite sure how it all worked, and she soon encountered another stumbling block.



It turned out that medicine is a ‘special case’. It has been decreed from ‘on high’ that your run-of-the-mill Leaving Cert/CAO hamster wheel is not enough of a hoop to jump through. You must also participate in the HPAT, the Health Professions Admissions Test, which was introduced in 2009 with the “intention of broadening access to medical school”. A review carried out in 2012 stated that “candidates from disadvantaged backgrounds represent less than 4 per cent of all applications to medical school. The reforms introduced in 2009 have not changed this trend”. So HPAT didn’t help to broaden access. Did it hinder it? The price of sitting the exam was €140 in 2019. There were reassurances at the outset that HPAT was an assessment based on aptitude and inherent personal qualities, rather than a test of knowledge, and therefore scores could not be improved by studying or tutoring. It became rapidly apparent, however, that those students who enrolled for preparatory courses were more likely to achieve higher scores, so lo and behold, some kind souls started to offer students the opportunity to hone their skills and increase their chances of success. These courses start from €200 for an online course, to €1,295 for a luxury package, complete with one-on-one coaching. One of the providers has this little gem on its website to justify the high cost: “Irish doctors who have not yet become fully-qualified GPs can receive pay of over €80,000 a year while they are still in training, and obviously this amount will significantly increase once they become fully qualified. Thus, relatively speaking, the cost of a HPAT preparation course is minor compared to your own potential earnings as a medical professional.”

On what planet does such a scenario encourage equal and equitable access to medical school? There is an immediate and explicit bias built in from the outset, before a person has even turned over their English Paper One in early June. These fees are extortionate, in my view. And it turns out that a high score on your HPAT doesn’t even make you a ‘good’ doctor. A 2017 study compared HPAT scores with the Jefferson Scale of Physician Empathy and showed no correlation, suggesting no clear link between a high HPAT score and better interpersonal skills.

And so the division persists, and the children of the bankers and lawyers and lecturers will fill our hospitals and surgeries, while everyone else is left behind.

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