A Hazard Model of the Probability of Medical School Drop-out in the UK Author(s): Wiji Arulampalam, Robin A. Naylor, Jeremy P.

Smith Source: Journal of the Royal Statistical Society. Series A (Statistics in Society), Vol. 167, No. 1 (2004), pp. 157-178 Published by: Blackwell Publishing for the Royal Statistical Society Stable URL: http://www.jstor.org/stable/3559804 Accessed: 03/09/2010 14:45
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J. R. Statist. Soc. A (2004) 167, Part1, pp.157-178

A hazardmodel of the probabilityof medical school drop-outin the UK

Wiji Arulampalam
of University Warwick, Coventry,UK,and Instituteforthe Study of Labour,Bonn, Germany

A. andRobin Naylor JeremyP.Smith and

of University Warwick, Coventry,UK [Received May2002. RevisedJune2003] individual longitudinal fortwoentirecohortsof medical level data studentsin Summary.From UKuniversities, use multilevel we modelsto analysethe probability an individual that student willdropout of medicalschool.We findthatacademicpreparedness-bothin termsof previous subjectsstudiedand levelsof attainment therein-is the major influence withdrawal on by medicalstudents.Additionally, studentsare morelikely withdraw to males and moremature thanfemalesoryounger studentsrespectively. findevidencethatthe factors We the influencing decisionto transfer coursediffer from those affecting decisionto dropoutforotherreasons. the Limited duration Medical Multilevel risks; model; students; models; Keywords:. Competing Student Survival probabilities; drop-out analysis (non-completion)

1. Introduction
Theissueof the determinants medicalstudentdrop-outprobabilities important topical of is and in both the UK and beyondfor a varietyof reasons.First, thereis seriousand growingconcernin the UK and elsewhere a regarding shortagein the domesticsupplyof medicaldoctors. The thirdreportof the UK's MedicalWorkforce StandingAdvisoryCommitteeobservedthat therewill be a deficitof doctorsin Europeearlyin this century(MedicalWorkforce Standing AdvisoryCommittee(1997),page 30). This has led to Government-supported enquiriesinto the causesand potentialcuresfor this problem.The most obvious policy initiativeis to train moredoctors.The MedicalWorkforce StandingAdvisoryCommittee(1997)concludedthat a to substantial increasein medicalschool intakewas required meet the futureworkforce needs of the UK National HealthService.In response,the Government allocated1129new medical in NationalHealthService'Plan places,in a three-stage processbeginning 1999.Thesubsequent 2000' announcedthe Government's targetof a further1000medicalplaces,with the expectation that the majorityof the additionalstudentintakewill be in place by 2006. Thesechanges implythatthe total medicalschoolintakewill havealmostdoubledovera 10-yearperiodfrom 1997. As has been highlightedin policy discussions(MedicalWorkforce StandingAdvisory Committee,1997),an expansionin the numbersof medicalstudentsbegs questionsregarding both the qualityandthe retention students. of Thispaperattempts informourunderstanding to of the latterissue.
Address correspondence: Robin A. Naylor, Departmentof Economics, Universityof Warwick,Coventry, for CV4 7AL, UK.

E-mail: robin.naylor@warwick.ac.uk

Society ? 2004 RoyalStatistical

0964-1998/04/167157

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W Arulampalam, A. Naylorand J. R Smith R.

relatesto the UK deA secondreasonfor examiningmedicalstudentdrop-outbehaviour of accessinto highereducation,in general,and into medical bateon the desirability 'widening' Therehas been a lively and high profiledebatein the UK concerning schools in particular. of the extent of accessibilityof medicalschools to studentsregardless their social or school (see background McManus(1998)and the relateddiscussion).This has led to explicitrecommedicaleducation(AngelandJohnson,2000). mendations broadenaccessto undergraduate to is the Predicting likelyeffectof suchpolicieson retentionand progression clearlyan important issue. A third reason for analysingwithdrawal medical studentsis relatedto the debate by concerningthe extent to which previouseducationalqualificationsaffect the performance of and progression medicalstudents(see, for example,McManuset al. (1999)).Additionally, et of Arulampalam al. (2003) analysethe determinants first-yeardrop-outsover the period 1980-1992.An issue here concernswhetherit should be compulsoryfor medicalstudentsto havestudiedsciencesubjectsbeforeenrolment. The rest of this paperis organizedas follows.Section2 presentsa discussionof the institutionaland policycontexts,whichprovidethe backdropto our analysisof dataon UK medical students.Section3 describesthe data set. Section4 presentsthe econometricmodel together We our with a discussionof relevantissues regarding model estimationprocedure. note that to our studyis the firstin the literature applya hazardmodelto the analysisof withdrawals by students.We also observethat no previousanalysisof withdrawals medical by undergraduate studentsin the UK has exploiteddata on full cohorts of medicalstudents.In Section 5, we hazard of based on a single-risk presentestimatesof the determinants drop-outprobabilities model. The basic drop-outprobabilitymodel that is presentedin Sections 4 and 5 is then extendedin Section 6 to a more detailedanalysisof the underlyingreasonsfor withdrawal risks'framework. Finally,Section7 closes the paper throughthe applicationof a 'competing with conclusionsand furtherremarks.

2. Institutional context and publicpolicy

labourmarketsin which Laboureconomicsfocuses chieflyon the analysisof decentralized from the interplayof the forces of supplyand demand,where outcomesemerge equilibrium these forcesare governedsignificantly the priceof labour.In importantrespects,however, by in the labourmarketfor medicalpractitioners the UK is betterdescribed a planningmodel by market.Primarily, is becauseof the natureof the this thanby a modelof a purelydecentralized in regulation the market.In the UK, doctorsaretrainedwithinmedicalschools that necessary followsfromthe In arefundedand regulated the Government. largepart, this arrangement by nature medicalprovision of underthe auspicesof theNationalHealth stillpredominantly public a in Service. Currently the UK, as in manyothercountries,therearemajorconcernsregarding of medicaldoctors.The UK solutionto this problemis perceivedas requirgrowingshortage This is a very differentapproachfrom ing more efficientplanningof the medicalworkforce. froman analysisof the shortageof post-graduate that whichhas recentlybeen recommended studentsof economicsin the UK (see Machinand Oswald(2000)).In that case, the problem
was attributed largely to a distortion in the relative price of labour. The third report of the Medical Workforce Standing Advisory Committee (1997) to the Secretary of State for Health bears testimony to this reliance on a planning approach and also makes plain how such an approach-to be effective and efficient--demands a wealth of detailed data and appropriate accompanying analysis. In part, the nature of this information requirement is a consequence of the lengthy training period and the time lags between forecasting future supply and demand and the subsequent 'production' of the medical workforce. Uncertainties in demographic trends

MedicalSchool Drop-out

159

that and in the evolutionof medicaltechnologies compoundthe difficulties areassociatedwith and planning. forecasting The MedicalWorkforce to AdvisoryCommittee (1997)proposedvariousmeasures Standing whatit described 'thecurrent as imbalance' betweendemandandthe domesprevent significant severe'.A mainconclusionof the reportwas tic supplyof doctorsfrombecoming'increasingly that thereshould be a substantial increasein the intakeof medicalstudents(about 1000 per levelsof wastagefromsuchcourses,thereby annum) togetherwithpoliciesto ensure'minimized who qualifyas doctors'.Of course,a significant incentive the increasing proportionof entrants to reducewastagerateslies in the high cost thatis associated with medicaltraining. Thereis no consensusfigureon the full cost of a medicaltraining-partly becausethe costs vary between institutionsand are borne by a varietyof parties-but a figureof around?50000 per annum to has often been quoted.One elementof the proposedpackageof measures addressthe issue of of minimizing for wastageconcernschangesin the selectionprocedures candidates medical schools to 'obtain graduateswith a wider range of skills and interests'.The relatedissue of selectionand admissionof studentsinto medicalschools in the UK has itself been the recent focus of significant debate. As the MedicalWorkforce StandingAdvisoryCommittee(1997)emphasized,the developmentof strategies minimizethe drop-outrateof medicalstudentsshouldbe conductedin the to of behaviour medical by light of an analysisof the determinants completionand withdrawal This has beenrendered difficultin the UK by a lack of reliable dataand analysis.The students. that thereis signifiMedicalWorkforce StandingAdvisoryCommittee(1997) acknowledged ratesfor medicalschools.Estimatesare cant uncertainty estimatesof qualification regarding betweenthe annualintakeof studentsat each medicalschool typicallybased on the difference and the numberqualifying5 years later.This is imprecisepartlybecauseof variationsover in timeandacrossinstitutions the numberof studentstakingintercalated degrees,for example, and hencetakinglongerto qualify. that Thus, it is not surprising thereis so muchvariationin the estimated (withno systematic trend)between8%and 14% drop-outrates,whichfluctuated duringthe period from 1986-1987to 1991-1992(see MedicalWorkforce StandingAdvisory the Committee (1997),page 65). So severeis the information problemregarding drop-outrate that the MedicalWorkforce that all its StandingAdvisoryCommittee(1997) acknowledged restedon an estimatedwastagerateof studentswhichis itself analysisand recommendations based on 'some anecdotalevidencethat drop-outis falling' (page 25). One of the eight recommendations the reportcalledfor moreinformation research of and into wastageratesfrom medicalschools, interalia. In the absenceof reliable dataon drop-outratesfrommedicalschools,differentstudieshave estimates the average of nationalrate.Parkhouse widelyvarying (1996)used Univerproduced dataon theintakes sities'Statistical RecordandHigherEducation CouncilforEngland Funding of medicalschoolsandnumbers 5 yearslaterandestimated average an qualifying drop-outrate in the UK of between11.7% 14.1%. and McManus(1996)disputedthesefiguresand cited survey evidencethat the rateis around7%or 8%,with about half of the studentswho drop out reasons. doing so for non-academic Previousdata and accompanying analyseshavebeen based, typically,eitheron aggregated
(medical school level) official data from the Universities' Statistical Record or Higher Education Funding Council for England or on follow-up surveys of particular subsamples of medical students. This mirrors the situation regarding the analysis of all UK university students across all subject areas. Very recently, however, (anonymized) individual student level administrative data for full population cohorts of students have become available to researchersfor the period 1972-1993. These data contain rich information not only on the academic characteristics of

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studentsin UK universities and affiliation, (theircourses,institutional performance reasonsfor interalia) but also on theirpersonal,socialandprioreducational characteristics. These leaving, data offerthe prospectof muchmorepreciseestimatesof drop-outratesand of detailedanaThis is of clear of lyticalinvestigation the factorsthat are associatedwith drop-outbehaviour. to on interestand relevance the issueof examiningthe effectof changingselectionprocedures medicalstudents'drop-outprobabilities (see, for example,Angel and Johnson(2000)).Given the importanceof the issue to public policy, in the currentpaper we focus exclusivelyon a of of detailedanalysisof the determinants the probability withdrawal UK medicalstudents. of IndividualUK studentlevel data havepreviouslybeen exploitedto analyseacademicperformanceand drop-outprobabilities studentson 3- or 4-yeardegreeprogrammes of (Smith and Naylor, 2001a,b). These studieshave omittedmedicalstudentsfor a varietyof reasons, longer than standardundergraduate includingthe fact that medicalcoursesare significantly and the fact that medicalstudents'characteristics typicallyratherdifferent are programmes fromthose of other students.The average A-levelattainment, example,is much higherfor for A-levelpoints scorewas 26 for the cohortsthatareconsidered medicalstudents,whoseaverage in this paper,comparedwith a scoreof less than 22 points for contemporaneous non-medical it to students-a difference morethantwo A-levelgrades.Accordingly, is appropriate model of the behaviour medicalstudentsseparately of fromthat of otherstudents.

3. The data
All highereducationinstitutions-includingall medicalschools-in the UK arerequired annuindividual studentrecords datawitha centralgovernallyto depositcomprehensive longitudinal individual Our data mentagency. dataset is basedon theseadministrative fromthe anonymized studentsleavinguniUniversities' StatisticalRecordfor the full populationsof undergraduate on years 1985-1993.Frominformation each of these versityin the UK in one of the academic all a 'leavingcohorts',we havegenerated data set comprising those full-timestudentswho enat tereduniversity the startof the academic year 1985or 1986to studyfor a medicaldegreeand who had eithercompletedtheircourseby the end of July 1993or had left theirmedicaldegree beforecompletion. programme of The reasonfor the choice of startingyears 1985and 1986is basedon considerations the no later than 1993. In of data. The availability data restrictsus to cohorts leavinguniversity congeneral,a medicaldegreein the UK takes5 yearsto completeand the analysisis therefore the first2 years ductedon studentswho enrolledfor a 5-yeardegreeprogramme. Traditionally, At and havebeenclassified preclinical thelast 3 yearsas clinicalpartsof the degree. the endof as to the secondyearof the programme thosewho performwellaregiventhe opportunity takean withtheirmedicaldegree. of extrayearto completea Bachelor Sciencedegreebeforecontinuing If theyaresuccessful, will thesestudents thenhavetakena minimum 6 yearsto completetheir of Studentsarealso allowedto retakeanyfailedexaminations duringtheircourse originaldegree. to of studies. proceedto the nextyearof the degreeprogramme, studentis required pass the To at the firstattemptor afterresittingthem). Studentswho completed the examinations (either
their medical degree programme in 1993 after 5 years of study would have first enrolled in 1988. However, if we study only these students, we shall fail to observe students taking more than 5 years to complete the course. For this reason, we prefer to consider students who enrolled no later than 1986 as this gives us a minimum of 7 years over which to observe their withdrawal or completion. To increase the size of our data set, we also include the cohort starting in 1985. The two cohorts will have faced very similar labour market and related conditions. This becomes less true if we take additional earlier cohorts.

MedicalSchool Drop-out

161

In the event of non-completion,an administrative leavingdate is recordedalong with a Fromthis information, find that, we reasonfor the student'swithdrawal. university-recorded those who registered a medicaldegree,coursetransfers for accountfor around26%of among with academicreasonsaccountingfor 36%and otherreasonsaccountingfor all withdrawals, 32%.Fromthe point of view of the medicalprofession,whatmattersis the simpledichotomy In betweencompletionand withdrawal. our basic model, this distinctionforms the basis for In variable. Section6, we also exploitinformationon the reason our dichotomousdependent for withdrawal withina competingrisksframework. In this paper,an individual assumedto havesuccessfully is completedif she or he obtainsa the medicaldegreeby theendof 5-7 years(and8 yearsforthe 1985cohort)regardless whether of had fromthe medical individual to resitsomeexaminations. Drop-outis definedas withdrawal reason.All those who areobservedto havedroppedout of the for degreeprogramme whatever after five programme years are assumedto have droppedout in the final year of programme whichis 5 years,is usedas theprogramme. Thus,the standard lengthof the medicalprogramme, the durationtime in our analysisratherthan the actual calendartime taken for completion. a Hence, by the end of the fifth year there is assumedto be a forcedtermination: successful completion,or a drop-out. The second and thirdcolumnsof Table 1 providesome informationabout drop-outrates. The 1985 cohort consists of 3889 students,whereasthe 1986 cohort has 3900 students.The unconditional rate non-completion for all studentswho starteda medicaldegreein either1985 or 1986is around11%. Fromthesetwo cohortsof medicalstudents,8.1%actuallydroppedout fromuniversity (with2.8%droppingout of a medicaldegreebecauseof a changein altogether rate with a valueof 8.9%thatwas obtainedby course).Thisnon-completion of 8.1%compares Smithand Naylor (2001b)lookingat all 3- and 4-yeardegreecoursesfor studentsbeginninga yearin 1989. degreeat the startof the academic Looking at the conditionaldrop-outratesof medicalstudents,we see that, as the student the progresses throughthe programme, conditionaldrop-outratedeclinesquite dramatically. About 50%of those who do not completetheirmedicaldegreeleavebeforethe start of their secondyear.This findingis verysimilarto that of Smithand Naylor(2001b),whereacrossall studentstheequivalent figurewas 55%,and is similarto thatof Porter(1990)acrossall students is in the USA. The conditionaldrop-outratein the finalyearof the programme only 0.37%.
Table1
Overalldrop-out for thefollowingyears: 1985 1986 Results thefollowing for reasons drop-out: for Coursechange 1985 + 1986 7789 1.85 0.79 0.20 0.00 0.00 2.77 Other, 1985 + 1986 7789 3.58 1.82 0.92 1.40 0.36 8.09

Number of students(initial) Conditionaldrop-outrate (%) Year 1 Year2 Year3 Year4 Year5 Unconditionaldrop-outrate (%)

3889 5.32 3.04 1.01 1.33 0.37 10.67

3900 5.54 2.39 1.39 1.47 0.37 10.74

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of Table2. Definitions descriptive and statistics variablest

name Variable andcategories Definitions Meansfor thefollowing samples: Overall sample Entryage (binaryindicators) Aged < 18 Aged 18 yearsor less in Septemberof entryyear Aged 19-21 Aged 19-21 years Aged > 21 Aged more than 21 years Sex-male 1 if the studentis male 1 if the studenthas British Nationality nationality 1 if the studentpays non-UK fee Non-UK fee Accommodation Accommodationin the firstyear at university (binaryindicators) Livingat home Livingat home Livingon campus Livingat universitycampus accommodation Other Not livingat home or university campus School attended Typeof school attendedbefore (binaryindicators) entryto the medicalprogramme Local education School is non-selective authorityschool Grammarschool Statefunded,but selectionis typicallybased on ability school Independent Fee-payingschool and is also selective College of further College of furthereducation education Other Residualcategorywhichincludes Churchschools Main entryqualifications the Type of qualifications individual had on entryto the programme A-level scoresBest of 3 total A-level scores best-of-3 total Best of 5 total Scottishor Irish Highersscoresbest-of-5 total Higherscores(averageamong those with these qualifications) of Percentage students havingmore than 3 A-levels OtherA-levelscores Excludesthe best 3 A-levels of Percentage students havingmore than 5 Highers OtherHighersscores Excludesthe best 5 Highersscores Top score 1 if the total score was the highest achievable(out of 3 for A-level subjects,and out of 5 for Higher level subjects 1 if subjectstaken included 1 from 1 favouredsubject chemistry,physicsand biology among the A-level or Highersubjects Drop-out sample Completion sample

0.619 0.320 0.061 0.543 0.942 0.042 0.110 0.773 0.117

0.573 0.311 0.116 0.586 0.926 0.058 0.118 0.739 0.143

0.625 0.321 0.054 0.538 0.944 0.040 0.108 0.778 0.114

0.381 0.135 0.343 0.080 0.061

0.382 0.101 0.333 0.076 0.108

0.381 0.139 0.344 0.080 0.056

26.2 (3.9) 13.7 (1.9) 42.9 8.9 (4.9) 7.2 2.8 (1.3) 0.272

25.4 (4.3) 13.5 (1.9) 61.4 13.3 (6.1) 7.7 2.7 (1.3) 0.139

26.3 (3.9) 13.7 (1.9) 40.7 8.1 (4.2) 7.1 2.8 (1.3) 0.288

0.013

0.016

0.012 (continued)

MedicalSchool Drop-out
Table 2 (continued) Variable name andcategories Definitions Meansfor thefollowing samples: Overall Drop-out sample sample 2 favouredsubjects 3 favouredsubjects Otherentryqualifications (binaryindicators) A-levels or Highersonly 0.439 1 if subjectstakenincluded2 from chemistry,physicsand biology among the A-level or Highersubjects 0.503 1 if subjectstakenincludedchemistry, physicsand biology among the A-level or Highersubjects 0.474 0.416

163

Completion sample 0.435 0.513

0.920 Studentswho haveonly A-levels or Scottish Highers UK universityqualifications Mainlystudentswho alreadyhavea 0.039 degree Other Studentswith no qualification,Business 0.041 and TechnologyEducationCouncil or other UK or foreignqualification Parentalsocial class Social class of the head of household (binaryindicators) Professional 0.343 Socialclass I Intermediate 0.383 Social class II Skillednon-manual 0.080 Social class III non-manual Other Socialclass III manual, social class IV 0.194 and social class V:manual or other workersincludingnon-workers Fatheris a doctor 0.137 Parentor guardianwas a medical practitioner Numberof students tStandarddeviationsare given in parentheses. 7789

0.868 0.056 0.076

0.925 0.038 0.037

0.331 0.342 0.094 0.233 0.126 834

0.345 0.388 0.078 0.189 0.139 6955

In the UK, the usual age of entryinto a universitymedicalschool is 18 years.Looking at Table2 we seethat 62%of oursamplemembers aged 18yearsor lesson entry,witha slightly are lowerproportionfoundamongthe drop-outscomparedwith those who successfully complete the course.Although our samplecontains an approximately equal split of male and female students,malesarefoundto predominate amongthe drop-outs. In the two cohortsthat areusedin the analysis,94%of the studentswereof UK nationality. The feesthatarecharged universities as by dependon the nationality wellas on someresidency conditions.In general,UK studentsare liable for a UK fee, which is much smallerthan the overseasstudent's In anycase,for the cohortsthatwe areanalysing the presentpaper,all fee. in fees facinga UK studentwerepaidfor by the student's local educationauthority. European A Union studentwouldbe liableto pay the UK levelof fee. In the academicyear2002-2003,this was just over?1100 per annum.The overseasfee variesacrossuniversities, in 2002-2003 but was around?9000per annumfor the two preclinical and ?17000per annumfor the three years clinicalyears.Overseasfee payingstudentsaccountfor only 4%of the population,but for 6% amongthe drop-outs. Beforeenteringuniversity,most UK studentsstudy in secondaryschool towardsqualifiin cations, the level of performance whichwill determinethe successof their applicationsto

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R. W.Arulampalam, A. Naylorand J. P Smith

highereducation.Broadly,we can distinguishbetweentwo types of school: those which are in the privatesector (henceforth,'independent' schools) and those that are in the broadly defined state sector. The latter consists of various subcategoriesof school, includinglocal educationauthoritycomprehensive schools, grammarschools (to which admissionis selective and subjectto educationaltests) and colleges of furthereducation.In the school popuschool. In contrast, lation of the UK as a whole, about 7%of pupils attendan independent around 34%of medical studentswent to an independentschool. This is markedlyhigher UK students. even thanthe 27%thatis observedfor the groupof all (non-medical) university school qualifications formthe basis for offersof placesat that The pre-university secondary medicalschools are, typically,A-levelsfor school pupilsfrom England,Walesand Northern Ireland,and 'Highers'for school pupils from Scotland.A-levelsare classifiedas A-E. These gradescan be convertedinto a points score:A- 10 points, B - 8 points, C - 6 points, D 4 points and E- 2 points.Highersare classifiedas A-C: A- 3 points, B_ 2 points and C 1 in performance places are typicallyconditionalon the candidate's point. Offersof university their best threeA-levels (or best five Highers).In addition, some medicalschools interview beforemakingan offerof a placeon the course. candidates was A-levelor Higherscorefromthe best threeor fivesubjectsrespectively 26.2 The average or 13.7points,with about27%of the cohorthavingthe maximum30 or 15 pointsrespectively. 50%of studentsarrivingfor a medicaldegreehad eitherA-levelsor Highers Approximately in chemistry, physicsand biology.Not all medicalstudentsenterwith the standardA-levelor recorded only had a or About 4%of studentshad no priorqualifications Higherqualifications. In EducationCouncilor similarqualification. addition,another4% Businessand Technology in that alreadyhad a priorqualification had been obtainedfroma university the UK. shows that of The social class background studentsenteringa medicaldegreeprogramme around34%come fromsocialclass I (professional) (with39%of theseactuallycomingfroma is and in background whichone of theparentsor the guardian a medicalpractitioner) 38%from This compareswith only 19%of all studentsstarting socialclassII (intermediate professions). and a 3- or 4-yeardegreecomingfrom a professional background 43%from an intermediate background. professional with respectto the characteristics those amongthe drop-outsample,comof Summarizing there is a slightlylarger completethe degreeprogramme, paredwith those who successfully of proportion individuals (a) (b) (c) (d) (e) who are agedmorethan 19 years, who aremen, who arepayingnon-UK fees, A-levelscorewhichis slightlylowerthanABB and who havean average threeA-levels. who havemorethan the standard

4. Econometric model
that an individualstudentwill In the currentpaper,our objectiveis to model the probability on duringsome smalltimeinterval,conditionally not dropout of a medicaldegreeprogramme
having dropped out up to that point. As indicated above, the underlying variable is the time that is spent on the programmeratherthan calendar time. Unlike in conventional duration (survival) models, two specific characteristics of the programme need to be addressed. First, the duration of the programme is limited to 5 years. Because of this limited duration, the underlying continuous time duration variable will have a distribution that is continuous over the interval (0,5) and a discrete probability mass at the end point of 5 years. Second, the programme cannot be com-

SchoolDrop-out 165 Medical of completingthe programme pletedbeforethe end of 5 years,i.e. the probability successfully the first5 yearsis 0. Wearenot awareof anypreviousstudythatappliesa hazardmodel during Mealli et al. (1996) considereda to the analysisof the undergraduate drop-outprobability. Booth risksmodel in the context of youth trainingprogrammes. duration-limited competing and Satchell(1995)and van Oursand Ridder(2000)looked at a relatedmodelfor completion ratesfor doctoralcourses. 4. 1. Cox'sproportional hazards model of hazardsmodel. Giventhe abovecharacterization the prowith Cox'sproportional Westart as of studies,the hazardfor individual hi(t), is parameterized i, gramme
hi(t) = A(t)exp(x)3) (t < 5 years) (1)

for whereA(t)is the base-linehazardat time t, xi is the vector of characteristics individuali As vectorof unknowncoefficients. the interceptterm)and 3 is the corresponding (excluding of errorsin the recording the date of dropdiscussedearlier,becauseof possiblemeasurement has here,thedurationinformation beenrecodedin out, forthepurposeof the analysis presented A durationof t wholeyearstherefore indicates duratermsof wholeyearscompleted. recorded of tion on the continuoustimescale,betweent - 1 andt years.Hence,the probability exitingby at on timet conditional xi, giventhatthestudentwasstillon theprogramme timet - 1,is givenby
qli(t Ixi) = Prob(Ti < tit - 1 < T) = 1 - exp = 1exp

-j

hi(r) dr

-j

A(r) exp(x~p3) dr}

= 1- exp[-exp{x'o+ 6(t)}] where

6(t) = In j A(r)dr .

(2)

(3)

time.See valueformforthedrop-out modelin discrete Wethushavean extreme probability in for a modelof unemployment duration discrete Narendranathan Stewart and (1993a,b) time. is finishes the endof year5. There thusa forced at As seenearlier, degree the programme we do not makeanydistinction termination thispoint.Because possible at of endogeneity, a and thosewhohadan intercalated to complete science between degree thosewhodid year take we assume theselimitpointprobabilities that not.Toaccount theforced for termination, as set This form before, witha different of coefficients. is specified as thesame extreme value but out 51survival to year5,xi) q2i(t = 51xi)= Prob(dropping in year up
= 1 - exp{-exp(x a + ?7)} (4) where a is the vector of unknown coefficients and rl is the intercept term. Let Ti be the recorded duration in years for individual i. Then the likelihood contribution by individual i with a recorded duration of Ti < 5 is given by
i li()
t=2 {1

- qli(t - 1)}.

(5)

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R. W Arulampalam, A. Naylorand J. P Smith

i The likelihoodcontribution individual who proceedsto year 5 is givenby by

5

1-di

di

Li=

(1 - q2i) II{1 -q1i(t 1)

t=L2

2i

{1 -qi(tt=2

1)}

(6)

whichtakesthe valueof 1 if the individual whered is a binaryvariable dropsout duringthe final The of the programme is equalto 0 otherwise. likelihoodfunction,whichwill be made and year up of termsgivenby equations(5) and (6), will factorinto two partsand thus will facilitatea The of estimationof the parameters the two exitprobabilities. abovemodelalso can be separate wherethe two risksthatarefacedby the individuals of in a competingrisksframework thought lasts for a minimumof 5 years, arecompletionand droppingout. Sincethe degreeprogramme the completionspecifichazardmust be set equal to 0 for the periodsup to the 5 years.This above. modelthencollapsesto the modelspecified A usefulway of lookingat the abovespecification in termsof a binaryresponsemodel. In is variable be thoughtof as taking can of the estimation the firstexitprobability the dependent qi, the value of 0 in the yearsbeforeexit and a value of 1 in the year of exit beforeyear 5. Each who here.An individual will to individual makea maximum fourcontributions theestimation of to the finalyearwill havea binarysequence,whichis entirelymadeup of Os.The estiproceeds of mationof the parameters the secondhazardis then carriedout by usingonly the subsample who to This of individuals haveproceeded the finalyearof theprogramme. againcanbe thought variable d, as definedabove. is of as a simplebinaryresponsemodelwherethe dependent is The main advantageof workingwithin the binaryvariableframework that we can then relaxthe extremevalue assumptionand use popularmodels such as the probitand logit that For timeframework. example, continuous hazardin the underlying implya non-proportional as in the case of a logit model,the conditionalprobabilities and q2iwill be specified qli + exp{x3: 6(t)} + exp{xfx + 6(t)} 1 and
q2i exp(x a + rl) 1 + exp(xa + /)

functionsare then used in equations(5) and (6). Unlike the and theseconditionalprobability are with respectto their extremevalue distribution, probitand logit distributions symmetric means,althoughthey do differin the tail behaviour.

effects that It is well known that a failureto control for any unobservedindividual-specific inference to inconsistent due the hazardfunctionwillresultin misleading parameter mayaffect for estimators (Lancaster, 1990).Thepreviousmodelcan be extended thispurposeby including term along with the vector of characteristics This requiresan assumption a random-error x.
regarding the distribution of this unobservable individual-specific error term. In addition, we also require the assumption of independence of the unobservables and the included regressors to marginalize with respect to these unobservables. The models for the unobservables that were tried were normally distributed unobservables, normally distributed unobservables with allowance for different masses at the end points and a two-mass-point discrete distribution. In none of the models that we estimated could we find any evidence ofunobservable heterogeneity. Models

4.2. Unobserved heterogeneity

Medical SchoolDrop-out 167 to whichallowedforunobserved heterogeneity alwaysconverged thesamepointas modelswithout unobservables, hencewe reportresultsonly fromthe latter. and

4.3. Multilevel models: fixedversusrandom medical schooleffects

is One further issuethatneedsto be addressed the issue of possibleclustering drop-outrates of natureof our data set. Wetherefore withinuniversities need to allowfor giventhe hierarchical medicalschoolfactorsto affectstudentdrop-outprobabilities. can eithertreat We unobservable the unobservable medicalschooleffectsas fixedor as random.The firstmodel is knownas the fixedeffects(FE) model and the secondas the random-effects (RE) model. These models are knownas multilevelmodels.The FE model can be thought of as providinginferencesconditionallyon the medicalschoolsin the sample.In contrast,the RE model can be thoughtof as our that marginalinferences will enableus to generalize resultsto the populationof providing for all medicalschools.Weconsiderthe FE modelas moreappropriate our analysisas the data and the samplethatwereanalysedcoverthe full populationof medicalschoolsin the UK. We and therefore includea set of medicalschool indicatorvariables estimatethe effectsas part of of the parameters the model(model1). However,we also provideestimatesthatwereobtained underthe assumptionof an RE modelto makecomparisons acrossdifferentspecifications. to Thereare advantagesand disadvantages the two approaches, which shouldbe borne in mind in the comparisonsof estimatesacrossdifferentmodels.The FE model does not allow of us to includecharacteristics the medicalschools in additionto the medical-school-specific hence, we also estimateour FE model by replacingthe medical binaryindicatorvariables; school indicatorvariables a set of medicalschool characteristics (model2). This problemis by not presentin the RE model sincethe medicalschool effectsare assumedto be randomdrawthe distribution. But, to marginalize likelihoodfunctionwith respectto ings froma particular in the unobservables this model,we need to assumethat the covariatesincludedand the REs distributed. are independently medicalschool Althoughthe RE model treatsthe unobserved effectsas randomdrawingsfrom a distribution, could obtain the estimatesof 'shrunken' we residuals(or empiricalBayesestimates)of these effects(Goldstein,2003), whichcan then be with the estimated medicalschool'FE'. Becausewe aredealingwithverylargenumcompared bers of observations university, expectto see that the estimatedmedicalschool effects we per will be very similaracrossthese models.In this specification, assumethat the unobservwe All able medical-school-specific are drawnfrom a normal distribution. the models were RE estimated using STATA7(StataCorporation, writtenby Rabe-Hesketh 2001)and gllamm by et al. (2001). 4.4. Modelspecification The analysisof studentdrop-outbehaviour received has muchattentionin the USA, whereone of the attritionof studentsis the path analyses of the most influential theoretical explanations model of Tinto (1975, 1987).This model and relatedanalysessuggestthat the major determinantsof completionarelikelyto be the student's and (a) academic preparedness into the educationalinstitution. (b) socialand academicintegration
The analysis identifies several key influences on the probability of withdrawal, including the student's previous schooling, prior academic performance, family background and personal characteristics, as well as institutional characteristics. All the covariates in the model refer to the first year of the programme. In our model of student drop-out probabilities, we include control variables reflecting the student's prior academic preparedness, their social background

168

R. W Arulampalam, A. Naylorand J. P Smith

of Table3. Derived effects(x100) on the conditional probability withdrawal the medical exit from marginal logit degreeprogramme, modelst
Variablet Withuniversity dummy variables(FE)--model 1 Withuniversity ??-model 2 characteristics? Drop-out versus completion (q2) (4) -3.527 Randomuniversity effects (RE)-model 3 Drop-out versus continuation (ql) (5) -2.037 -1.882 Drop-out versus completion (q2) (6) -3.927

Drop-out Drop-out Drop-out versus versus versus continuation completion continuation (q2) (2) (ql) (1) (ql) (3) Intercept Time trendtt 1986year dummy Entryage (aged < 18) Aged 19-21 -2.248 -1.743 -4.512 -1.055 -1.764

(0.02)*
0.061 (0.73)

(0.00)**
0.033 (0.82)

(0.54)

(0.02)*
-0.212 (0.45) 0.533 (0.04)* 3.428 (0.02)* 0.549 (0.00)** 0.667 (0.00)** 0.675 (0.30) 0.365 (0.13) 0.396 (0.38) -0.161 (0.55) -0.112 (0.60) -0.451 (0.10) 0.658 (0.31) -0.066 (0.01)** -0.059 (0.33) 0.004 (0.86) -0.157 (0.09) 0.087 (0.75) 0.131 (0.63)

(0.05)*
0.055 (0.78)

(0.00)**
0.033 (0.82) 0.391 (0.03)* 1.251 (0.00)** 0.490 (0.00)** 1.029 (0.00)** 0.468 (0.14) 0.457 (0.09) 0.424 (0.15) -0.095 (0.71) -0.069 (0.72) -0.530 (0.19) 0.514 (0.12) -0.049 (0.03)* -0.049 (0.33) 0.011 (0.55) -0.088 (0.25) 0.104 (0.63) 0.119 (0.61) (continued)

(0.00)**

-0.662 (0.05)* -0.056 (0.79) 1.153 (0.09) 0.367 (0.05)* -0.860 (0.13) -0.459 (0.33) -0.223 (0.52) 0.494 (0.27) -0.496 (0.10) 0.094 (0.69) 0.216 (0.57) 0.022 (0.97)

(0.00)**

(0.00)**

-0.094 0.435 (0.65) (0.05)* 1.035 2.776 Aged > 21 (0.11) (0.02)* 0.346 Sex-male 0.498 (0.05)* (0.00)** Britishnational -0.834 0.625 (0.13) (0.00)** -0.331 Non-UK fee 0.549 student (0.50) (0.31) Accommodation(living at home) -0.253 0.417 Campus (0.48) (0.04)* 0.470 Other 0.674 (0.29) (0.18) School attended(local educationauthority) -0.460 -0.152 Grammar school (0.13) (0.50) 0.101 -0.057 Independent school (0.67) (0.76) 0.217 -0.407 Collegeof further (0.57) (0.07) education 0.036 Other 0.747 (0.95) (0.23) Main entryqualifications A-level scores -0.077 -0.053 (0.01)** (0.02)* -0.034 -0.058 Higherscores (0.61) (0.27) OtherA- or -0.015 0.013 AS-levelscores (0.54) (0.49) OtherHigher -0.173 -0.084 scores (0.05)* (0.29) Achievedtop -1.064 0.117 score (0.00)** (0.62) Has mathe0.180 0.099 maticsA-level (0.54) (0.67) or Higher

-0.116 (0.61) 0.965 (0.06)* 0.374 (0.06)* -0.783 (0.09) -0.489 (0.43) -0.237 (0.52) 0.476 (0.25) -0.590 (0.11) 0.156 (0.53) 0.230 (0.54) 0.099 (0.87) -0.082 (0.01)** -0.039 (0.61) -0.013 (0.61) -0.193 (0.05)* -1.158 (0.00)** 0.190 (0.56)

-0.077 (0.01)** -0.029 (0.67) -0.018 (0.47) -0.181 (0.04)* -1.046 (0.00)** 0.190 (0.53)

MedicalSchool Drop-out
Table 3 (continued) Variablek Withuniversity dummy variables (FE)-model 1 Withuniversity characteristics? ?--model 2

169

Randomuniversity effects (RE)-model 3 Drop-out Drop-out versus versus continuation completion (q2) (6) (ql) (5) 1.992 -0.869

Drop-out Drop-out Drop-out Drop-out versus versus versus versus continuation completion continuation completion (q2) (2) (ql) (1) (q2) (4) (ql) (3) No favoured 2.686 -0.575 2.741 -0.695

subject 1 favoured

(0.05)* -0.016

(0.01)** -0.422

(0.05)* 0.026
(0.97) -0.547 (0.05)* -1.481 (0.00)** -1.995 (0.00)** -0.091 (0.72) 0.719 (0.11) 0.322 -0.207 (0.50)

(0.00)** -0.458
(0.19) -0.451 (0.08) 0.420 (0.43) 0.137 (0.84) -0.456 (0.03)* -0.245 (0.36) -0.200 -0.195 (0.44)

(0.01)** -0.010
(0.99) -0.586 (0.05)* -2.289 (0.00)** -3.883 (0.00)** -0.113 (0.68) 0.700 (0.07) 0.309 -0.224 (0.52)

(0.18) -0.588
(0.34) -0.315 (0.14) 0.328 (0.31) 0.091 (0.86) -0.396 (0.04)* -0.172 (0.56) -0.163 -0.189 (0.45)

(0.98) (0.14) subject 3 favoured -0.339 -0.527 (0.05)* (0.12) subjects Otherentryqualifications(A-levelsor Highers) UK university 0.442 -1.460 (0.00)** qualifications (0.37) Other 0.132 -1.993 (0.00)** (0.82) Parentalsocial class (professional) Intermediate -0.381 -0.094 (0.71) (0.03)* -0.158 Skillednon0.756 manual (0.09) (0.52) Other -0.159 0.310 Fatheror -0.215 guardian (0.48) is a doctor Medicalschool characteristics Numberof undergraduates Numberof taughtpostgraduates Number of researchpostgraduates Salariesper medical student Otherexpenses per medical student of Percentage all staff-professors of Percentage all staff--senior of Percentage all staff--research of Treatment Fixed universityeffects Likelihoodratio test for the variance of the RE = 0

(0.32)

-0.169 (0.43)

(0.40)

(0.31)

(0.36)

(0.32)

(0.45)

0.001 (0.37) 0.008 (0.05)* -0.010 (0.31) 0.047 (0.01)** 0.097 (0.33) -0.146 (0.05)* -0.028 (0.36) 0.011 (0.43) Excluded

0.002 (0.03)* 0.004 (0.24) -0.024 (0.01)** -0.005 (0.74) -0.042 (0.63) 0.128 (0.04)* -0.093 (0.01)** 0.028 (0.03)* Excluded

Fixed

Random 30.12 (0.000)

Random 54.96 (0.000) (continued)

170

R. W.Arulampalam, A. Naylorand J. P Smith

Table3 (continued)
Variablet Withuniversity dummy variables (FE) -model 1 Drop-out Drop-out versus versus continuation completion (q2) (2) (ql) (1) Maximizedloglikelihoodvalue Number of observations -2935.49 7789 -507.77 Withuniversity characteristics? ?--model 2 Drop-out versus continuation (qI) (3) -2941.62 7789 Drop-out versus completion (q2) (4) -530.56 Randomuniversity effects (RE)--model 3 Drop-out versus continuation (qI) (5) -2958.42 7789 Drop-out versus completion (q2) (6) -529.82

are tp-values givenin parentheses. of variables default the classis indicated parentheses. in tFor classes dummy 2 includes individual variables theUniversity London, of Scottish a for universities, ?Model additionally dummy Welsh and university an Irish university. was to from0. different ?WhenREwereadded model2, theREvariance insignificantly at level. *Significance the5% at level. **Significance the 1% ratio for this in time variables was ttThe likelihood statistic testing specification themodelwithseparate dummy 0.22(0.99)formodel1 and0.24(0.99)formodel2.

In and personalcharacteristics. an analysisof the drop-outbehaviourof all UK university studentsmatriculating 1989,Smithand Naylor (2001b)foundevidencein supportof a role in and for both academicpreparedness socialintegration. Previousschoolingincludesboth prior of beforeuniversity. of the Part qualifications studentsandthe typeof schoolthattheyattended motivationfor the lattercomes fromthe generalissue of the influenceof the qualityand type of schoolon lateroutcomes(seeMoffitt(1996)).As discussed the previoussubsection, one in in of our modelswe includedummyvariables the medicalschool thatwas attended(model 1). for Becauseof smallcellsizesandthe amalgamation someLondonmedicalschoolsoveroursamof ple period,the Universityof Londonmedicalschools weretreatedas a singlemedicalschool. In a secondmodel (model 2), we replacethe medicalschool dummyvariableswith a set of variables characteristics the medicalschoolthatwas attendedby the student.The of measuring thirdmodelpresented the RE versionof model 1 (model3). is To obtain data on a satisfactory numberof drop-outsin each year of the programme, the modelshavebeenestimated combining 1985and 1986entrycohorts,with a yeardummy the by includedto accountfor anyaggregate timeeffect.The dependent variable takesthe value 1 in a if the individual out of the programme that year and 0 otherwise. in Becauseof the year drops smallnumberof withdrawals afteryear4, the finalyearconditionalexit probability refers very to year4 or year 5. We thus haveone conditionalexit probability model for years 1-3 (see q1 in equation(2)), whichmodelsthe drop-outor continuation process,and anotherspecification for the restof the period(q2in equation(4)), whichmodelsthe drop-outor completionprocess. Beforediscussing results, considerthechoiceof the distributional the we that assumptions are used for ourmodels.Threetypesof modelwereused-extreme value,logit and probit.Among the distributions probitperforms no the between poorly,althoughthereis essentially difference the extreme valuemodeland the logit model.The estimated effectswereverysimilar marginal acrosstheextreme valueandthelogitmodels.Therestriction theeffectsof thecovariates that are the samein both the drop-outprobabilities and q2in the logit specification easilyrejected is q1

MedicalSchool Drop-out

171

coefficients across by the data.On the basisof this, we choosethe logit modelwithunrestricted the two drop-outprobabilities our preferred as modelfor both the FE and the RE models.

results 5. Empirical
and The derived effectson the ratesof withdrawal the corresponding p-valuesfor the marginal in estimated logitmodelsarereported Table3. Model 1includesa set of medicalschoolindicator in The variables amongthe covariates. resultsfrommodel 1 arepresented columns(1) and (2). medicalschooleffectsaretreated fixednumbers. as Thisis theFE modelwheretheunobservable effectsof medicalschools,as discussedearlier,we also To investigate furtherthe ceterisparibus with some variablesthat reflectedthe nature by experimented replacingthe dummyvariables Thesewerethe numberof undergraduates, of the medicalfacultyin that particular university. on on the numberof post-graduates degreestaught, the numberof post-graduates research on per degrees,the expenditure salariesper medicalstudent,the expenditure medicalstudent of fromresearch grants,the percentage professorsamongthe staff in the faculty,the percentof staffand separate binaryindicatorsfor London, age of seniorstaff,the percentage research Resultsfromsubstituting medicalschooldummyvarithe Scottish,WelshandIrishuniversities. in model2, arepresented columns(3) and (4). ableswithmedicalschoolcharacteristics, labelled Columns(5) and (6) reportresultsfromthe RE model wherethe medicalschool unobservable froma normaldistribution labelled and model3. Columns effectsaretreated random as drawings continuationprobabilities and col(1), (3) and (5) referto the conditionaldrop-outversus ql, umns(2), (4) and (6) to the conditionaldrop-outversus completionprobabilities q2. First,we note that the estimatedmarginaleffectsfromthese threemodels are broadlysimcan ilar.The restriction that the medicalschool characteristics be used in the model in place is of the binarymedicalschool indicatorsin the q2-probability rejectedvery easily (X2(6)= it level (X2(6)= 45.6 (0.000)), but in the ql-probability is not rejectedat the 5%significance is 12.26 (0.057)).We also find that the maximizedvalue of the log-likelihood highestfor both medical of and q2 frommodel 1 (the FE model). One advantage treatingthe unobservable ql as school effects as randomis that we can includemedicalschool characteristics additional in But covariates. havingincludedthe medicalschool characteristics model 3 (or equivalently of on medicalschoolREs in model2), wecouldnot rejectthehypothesis a zerovariance theREs medicalschool characteristics seemto i.e. the additional at all conventional levels, significance variations. Hencewe present out completelyall the unobservable medical-school-specific wipe and medicalschoolcharacteristics formodel2 withresultsonlyformodel3 withoutadditional medicalschoolREs.Wefirstdiscussthe resultsfrommodel 1 and thenhighlight out additional betweentheseresultsand those of model2 and model 3. the differences age Significant effectsare foundonly in q2. These suggestthat conditionallyon progressing relativeto someonewho is 18yearsold at the timeof enrolto the finalyearsof theprogramme, to withdrawal an individual who is aged22 yearsor moreis estimated havean increased ment, more likely ceterisparibus.Males are found to be significantly rate of 2.8 percentage points, thanfemalesto withdraw duringall partsof the programme. but role in the drop-outbehaviour, nationality Fee statusis not found to play a significant
has a significant effect in the latter part of the programme. A student who is a British national is found to be 0.63 percentage points more likely to drop out during the latter part of the programme compared with someone who is a foreign national, ceteris paribus. There are very strong and well-determined coefficients on prior qualifications. These effects are picked up by various binary indicator variables on the type of prior qualifications as well as by the actual scores that were obtained for students who had taken either A-level or Higher

172

R. W Arulampalam, A. Naylorand J. P Smith

at With respectto performance A-level or in Highers,we note that, although qualifications. threeor five it is customaryin UK medicalschools to requirea studentto obtainrespectively A-levelor Higherpassesbeforeentry,some studentsdo moresubjectsthan the required numtheirbest ber.To allowfor this, we includethe actualscoresthat they obtainedin respectively and threeor fiveA-levelor Higherexaminations also the scoresfromthe rest,if they had more As thanthe required number. expected,the effectfromA-levelson the probability drop-out of duringthe entiredegreeprogramme periodis estimatedto be negativeand decliningtowards An the finalyearsof the programme. extra2 pointson the A-levelaverage (whichis equivalent of to an extraA-levelgrade)reducesthe probability drop-outby about0.15 percentage points, ceteris and points paribus,duringthe earlierpartsof the programme, by about0.11 percentage in the finalyear of the programme. However,other A-level scoresin additionto those which wereachievedin the student's best threeA-levelshad no significant effect on the probability of drop-out.In contrast,the Highersscorefrom the best five subjectsis not found to have a effect, althoughstudentswho havemore than the five minimumrequiredHighers significant are found to be significantly likely to drop out in the early parts of the programme. In less additionto the effect coming via the total A-level or Highersscore, we also find that those enteredwith the maximumpossiblescorefor theirbest threeor five studentswho respectively A-level or Higherssubjectswere significantly likely to drop out duringthe earlypart of less the programme. findingthat the student'slevel of performance A-levelor Highershas The at of effectson the probability drop-outis in line with the hypothesisthat statistically significant academicpreparedness a medicaldegreeis an importantfactor determining for continuation and completion. in that Lookingat A-levelor Highersubjects, assuming a strongbackground biology,chemisis for we tryandphysics likelyto be appropriate medicalstudents, includethreedummyvariables An for those studentswho havenone, one or threeof thesesubjects. originalspecification had or for the dummyvariables whether studenthad A-levelsor Highersin physics,chemistry biology or some combinationof these. The resultsin Table 3 were arrivedat havingtested the Relativeto those withjust two of the threeof thesesubjects,studentswho impliedrestrictions. are enternot havingdone anyof thesesubjects foundto be significantly morelikelyto dropout but in duringthe first few yearsof the programme, this effect is completelyreversed the final are year.As expected,studentswithall threeof thesesubjects foundto havea lowerprobability of withdrawal to a relative thosewithonlytwoof the threesubjects, Whether stuceterisparibus. dententerswithonlyone or two of thesesubjects of the threepreferred out is subjects not found to makeanydifference the probabilities withdrawal. to of theredoes not seemto Interestingly, be any additionaleffectcomingvia the possessionof an A-levelor Higherin mathematics. We find that studentswho enter with qualificationsother than the standardA-levels or Highers are significantlyless likely to drop-out during the early parts of the programme. For example,studentswho had previouslyobtaineda UK universityqualification more are to continuebeyondthe thirdyear.Therewas no significant effectin the finalpart of the likely programme. It hasbeenarguedthattheA-levelperformance studentsfromthe non-independent-school of sectormight be an underestimate theirunderlying of abilityand hence the negativeeffect of A-levelperformance mightbe lowerfor ex-pupilsof stateschoolscomparedwith independent schools (see, for example,Smith and Naylor (2001a)).To test for these kinds of effect, we includedbinaryindicatorsfor the type of school and also interactions thesewith the actual of scoresthatwereobtainedin the mainentryqualification. did not findany significant We effect of A-levelperformance we varyingwith the type of school, and therefore reportin Table3 only those resultsthat were obtainedwithout these interactions. The only consistentlysignificant

MedicalSchool Drop-out

173

effecton probabilities withdrawal of associatedwith the type of school attendedwas for studentswho had attendeda collegeof further education.This significant negativeeffectwas only presentin the finalyearof the programme. The socialclasseffectsare foundto be weakin generaland show littleeffect.One exception is the significant fromsocial class 'intermediate' negativeeffectfor individuals (socialclass II) in for on the rateof withdrawal the latterpartsof the programme students.We also note that a studentwhose parentis a medicalpractitioner less likelyto withdraw, is althoughthe effect with social class is not well determined. havealso interacted We prior academicperformance but effects. background, we foundno significant Frommodel 1, the estimatedcoefficientson the medicalschool indicatorvariablespermit the constructionof a rankingof medicalschools. In Fig. I we plot, for illustration,for the the medicalschooleffects(marked with a cross)along with their95% q -probability, estimated We confidence intervals. findthatonly a fewof the individual institution effectsaresignificantly differentfromthe medianmedicalschool, with five and one significantly aboveand below the medianrespectively. In model2 we replacethe binaryindicator for withvarious variables medicalschoolattended of characteristics medicalschools.The resultsfor the model2 specification reportedin colare umns(3) and (4) of Table3. Althoughthe estimated effectsin the qi-probability were marginal broadlysimilaracrossthe two models,thereweresome notableexceptionsin q2. The absolute of effectsin the q2in model2 was typicallyhighercompared magnitude the estimated marginal with model 1. Of the effects of the medicalschool characteristics themselves,we note from Table3 that thereis evidencethat the probability drop-outis lowerthe fewerstudentsthere of areon the degreeprogramme the greater numberof post-graduate and the studentsin research the medicalschool. We next turn to the resultsthat are reportedin columns(5) and (6) of Table3. These refer to model 3 which is based on the RE specifications. First, we note that a test of hypothesis Ho:variance= 0 can be testedas a likelihoodratiotest but the statisticwill not be a standard since the parameter restrictionis on the boundaryof the parameterspace. The X2-statistic,
E
T1

1.5

0.5

S10 a
0
-0. " t' I

I,

12 12 13 13 14 14 15 15 16 16 17 17

18

18

<

-1.5

Medical school medical schoolcoefficients 95%confidence and intervals: FE;o, RE Fig. 1. Estimated x,

174

W Arulampalam, A. Naylorand J. FP R. Smith

likelihoodratiostatistichas a probability massof 0.5 at zeroand0.5 X2(1)forpositive standard the values.Thusa one-sided5%significance requires use of the 10% level criticalvalue(Lawless, 1987).The likelihoodratiostatisticfor testingthat the varianceof the medicalschool REs is 0 is 30.12 in the model for q1 and 54.96 in the model for q2, both of whichare easilyrejectedat conventional levelsof significance. Weturnnextto the estimated effectsof thecovariates simplynote thatthe effectsarevery and similarto the effectsthatwereobtainedfrommodel 1. This shouldnot be surprising since,becauseof ourextremely largesampleof the studentpopulationin eachmedicalschool,we would of medicalschool effectsto be the same. expectthe RE and the FE estimates the unobservable As alreadynoted, Fig. 1 plots the estimatedmedicalschool coefficientsfromthe FE model (model 1)forq1.In addition,Fig. 1 also plots (forq1for the RE model(model3)) the estimated shrunken residuals(empirical Bayesestimates)for each medicalschool (usingthe same order of medicalschools as for the FE estimates)along with the 95%confidenceintervals-marked with a diamondsymbol. From the RE model, seven medicalschools are significantly above the median,althoughnone are significantly below.It is clearfrom Fig. 1 how similarthe estiin matedmedicalschooleffectsarefromthe two models(witha rankcorrelation excessof 0.98), moreprecisely. althoughthe effectsfromthe RE modeltend to be estimated

6. A competingrisks analysis
The models that have been consideredso far are for the conditional probabilityof withdrawalfrom the programme, conditionedon not havingwithdrawn to that point. These up are 'single-risk' models, in the sense that no distinctionis made betweenvariousalternative A for reasonsforwithdrawal. studentcanwithdraw fromthe programme reasonssuchas transfers betweencourses, academicfailureand health problems,interalia. The fourth and fifth of columnsof Table1providethebreakdown the number drop-outs reasonforwithdrawal. of by the Sincein ourmodelspecification continuationversus drop-outprobabilities was specified ql for over the first3 yearsof the programme, reportthe relevantfrequencies this part of the we due only.Wenotethattherewereno withdrawals to changesin coursein years4 or 5. programme Of those studentswho droppedout of the medicalprogramme, proportionof studentswho the theircourseof studywasabouta third.Fromthe point of viewof publicpolicymakers changed of betweenreasons seekingto expandthe number fullytrainedmedicaldoctors,distinguishing for droppingout may not be important: drop-outis a drop-out.Againstthis, strategies a for the rateof drop-outmightbenefitfroma betterunderstanding the natureof the of minimizing in decisionto drop-out.Additionally, the university whichthe medicalschoolis located,the for for courseand droppingout of the medicalprogramme other distinctionbetweentransferring if only the latterimpactsadversely the institution's reasonsmay be particularly on important indicatorscore. performance In this section, since the FE model (model 1) producedthe highest maximizedlog-likelihood value,we extendthismodelto the competingriskscase wherewe distinguish betweenthe and for an exampleof a hazreasonsforthe exit.SeeNarendranathan Stewart (1993b) reported ardmodelwith competingrisksin the contextof exitingfromunemployment employment. to
In the current paper, given the small number of exits, we consider only two possible alternative reasons for exit: a 'course transfer' or 'other reasons'. We wish to model the determinants of the conditional probability of exiting out of the medical programme for one of these two reasons, assuming that the exits occur at the start of the interval. Two separate logit models were fitted where, in the model for drop-out due to other reasons, a course transfer is treated as a right-censored event, and vice versa. The coefficient estimates for

MedicalSchool Drop-out

175

the conditionalprobability exitingout of the medicalprogramme otherreasons(model of for of becauseof course 4a) and the conditionalprobability exitingout of the medicalprogramme For transfer(model 4b) are presentedin columns(2) and (3) of Table4 respectively. ease of comparison,the coefficientestimatesfrom the single-riskmodel (model 1) are reportedin column(1). Withrespect personal to effectsarefoundto be significant characteristics, andgender age only in the conditional for In probability exitingdue to reasonsotherthancoursetransfers. contrast, the nationalityand fee status variablesare found to exert a significantinfluenceonly on the relativeto progression. coursetransfer conditionalprobability Unlikein the single-risk model school comparedwith someonecomingfroma (model 1), a studentwho attendeda grammar local educationauthorityschool,beforeentryinto medicalschool, is foundto be significantly less likelyto exit for otherreasons,ceteris paribus. the Withrespectto priorqualifications, total A-levelscoresin the best threesubjects found is to play an importantand significantrole only in the exit probabilitythat is associatedwith effect on both. We note other reasons,althoughhavingachieveda top scorehas a significant more likely to drop out for that studentswith no favouredA-level subjectsare significantly In reasonsotherthancoursetransfer. contrast,havingthree,ratherthantwo, favoured subjects reducesthe probabilityof transferring course:we infer from this that matching significantly seemsto be important. The significant positiveeffectthat was foundfor studentscomingfrom a 'skillednon-manin ual' socialclass background model 1 is now foundto act via the risk that is associatedwith for we withdrawals otherreasons.Interestingly, also findthat studentscomingfroma medical are fromthe medicalschool but aresignificantly background no moreor less likelyto withdraw less likelyto transfercourse.This resultis consistentwith the idea that such studentshave a commitment theirchosencourseof medicalstudy. to greater

7. Discussion and furtherremarks

In the context of a shortageof traineddoctors in the UK, the Government's policy for the medicalworkforce an restson a plan to implement on-goingmajorexpansionin total medical school intake(see MedicalWorkforce StandingAdvisoryCommittee(1997)and HigherEducation FundingCouncilfor England(2001)).As partof the strategyof expansion,the Medical Workforce into the factors affectingthe progresStandingCommitteehas called for research sion and withdrawal behaviourof medicalstudents.A substantialbody of previouswork on withdrawals UK university of studentshas exploiteddata on full cohorts of studentsbut has omittedanyanalysisof medicalstudentsas it is generally acceptedthat,for a varietyof reasons, the characteristics medicalstudentsand their coursesdiffer from those of other students of and hencejustify a separateanalysis.In this paper,we conducteda statisticalanalysisof the of drop-outbehaviour UK medicalstudents,exploitingdata on full studentcohorts. Our statisticalanalysisextendspreviousresearch the generalareaby adoptinga hazard in of out. risksframework. The modelto modeltheprobability dropping Wealso offera competing exit probability modelis basedon the initialdistinctionbetweendroppingout and continuing and the subsequent distinctionbetweendroppingout and completing,conditionalon continuation. For each of our single-risk models, we firstconsideredtwo alternative specifications: in one, includingbinaryindicatorvariables the particular for medicalschool attended(the FE medicalschool characteristics. also re-estimated We model) and, in the other, incorporating our single-riskmodel, treatingthe unobservedmedicalschool effects as random,and found the results to be broadlysimilarto those of the FE model. The competingrisks analysis

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W Arulampalam, A. Naylorand J. P Smith R.

Table4. Maximum likelihood estimates: riskslogitmodelst single-and competing

Variablet Model1-single risk, Model4a-competing Model4b--competing versus risks,drop-out reasons risks,drop-out reasons drop-out for for continuation otherthancoursetransfers of coursetransfers versus (ql) versuscontinuation continuation (1) (2) (3) -0.973 (0.02)? -0.754 (0.00)?? 0.026 (0.74) -0.041 (0.65) 0.380 (0.06) 0.151 (0.06) -0.315 (0.09) -0.153 (0.53) -0.106 (0.46) 0.190 (0.25) -0.214 (0.16) 0.043 (0.66) 0.091 (0.55) 0.016 (0.95) -0.033 (0.01)? -0.015 (0.61) -0.006 (0.54) -0.075 (0.05)? -0.506 (0.00)? 0.079 (0.55) 0.804 (0.01)?? -0.007 (0.98) -0.227 (0.06) -0.920 (0.00)? -1.588 (0.00)? -0.041 (0.71) 0.291 (0.06) 0.129 (0.30) -0.096 (0.50) Yes -2935.48 0.091 -1.676 (0.00)? -0.638 (0.00)?? -0.085 (0.36) 0.022 (0.84) 0.669 (0.00)?? 0.181 (0.06) -0.083 (0.71) 0.153 (0.57) -0.115 (0.50) 0.281 (0.13) -0.342 (0.07) 0.000 (1.00) 0.080 (0.66) -0.085 (0.76) -0.035 (0.02)? -0.038 (0.27) -0.019 (0.14) -0.050 (0.21) -0.499 (0.00)? 0.150 (0.34) 0.974 (0.00)? -0.015 (0.97) -0.146 (0.32) -0.836 (0.00)? -1.538 (0.00)? 0.077 (0.57) 0.470 (0.01)? 0.224 (0.15) 0.160 (0.33) Yes -2204.29 0.063 -2.050 (0.00)? -1.021 (0.00)? 0.291 (0.04)? -0.224 (0.18) -0.224 (0.18) 0.075 (0.60) -0.924 (0.00)? -1.099 (0.05)? -0.035 (0.90) -0.249 (0.51) 0.061 (0.81) 0.140 (0.43) 0.117 (0.65) 0.336 (0.46) -0.020 (0.42) 0.031 (0.56) 0.016 (0.35) -0.099 (0.10) -0.530 (0.01)? -0.052 (0.82) 0.250 (0.75) 0.083 (0.89) -0.363 (0.08) -2.825 (0.00)? -2.825 (0.00)? -0.250 -0.094 -0.086 -0.700 (0.17) (0.73) (0.68) (0.01)?

Intercept Time trend 1986year dummy Entryage (aged < 18) Aged 19-21 Aged > 21 Sex-male Britishnational Non-UK fee student Accommodation(livingat home) Campus Other School attended(local educationauthority) Grammarschool school Independent College of furthereducation Other Main entryqualifications A-levelscores Higherscores OtherA- or AS-level scores OtherHigherscores Achievedtop score Has mathematics A-levelor Higher No favouredsubject 1 favouredsubject 3 favouredsubjects Otherentryqualifications (A-levelsor Highers) UK universityqualifications Other Parentalsocial class (professional) Intermediate Skillednon-manual Other Fatheror guardian is a doctor Universitydummy variablesincluded Maximizedloglikelihoodvalue Proportionwho exit into given state duringthe earlypart of the programme

Yes -1077.32 0.028

tp-values are given in parentheses.Becauseof a lack of enough observationsto identify the effects, the model enteredas a sum. Thesewereon 'otherentryqualifications' the age and presentedin column (3) has two variables dummyvariable. $Forclassesof dummyvariablesthe defaultclass is indicatedin parentheses. at ?Significance the 5%level. ?Significanceat the 1%level.

MedicalSchool Drop-out

177

betweendroppingout becauseof coursetransferand droppingout for all other distinguishes reasons. Ourmain findingis that academic on of is preparedness the majorinfluence the withdrawal medicalstudents.Studentswho scoredhighlyin theirpre-university (at qualifications A-level or Highers,for example)are significantly likely to drop out of medicalschool: they are less both more likely to continueand more likelyto completethan studentsperforming well less beforeenteringuniversity. also find that the choice of pre-university We subjectsexertsa significantinfluenceover the medicalstudent'sdrop-outprobability. example,studentswho For had takenchemistry,physicsand biology at A-level were significantly likelyto drop out less thanwerestudentswith only two (or fewer)of these threesubjects. particular, In studentswith all threeof chemistry,physicsand biologywere significantly likelyto transferfrommedless icine to some other course:we infer that the extent of the pre-university subjectmatch is an characteristic medicalstudents. of This is not truefor all university important degreesubjects we (see Smithand Naylor (2001b)).On other entry qualifications, find that medicalstudents who had alreadyobtaineda UK university are less qualification significantly likelyto dropout of medicalschool: this could haveimplicationsfor a loweraveragedrop-outrate on recently introduced medicaldegreeprogrammes. post-graduate influences drop-out on Amongotherresults,we also findthatageand gender'exert significant withmalesandmoremature studentsmorelikelyto withdraw thanfemalesor younbehaviour, we little effect associatedwith either ger studentsrespectively. Conversely, find surprisingly school or family social class background, althoughwe do note that studentswith a medical doctoras a parentare significantly likelyto transfer of a medicalprogramme. find less We out that thereare some significant in differences drop-outprobabilities acrossthe medicalschools, for aftercontrolling the students'observedcharacteristics. the specifications In basedon medical school characteristics, find evidencethat the drop-outprobabilityis lower in smaller we medicalschools and in medicalschoolswith a high proportionof post-graduates a medical on In programme. termsof the debateon wideningaccessinto medicalschoolfor studentswho do not meet the traditionallevelsof attainment theirpre-university in our qualifications, results raisethe seriousconcernthat,potentially,the ex ante completionprobability such students of will be relatively This is not to argueagainstpoliciesof wideningaccess.It is to point out, low. that suchpoliciesmaybe most successfully if however, accomplished they are accompanied by of studentsupport(includingappropriate complementary strategies training) supplementary and by well-targeted recruitment activity.With respectto the latter,it has been shown that, fornon-medical levelsof attainment students,prior mightunderpredict university performance For for studentsfrom certainbackgrounds. example,studentswho previouslyattendedstate schoolstend to performbetterat university than studentsfromthe independent school sector, in ceterisparibus(see Smithand Naylor (2001a)).Accordingly, our currentstudy of medical studentdrop-outbehaviourwe have includedcontrolsboth for type of previousschool and for potentialinteractions betweenpriorqualification and attainment type of school. Wefound no clearevidenceof significant effects.Nor do we find significant interaction effectsassociated withfamilybackground priorqualifications. followsthat,if targeted and It to recruitment widen the accessis to be successfulin minimizing effect on the drop-outprobability, targetingmay
need to be more precise than simply making differential offers according to the type of school, as has begun to occur elsewhere in the UK higher education sector. Acknowledgements We are grateful to Norman Ireland, Chris McManus, Costas Meghir, Geert Ridder, Jim Walker,

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R. W Arulampalam, A. Naylorand J. P Smith

seminar at for of Bonn,at theUniversity Warwick participants theInstitute theStudyof Labour, andthe Centrefor HealthServiceStudies. fromtwo referees theJointEditorare and Comments also gratefully We both the Universities' Statistical Record,as the acknowledged. acknowledge and for original depositors, theUK DataArchive theuseof dataset SN:3456of the Universities' Record.None of theseindividuals organizations or for Statistical bearsany responsibility any in of the analysisor interpretations arepresented this paper. that

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