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Widening Access: Achieving Equity in Medical Education: Research, Theory and Practice
Abstract
the synergies and tensions between WA and maintaining quality;
... Inherent in doing so is being explicit about the influence of the multiple, and fluid, social, cultural and political contexts in which medical and health professions education is situated (e.g., Bates & Ellaway, 2016;. For example, many medical schools in the UK and elsewhere invest heavily in initiatives to widen participation and access (e.g., outreach to high schools, mentoring possible applicants, summer schools, preparatory programmes, the use of different selection criteria, additional support throughout the year [e.g., Cleland & Nicholson, 2018;Cleland et al., 2015;Duenas et al., 2021;Vick et al., 2018). If one was to look at efforts to increase the diversity of medical students purely in terms of cost, then the return on investment in respect of recruitment, retention and graduate outcomes would arguably not represent value for money as the numbers of these applicants remains relatively low. ...
Studies of cost and value can inform educational decision making, yet our understanding of the barriers to such research is incomplete. To address this gap, our aim was to explore the attitudes of global thought leaders in HPE towards cost and value research. This was a qualitative virtual interview study underpinned by social constructionism. In telephone or videoconference interviews in 2018–2019, we asked global healthcare professional thought leaders their views regarding HPE cost and value research, outstanding research questions in this area and why addressing these questions was important. Analysis was inductive and thematic, and incorporated review and comments from the original interviewees (member checking). We interviewed 11 thought leaders, nine of whom gave later feedback on our data interpretation (member checking). We identified four themes: Cost research is really important but potentially risky (quantifying and reporting costs provides evidence for decision-making but could lead to increased accountability and loss of autonomy); I don't have the knowledge and skills (lack of economic literacy); it's not what I went into education research to do (professional identity); and it’s difficult to generate generalizable findings (the importance of context). This study contributes to a wider conversation in the literature about cost and value research by bringing in the views of global HPE thought leaders. Our findings provide insight to inform how best to engage and empower educators and researchers in the processes of asking and answering meaningful, acceptable and relevant cost and value questions in HPE.
This article presents a critical review of the use of cognitive ability testing for access to graduate and higher professional occupations to promote further debate and reflection in both the academic and practitioner community. The main contentions are that the practice of applying cognitive ability testing in these contexts has strong potential to both maintain and exacerbate social inequality in access to higher occupations and professions, and that validity evidence does not justify this to the extent that has previously been presumed. Five critical observations are examined, namely (1) evidence of adverse impact in test outcomes; (2) the tendency to position cognitive ability testing early in selection processes in high‐volume recruitment; (3) recent evidence challenging the meta‐analytic validity of cognitive ability tests; (4) weaknesses in historical primary validity studies; (5) conceptually flawed examination of differential validity evidence in the literature. Implications for practice are discussed, contrasting strategies that involve modifying selection systems that include cognitive testing, versus removing and replacing cognitive tests.
First-generation students, whose parents do not have baccalaureate degrees, are less likely to apply to MD-PhD programs than to MD programs, which has led to a worrying lack of diversity among physician-scientists.
Despite repeated calls for change, the problem of widening access (WA) to medicine persists globally. One factor which may be operating to maintain social exclusion is the language used in representing WA applicants and students by the gatekeepers and representatives of medical schools, Admissions Deans. We therefore examined the institutional discourse of UK Medical Admissions Deans in order to determine how values regarding WA are communicated and presented in this context. We conducted a linguistic analysis of qualitative interviews with Admissions Deans and/or Staff from 24 of 32 UK medical schools. Corpus Linguistics data analysis determined broad patterns of frequency and word lists. This informed a critical discourse analysis of the data using an “othering” lens to explore and understand the judgements made of WA students by Admissions Deans, and the practices to which these judgments give rise. Representations of WA students highlighted existing divides and preconceptions in relation to WA programmes and students. Through using discourse that can be considered othering and divisive, issues of social divide and lack of integration in medicine were highlighted. Language served to reinforce pre-existing stereotypes and a significant ‘us’ and ‘them’ rhetoric exists in medical education. Even with drivers to achieve diversity and equality in medical education, existing social structures and preconceptions still influence the representations of applicants and students from outside the ‘traditional’ medical education model in the UK. Acknowledging this is a crucial step for medical schools wishing to address barriers to the perceived challenges to diversity.
Objectives
Differential attainment in school examinations is one of the barriers to increasing student diversity in medicine. However, studies on the predictive validity of prior academic achievement and educational performance at medical school are contradictory, possibly due to single-site studies or studies which focus only on early years’ performance. To address these gaps, we examined the relationship between sociodemographic factors, including school type and average educational performance throughout medical school across a large number of diverse medical programmes.
Methods
This retrospective study analysed data from students who graduated from 33 UK medical schools between 2012 and 2013. We included candidates’ demographics, pre-entry grades (adjusted Universities and Colleges Admissions Service tariff scores) preadmission test scores (UK Clinical Aptitude Test (UKCAT) and Graduate Medical School Admissions Test (GAMSAT)) and used the UK Foundation Programme’s educational performance measure (EPM) decile as an outcome measure. Logistic regression was used to assess the independent relationship between students’ background characteristics and EPM ranking.
Results
Students from independent schools had significantly higher mean UKCAT scores (2535.1, SD=209.6) than students from state-funded schools (2506.1, SD=224.0, p<0.001). Similarly, students from independent schools came into medical school with significantly higher mean GAMSAT scores (63.9, SD=6.9) than students from state-funded schools (60.8, SD=7.1, p<0.001). However, students from state-funded schools were almost twice as likely (OR=2.01, 95% CI 1.49 to 2.73) to finish in the highest rank of the EPM ranking than those who attended independent schools.
Conclusions
This is the first large-scale study to examine directly the relationship between school type and overall performance at medical school. Our findings provide modest supportive evidence that, when students from independent and state schools enter with similar pre-entry grades, once in medical school, students from state-funded schools are likely to outperform students from independent schools. This evidence contributes to discussions around contextualising medical admission.
Established since 1997, CFE is an independent not-for-profit company specialising in the provision of research and evaluation services across a broad field of education, employment and skills.
In the UK widening access (WA) activities and policies aim to increase the representation from lower socio-economic groups into Higher Education. Whilst linked to a political rhetoric of inclusive education such initiatives have however failed to significantly increase the number of such students entering medicine. This is compounded by a discourse that portrays WA applicants and students as lacking the essential skills or attributes to be successful in medical education. Much of the research in this area to date has been weak and it is critical to better understand how WA applicants and students negotiate medical admissions and education to inform change. To address this gap we amalgamated a larger dataset from three qualitative studies of student experiences of WA to medicine (48 participants in total). Inductively analysing the findings using social capital as a theoretical lens we created and clustered codes into categories, informed by the concepts of "weak ties" and "bridging and linking capital", terms used by previous workers in this field, to better understand student journeys in medical education. Successful applicants from lower socio-economic groups recognise and mobilise weak ties to create linking capital. However once in medical school these students seem less aware of the need for, or how to create, capital effectively. We argue WA activities should support increasing the social capital of under-represented applicants and students, and future selection policy needs to take into account the varying social capital of students, so as to not overtly disadvantage some social groups.
An undersupply of generalists doctors in rural communities globally led to widening participation (WP) initiatives to increase the proportion of rural origin medical students. In 2002 the Australian Government mandated that 25% of commencing Australian medical students be of rural origin. Meeting this target has largely been achieved through reduced standards of entry for rural relative to urban applicants. This initiative is based on the assumption that rural origin students will succeed during training, and return to practice in rural locations. One aim of this study was to determine the relationships between student geographical origin (rural or urban), selection scores, and future practice intentions of medical students at course entry and course exit. Two multicentre databases containing selection and future practice preferences (location and specialisation) were combined (5862), representing 54% of undergraduate medical students commencing from 2006 to 2013 across nine Australian medical schools. A second aim was to determine course performance of rural origin students selected on lower scores than their urban peers. Selection and course performance data for rural (461) and urban (1431) origin students commencing 2006-2014 from one medical school was used. For Aim 1, a third (33.7%) of rural origin students indicated a preference for future rural practice at course exit, and even fewer (6.7%) urban origin students made this preference. Results from logistic regression analyses showed significant independent predictors were rural origin (OR 4.0), lower Australian Tertiary Admissions Rank (ATAR) (OR 2.1), or lower Undergraduate Medical and Health Sciences Admissions Test Section 3 (non-verbal reasoning) (OR 1.3). Less than a fifth (17.6%) of rural origin students indicated a preference for future generalist practice at course exit. Significant predictors were female gender (OR 1.7) or lower ATAR (OR 1.2), but not rural origin. Fewer (10.5%) urban origin students indicated a preference for generalist practice at course exit. For Aim 2, results of Mann-Whitney U tests confirmed that slightly reducing selection scores does not result in increased failure, or meaningfully impaired performance during training relative to urban origin students. Our multicentre analysis supports success of the rural origin WP pathway to increase rural student participation in medical training. However, our findings confirm that current selection initiatives are insufficient to address the continuing problem of doctor maldistribution in Australia. We argue for further reform to current medical student selection, which remains largely determined by academic meritocracy. Our findings have relevance to the selection of students into health professions globally.
Objectives
Most UK medical programmes use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the UK Clinical Aptitude Test (UKCAT: http://www.ukcat.ac.uk), and 4 of its subscales, along with individual and contextual socioeconomic background factors, as predictors of performance during, and on exit from, medical school.
Methods
This was an observational study of 6294 medical students from 30 UK medical programmes who took the UKCAT from 2006 to 2008, for whom selection data from the UK Foundation Programme (UKFPO), the next stage of UK medical education training, were available in 2013. We included candidate demographics, UKCAT (cognitive domains; total scores), UKFPO Educational Performance Measure (EPM) and national exit situational judgement test (SJT). Multilevel modelling was used to assess relationships between variables, adjusting for confounders.
Results
The UKCAT—as a total score and in terms of the subtest scores—has significant predictive validity for performance on the UKFPO EPM and SJT. UKFPO performance was also affected positively by female gender, maturity, white ethnicity and coming from a higher social class area at the time of application to medical school An inverse pattern was seen for a contextual measure of school, with those attending fee-paying schools performing significantly more weakly on the EPM decile, the EPM total and the total UKFPO score, but not the SJT, than those attending other types of school.
Conclusions
This large-scale study, the first to link 2 national databases—UKCAT and UKFPO, has shown that UKCAT is a predictor of medical school outcome. The data provide modest supportive evidence for the UKCAT's role in student selection. The conflicting relationships of socioeconomic contextual measures (area and school) with outcome adds to wider debates about the limitations of these measures, and indicates the need for further research.
Context:
Widening access promotes student diversity and the appropriate representation of all demographic groups. This study aims to examine diversity-related benefits of the use of situational judgement tests (SJTs) in the UK Clinical Aptitude Test (UKCAT) in terms of three demographic variables: (i) socio-economic status (SES); (ii) ethnicity, and (iii) gender.
Methods:
Outcomes in medical and dental school applicant cohorts for the years 2012 (n = 15 581) and 2013 (n = 15 454) were studied. Applicants' scores on cognitive tests and an SJT were linked to SES (parents' occupational status), ethnicity (White versus Black and other minority ethnic candidates), and gender.
Results:
Firstly, the effect size for SES was lower for the SJT (d = 0.13-0.20 in favour of the higher SES group) than it was for the cognitive tests (d = 0.38-0.35). Secondly, effect sizes for ethnicity of the SJT and cognitive tests were similar (d = ~ 0.50 in favour of White candidates). Thirdly, males outperformed females on cognitive tests, whereas the reverse was true for SJTs. When equal weight was given to the SJT and the cognitive tests in the admission decision and when the selection ratio was stringent, simulated scenarios showed that using an SJT in addition to cognitive tests might enable admissions boards to select more students from lower SES backgrounds and more female students.
Conclusions:
The SJT has the potential to appropriately complement cognitive tests in the selection of doctors and dentists. It may also put candidates of lower SES backgrounds at less of a disadvantage and may potentially diversify the student intake. However, use of the SJT applied in this study did not diminish the role of ethnicity. Future research should examine these findings with other SJTs and other tests internationally and scrutinise the causes underlying the role of ethnicity.
Background
Medical students have historically largely come from more affluent parts of society, leading many countries to seek to broaden access to medical careers on the grounds of social justice and the perceived benefits of greater workforce diversity. The aim of this study was to examine variation in socioeconomic status (SES) of applicants to study medicine and applicants with an accepted offer from a medical school, comparing the four UK countries and individual medical schools.
Methods
Retrospective analysis of application data for 22 UK medical schools 2009/10-2011/12. Data were analysed for all 32,964 UK-domiciled applicants aged <20 years to 22 non-graduate medical schools requiring applicants to sit the United Kingdom Clinical Aptitude Test (UKCAT). Rates of applicants and accepted offers were compared using three measures of SES: (1) Postcode-assigned Index of Multiple Deprivation score (IMD); (2) School type; (3) Parental occupation measured by the National Statistics Socio Economic Classification (NS-SEC).
Results
There is a marked social gradient of applicants and applicants with accepted offers with, depending on UK country of residence, 19.7–34.5 % of applicants living in the most affluent tenth of postcodes vs 1.8–5.7 % in the least affluent tenth. However, the majority of applicants in all postcodes had parents in the highest SES occupational group (NS-SEC1). Applicants resident in the most deprived postcodes, with parents from lower SES occupational groups (NS-SEC4/5) and attending non-selective state schools were less likely to obtain an accepted offer of a place at medical school further steepening the observed social gradient. Medical schools varied significantly in the percentage of individuals from NS-SEC 4/5 applying (2.3 %–8.4 %) and gaining an accepted offer (1.2 %–7.7 %).
Conclusion
Regardless of the measure, those from less affluent backgrounds are less likely to apply and less likely to gain an accepted offer to study medicine. Postcode-based measures such as IMD may be misleading, but individual measures like NS-SEC can be gamed by applicants. The previously unreported variation between UK countries and between medical schools warrants further investigation as it implies solutions are available but inconsistently applied.
Context:
Selection methods used by medical schools should reliably identify whether candidates are likely to be successful in medical training and ultimately become competent clinicians. However, there is little consensus regarding methods that reliably evaluate non-academic attributes, and longitudinal studies examining predictors of success after qualification are insufficient. This systematic review synthesises the extant research evidence on the relative strengths of various selection methods. We offer a research agenda and identify key considerations to inform policy and practice in the next 50 years.
Methods:
A formalised literature search was conducted for studies published between 1997 and 2015. A total of 194 articles met the inclusion criteria and were appraised in relation to: (i) selection method used; (ii) research question(s) addressed, and (iii) type of study design.
Results:
Eight selection methods were identified: (i) aptitude tests; (ii) academic records; (iii) personal statements; (iv) references; (v) situational judgement tests (SJTs); (vi) personality and emotional intelligence assessments; (vii) interviews and multiple mini-interviews (MMIs), and (viii) selection centres (SCs). The evidence relating to each method was reviewed against four evaluation criteria: effectiveness (reliability and validity); procedural issues; acceptability, and cost-effectiveness.
Conclusions:
Evidence shows clearly that academic records, MMIs, aptitude tests, SJTs and SCs are more effective selection methods and are generally fairer than traditional interviews, references and personal statements. However, achievement in different selection methods may differentially predict performance at the various stages of medical education and clinical practice. Research into selection has been over-reliant on cross-sectional study designs and has tended to focus on reliability estimates rather than validity as an indicator of quality. A comprehensive framework of outcome criteria should be developed to allow researchers to interpret empirical evidence and compare selection methods fairly. This review highlights gaps in evidence for the combination of selection tools that is most effective and the weighting to be given to each tool.
In the UK, as elsewhere, the use of ‘contextual’ data has been strongly advocated in order to inform undergraduate admissions decision-making. More than a third of UK universities currently take the socioeconomic or other background context of undergraduate applicants’ attainment into account when deciding whom to shortlist, interview, make standard or reduced offers to, or accept at confirmation or clearing. Even more universities plan to do so in the future. Contextualised admissions policies are considered by many commentators to be intrinsically fairer, and to represent a potentially powerful means of addressing the persistent under-representation of HE students from less advantaged backgrounds, but their impact has not yet been rigorously evaluated. In order to be effective, the indicators must be accurate, appropriate, and complete, and policies for their use must demonstrably widen participation, presumably without compromising student achievement. This paper reviews the indicators available for judging context, and the existing evidence base on how contextually-identified students perform in higher education. It illustrates the considerable difficulties of using any available indicators, alone or in combination, in terms of trustworthiness. And it explains how their use could introduce new injustices while tackling merely the symptoms of stratified participation in HE. This is far from a counsel of despair. We need to widen participation and the use of context stills shows considerable promise. The paper therefore presents the case for a new study by the authors, looking at which of the available contextual indicators are best in practice, and what difference their use would really make to widening participation at HE.
Widening access to medicine in the UK is a recalcitrant problem of increasing political importance, with associated strong social justice arguments but without clear evidence of impact on service delivery. Evidence from the United States suggests that widening access may enhance care to underserved communities. Additionally, rural origin has been demonstrated to be the factor most strongly associated with rural practice. However the evidence regarding socio-economic and rural background and subsequent practice locations in the UK has not been explored.
The aim of this study was to investigate the association between general practitioners’ (GPs) socio-economic and rural background at application to medical school and demographic characteristics of their current practice.
The study design was a cross-sectional email survey of general practitioners practising in Scotland. Socio-economic status of GPs at application to medical school was assessed using the self-coded National Statistics Socio-Economic Classification. UK postcode at application was used to define urban–rural location. Current practice deprivation and remoteness was measured using NHS Scotland defined measures based on registered patients’ postcodes.
A survey was sent to 2050 Scottish GPs with a valid accessible email address, with 801 (41.5 %) responding. GPs whose parents had semi-routine or routine occupations had 4.3 times the odds of working in a deprived practice compared to those with parents from managerial and professional occupations (95 % CI 1.8–10.2, p = 0.001). GPs from remote and rural Scottish backgrounds were more likely to work in remote Scottish practices, as were GPs originating from other UK countries.
This study showed that childhood background is associated with the population GPs subsequently serve, implying that widening access may positively affect service delivery in addition to any social justice rationale. Longitudinal research is needed to explore this association and the impact of widening access on service delivery more broadly.
Recruiting medical students from a rural background, together with offering them opportunities for prolonged immersion in rural clinical training environments, both lead to increased participation in the rural workforce after graduation. We have now assessed the extent to which medical students’ intentions to practice rurally may also be predicted by either medical school selection criteria and/or student socio-demographic profiles.
The study cohort included 538 secondary school-leaver entrants to The University of Western Australia Medical School from 2006 to 2011. On entry they completed a questionnaire indicating intention for either urban or rural practice following graduation. Selection factors (standardised interview score, percentile score from the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and prior academic performance (Australian Tertiary Admissions Rank), together with socio-demographic factors (age, gender, decile for the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD) and an index of rurality) were examined in relation to intended rural or urban destination of practice.
In multivariate logistic regression, students from a rural background had a nearly 8-fold increase in the odds of intention to practice rurally after graduation compared to those from urban backgrounds (OR 7.84, 95% CI 4.10, 14.99, P < 0.001). Those intending to be generalists rather than specialists had a more than 4-fold increase in the odds of intention to practice rurally (OR 4.36, 95% CI 1.69, 11.22, P < 0.001). After controlling for these 2 factors, those with rural intent had significantly lower academic entry scores (P = 0.002) and marginally lower interview scores (P = 0.045). UMAT percentile scores were no different. Those intending to work in a rural location were also more likely to be female (OR 1.93, 95% CI 1.08, 3.48, P = 0.027), to come from the lower eight IRSAD deciles (OR 2.52, 95% CI 1.47, 4.32, P = 0.001) and to come from Government vs independent schools (OR 2.02, 95% CI 1.15, 3.55, P = 0.015).
Very high academic scores generally required for medical school entry may have the unintended consequence of selecting fewer graduates interested in a rural practice destination. Increased efforts to recruit students from lower socioeconomic backgrounds may be beneficial in terms of an ultimate intended rural practice destination.
Despite substantial prior research on higher education choice, top universities in the UK continue to stand accused of favouring socio-economically advantaged students, to the detriment of those from poorer backgrounds. The objectives of this study are to test whether students with the same or equivalent entry scores are more or less likely to enter a top (Russell Group) university based on their social class background, parental education, occupation, age and racial group. Are students from disadvantaged backgrounds achieving the same entry grades or scores as other students, and based on their grades, are they equally likely to be studying at Russell Group universities? The research is based on primary data from a national (UK) survey with 10,723 respondents from 140 universities and higher education institutions. The findings from binary logistic regression show that prior schooling (private schooling) and high entry grades are the best predictors of attendance at Russell Group universities in the UK. The model with twelve predictors is significant using the full sample and the random sub-samples, and four key variables are strong predictors for all models: schooling, entry scores, age (under-19) and non-widening participation status predict the likelihood of attending a Russell Group university in 70% of cases. The respondents in this study who attended a private school are one and a half times more likely to attend a Russell Group university than students who attended a state-funded school. Black students are also underrepresented in Russell Group universities, but their entry scores are significantly lower.
The UK Clinical Aptitude Test (UKCAT) was introduced to facilitate widening participation in medical and dental education in the UK by providing universities with a continuous variable to aid selection; one that might be less sensitive to the sociodemographic background of candidates compared to traditional measures of educational attainment. Initial research suggested that males, candidates from more advantaged socioeconomic backgrounds and those who attended independent or grammar schools performed better on the test. The introduction of the A* grade at A level permits more detailed analysis of the relationship between UKCAT scores, secondary educational attainment and sociodemographic variables. Thus, our aim was to further assess whether the UKCAT is likely to add incremental value over A level (predicted or actual) attainment in the selection process.
Data relating to UKCAT and A level performance from 8,180 candidates applying to medicine in 2009 who had complete information relating to six key sociodemographic variables were analysed. A series of regression analyses were conducted in order to evaluate the ability of sociodemographic status to predict performance on two outcome measures: A level 'best of three' tariff score; and the UKCAT scores.
In this sample A level attainment was independently and positively predicted by four sociodemographic variables (independent/grammar schooling, White ethnicity, age and professional social class background). These variables also independently and positively predicted UKCAT scores. There was a suggestion that UKCAT scores were less sensitive to educational background compared to A level attainment. In contrast to A level attainment, UKCAT score was independently and positively predicted by having English as a first language and male sex.
Our findings are consistent with a previous report; most of the sociodemographic factors that predict A level attainment also predict UKCAT performance. However, compared to A levels, males and those speaking English as a first language perform better on UKCAT. Our findings suggest that UKCAT scores may be more influenced by sex and less sensitive to school type compared to A levels. These factors must be considered by institutions utilising the UKCAT as a component of the medical and dental school selection process.
Most UK medical schools use aptitude tests during student selection, but large-scale studies of predictive validity are rare. This study assesses the United Kingdom Clinical Aptitude Test (UKCAT), and its four sub-scales, along with measures of educational attainment, individual and contextual socio-economic background factors, as predictors of performance in the first year of medical school training.
A prospective study of 4,811 students in 12 UK medical schools taking the UKCAT from 2006 to 2008 as a part of the medical school application, for whom first year medical school examination results were available in 2008 to 2010.
UKCAT scores and educational attainment measures (General Certificate of Education (GCE): A-levels, and so on; or Scottish Qualifications Authority (SQA): Scottish Highers, and so on) were significant predictors of outcome. UKCAT predicted outcome better in female students than male students, and better in mature than non-mature students. Incremental validity of UKCAT taking educational attainment into account was significant, but small. Medical school performance was also affected by sex (male students performing less well), ethnicity (non-White students performing less well), and a contextual measure of secondary schooling, students from secondary schools with greater average attainment at A-level (irrespective of public or private sector) performing less well. Multilevel modeling showed no differences between medical schools in predictive ability of the various measures. UKCAT sub-scales predicted similarly, except that Verbal Reasoning correlated positively with performance on Theory examinations, but negatively with Skills assessments.
This collaborative study in 12 medical schools shows the power of large-scale studies of medical education for answering previously unanswerable but important questions about medical student selection, education and training. UKCAT has predictive validity as a predictor of medical school outcome, particularly in mature applicants to medical school. UKCAT offers small but significant incremental validity which is operationally valuable where medical schools are making selection decisions based on incomplete measures of educational attainment. The study confirms the validity of using all the existing measures of educational attainment in full at the time of selection decision-making. Contextual measures provide little additional predictive value, except that students from high attaining secondary schools perform less well, an effect previously shown for UK universities in general.
To review the literature on the social and learning environments experienced by underrepresented minority (URM) medical students to determine what type of interventions are needed to eliminate potential barriers to enrolling and retaining URM students.
The authors searched MEDLINE, PubMed, Ovid HealthStar, and Web of Science, and the reference lists of included studies, published between January 1, 1980, and September 15, 2012. Studies of the learning and social environments and of students' satisfaction, experiences with discrimination or unfair practices, and academic performance or progress, as well as assessments of programs or interventions to improve URM students' academic performance, were eligible for inclusion.
The authors identified 28 studies (27 unique data sets) meeting the inclusion criteria. The results of the included studies indicated that URM students experienced less supportive social and less positive learning environments, were subjected to discrimination and racial harassment, and were more likely to see their race as having a negative impact on their medical school experiences than non-URM students. Academic performance on standardized exams was worse, progress less timely, and attrition higher for URM students as well.
For URM students, an adverse climate may be decreasing the attractiveness of careers in medicine, impairing their academic performance, and increasing attrition. Improvements to the social and learning environments experienced by URM students are needed to make medicine a more inclusive profession. The current environment of health care reform creates an opportunity for institutions to implement strategies to achieve this goal.
This research examined extracurricular activity (ECA) effects on students’ experiences, outcomes and future job prospects. A survey of diverse undergraduate students, along with alumni and potential employer interviews, revealed differences in students’ engagement with ECAs beyond the classroom. Variations between ‘traditional’ and ‘widening participation’ student groups emerged, with older and ethnic minority students spending more time with non-university ECAs, engaged in family, religious and solitary activities. Lower socio-economic status (SES) students spent more time working, and less time engaging in ECAs. Alumni reflected ECAs as key to developing self-identity, social networks and career prospects/pathways. Employers stressed the value of ECAs for ‘distinguishing’ candidates, providing evidence of cultural fit, leadership, commitment, and ‘selling’ original activities. As (university-linked) ECAs were key for undergraduate outcomes and graduate employment prospects, emerging ethnic, age and SES patterns of engagement have implications for persistent inequalities in employment (despite widening participation agendas).
Cultures of low aspirations, and more particularly young people's adaptation to them, are often presented as the major obstacle to an economic development agenda which requires more higher-level skills and a social agenda which is about enabling people from ‘non-traditional’ backgrounds to go to university. The article analyses and discusses some of the different sorts of constraints on the choices which we make and which may become unconsciously internalised and so constitute our adaptive preference. It argues, however, that all choice is significantly adaptive and has its roots in a self which neither in its development nor in its current agency is detached from the social context in which it has been constructed, with which it identifies and from which that identity itself derives many of its features. Finally the article discusses briefly the grounds on which intervention in the life of such a chooser might be justified and some implications for interventionist strategies which are sensitive to such a socially embedded view of the self.
The new student funding regime introduced by the 2004 Higher Education Act in England is predicated on the accumulation of student debt. Variable tuition fees, repaid by student loans, will increase average student loan debt on graduation. This article examines how fear of debt and financial constraints affect prospective students’ choices of where and what to study. Using data derived from a survey of about 2000 prospective students, it shows that financial issues constrain lower social class students’ choice of university far more than those from other social classes. It demonstrates that fear of debt is related to two key financially‐driven decisions – applying to a university with low living costs, and applying to one with good term‐time employment opportunities – but only for students from low‐income families. However, concerns about debt do not influence their choice of qualification and subject. The article concludes that low‐income students are more likely than their wealthier peers to perceive the costs of higher education as a debt rather than an investment.
This paper explores the conflicting philosophies within the widening participation debate. Two categories of inclusive educators are identified, 'meritocrats' and 'democrats'. Among the democratic educators, a subgroup, 'transformative' educators, exists, which seeks to invoke changes
in society and the education system. The positions taken by some of these authors are weakened by their neglect of sociological theory. For the debate to progress and for inclusion to be successful, a renewed understanding of sociological theory is needed. This will help those contributing
to the debate to grasp fully the political and economic constraints on students and institutions that have limited inclusion.
This paper sets out the author's view of discourse analysis and illustrates the approach with an analysis of discursive aspects of marketization of public discourse in contemporary Britain, specifically in higher education. It includes a condensed theoretical account of critical discourse analysis, a framework for analysing discursive events, and a discussion of discursive practices (including their marketization) in late capitalist society, as well as analysis of samples of the discourse of higher education. The paper concludes with a discussion of the value of critical discourse analysis as a method in social scientific research, and as a resource for social struggle.
Minority physicians are more likely than their counterparts to work in underserved communities and care for minority, poor, and uninsured patients, but much of this research has examined primary care physicians alone. Few have investigated whether non-primary care specialists of minority backgrounds are more likely to serve the underserved than nonminority specialists.
We examined whether underrepresented minority (URM) physicians from a wide variety of specialties are more likely than non-URM physicians to practice in underserved communities.
Using California Medical Board Physician Licensure Survey (2007) data for 48388 physicians, we geo-coded practice zip codes to medically underserved areas (MUAs) and primary care health professional shortage areas (HPSAs). Logistic regression models adjusting for age, gender, specialty, and other characteristics were used to explore associations with race, ethnicity, specialty, and designated underserved areas.
We found that African American, Latino, and Pacific Islanders were more likely to work in MUAs and HPSAs than were white physicians (adjusted odds ratio, 1.22-2.25; p < .05). Similar patterns of practice in MUAs and HPSAs by physician race and ethnicity were found when performing the analyses separately among primary care physicians and physicians in non-primary care specialties.
In summary, our study underscores the importance of underrepresented minority physicians in all specialties for the physician workforce needs of disadvantaged communities. To improve health care for underserved communities, continued efforts to increase physician diversity are essential.
To determine whether the use of the UK clinical aptitude test (UKCAT) in the medical schools admissions process reduces the relative disadvantage encountered by certain sociodemographic groups.
Prospective cohort study.
Applicants to 22 UK medical schools in 2009 that were members of the consortium of institutions utilising the UKCAT as a component of their admissions process.
8459 applicants (24,844 applications) to UKCAT consortium member medical schools where data were available on advanced qualifications and socioeconomic background.
The probability of an application resulting in an offer of a place on a medicine course according to seven educational and sociodemographic variables depending on how the UKCAT was used by the medical school (in borderline cases, as a factor in admissions, or as a threshold).
On univariate analysis all educational and sociodemographic variables were significantly associated with the relative odds of an application being successful. The multilevel multiple logistic regression models, however, varied between medical schools according to the way that the UKCAT was used. For example, a candidate from a non-professional background was much less likely to receive a conditional offer of a place compared with an applicant from a higher social class when applying to an institution using the test only in borderline cases (odds ratio 0.51, 95% confidence interval 0.45 to 0.60). No such effect was observed for such candidates applying to medical schools using the threshold approach (1.27, 0.84 to 1.91). These differences were generally reflected in the interactions observed when the analysis was repeated, pooling the data. Notably, candidates from several under-represented groups applying to medical schools that used a threshold approach to the UKCAT were less disadvantaged than those applying to the other institutions in the consortium. These effects were partially reflected in significant differences in the absolute proportion of such candidates finally taking up places in the different types of medical schools; stronger use of the test score (as a factor or threshold) was associated with a significantly increased odds of entrants being male (1.74, 1.25 to 2.41) and from a low socioeconomic background (3.57, 1.03 to 12.39). There was a non-significant trend towards entrants being from a state (non-grammar) school (1.60, 0.97 to 2.62) where a stronger use of the test was employed. Use of the test only in borderline cases was associated with increased odds of entrants having relatively low academic attainment (5.19, 2.02 to 13.33) and English as a second language (2.15, 1.03 to 4.48).
The use of the UKCAT may lead to more equitable provision of offers to those applying to medical school from under-represented sociodemographic groups. This may translate into higher numbers of some, but not all, relatively disadvantaged students entering the UK medical profession.
To determine whether new programmes developed to widen access to medicine in the United Kingdom have produced more diverse student populations.
Population based cross sectional analysis.
31 UK universities that offer medical degrees.
34,407 UK medical students admitted to university in 2002-6.
Age, sex, socioeconomic status, and ethnicity of students admitted to traditional courses and newer courses (graduate entry courses (GEC) and foundation) designed to widen access and increase diversity.
The demographics of students admitted to foundation courses were markedly different from traditional, graduate entry, and pre-medical courses. They were less likely to be white and to define their background as higher managerial and professional. Students on the graduate entry programme were older than students on traditional courses (25.5 v 19.2 years) and more likely to be white (odds ratio 3.74, 95% confidence interval 3.27 to 4.28; P<0.001) than those on traditional courses, but there was no difference in the ratio of men. Students on traditional courses at newer schools were significantly older by an average of 2.53 (2.41 to 2.65; P<0.001) years, more likely to be white (1.55, 1.41 to 1.71; P<0.001), and significantly less likely to have higher managerial and professional backgrounds than those at established schools (0.67, 0.61 to 0.73; P<0.001). There were marked differences in demographics across individual established schools offering both graduate entry and traditional courses.
The graduate entry programmes do not seem to have led to significant changes to the socioeconomic profile of the UK medical student population. Foundation programmes have increased the proportion of students from under-represented groups but numbers entering these courses are small.
Students from lower socio-economic groups remain underrepresented in UK medical schools. This enquiry explores the perspectives of medical student participants to better understand how medical students from lower socioeconomic backgrounds may be perceived, their experience of an undergraduate medical curriculum, and any issues concerned with what is required for them to learn in order to become doctors. A conceptual framework that encompasses both sociological and sociocultural learning theories that enable the professional development and learning processes of medical students, and students from lower socioeconomic backgrounds in particular, to be better understood was required. Theoretical concepts from the literature informed the iterative development of the research questions that addressed student perspectives, the relational aspects between student practice and medical school structures including the medical culture, and how student participation is pivotal to their learning. An interpretive methodology including focus groups and individual interviews was used to access the perspectives of medical students from across the curriculum of one medical school. Analysis used a priori concepts and a modified grounded theory approach which generated three main categories of themes: who becomes a doctor, students’ developmental processes and issues underlying their learning. Non-traditional medical students were found to possess certain socioeconomic characteristics that distinguished them from their peers from a more advantaged background. For some students this led to disadvantage inherent in their differing patterns of socialisation, issues with developing an effective medical habitus and resultant professional identity, and reduced or less effective participation in authentic learning activities. A more nuanced nondualistic understanding of the nature of medical professional knowledge and the undergraduate curriculum by incorporating a more balanced approach to the insights afforded by participatory models of learning have several implications for both medical pedagogy and medical student practice.
Context:
In the UK, applications to medicine from those in lower socio-economic groups remain low despite significant investments of time, interest and resources in widening access (WA) to medicine. This suggests that medical schools' core messages about WA may be working to embed or further reinforce marginalisation, rather than to combat this. Our objective was to investigate how the value of WA is communicated by UK medical schools through their websites, and how this may create expectations regarding who is 'suitable' for medicine.
Methods:
We conducted a critical discourse analysis of the webpages of UK medical schools in relation to WA. Our conceptual framework was underpinned by a Foucauldian understanding of discourse. Analysis followed an adapted version of Hyatt's analytical framework. This involved contextualising the data by identifying drivers, levers and warrants for WA, before undertaking a systematic investigation of linguistic features to reveal the discourses in use, and their assumptions.
Results:
Discourses of 'social mobility for the individual' justified WA as an initiative to support individuals with academic ability and commitment to medicine, but who were disadvantaged by their background in the application process. This meritocratic discourse communicated the benefits of WA as flowing one way, with medical schools providing opportunities to applicants. Conversely, discourses justifying WA as an initiative to benefit patient care were marginalised and largely excluded. Alternative strengths typically attributed to students from lower socio-economic groups were not mentioned, which implies that these were not valued.
Conclusions:
Current discourses of WA on UK medical school websites do not present non-traditional applicants as bringing gains to medicine through their diversity. This may work as a barrier to attracting larger numbers of diverse applicants. Medical schools should reflect upon their website discourses, critically evaluate current approaches to encouraging applications from those in lower socio-economic groups, and consider avenues for positive change.
Whilst participation rates in higher education have increased rapidly since the 1960s, the most selective universities across the UK continue to be dominated by young people from the most socially advantaged backgrounds (Raffe and Croxford, 2015). Successive Scottish and UK Governments have stressed the need for increased participation in higher education, but have also emphasised the need for fairer access. Since 1997 there has been a growing expectation that students and their families will make a significant contribution to the cost of higher education by shouldering part of the burden of tuition fees and living expenses. This policy has led to anxiety that students from poorer backgrounds, who may be deterred from accepting a university place. However, we know very little about Scottish young people’s views of this important issue, and whether their views are distinctively different from those of young people living in England. This chapter gives an overview of the literature on UK attitudes to tuition fees and student debt. It then draw on interviews with young people in Scotland and England to explore views of fees regimes in different parts of the UK, contrasting the attitudes and awareness of those from more and less socially advantaged backgrounds.
Context:
Medical schools are increasingly using novel tools to select applicants. The UK Clinical Aptitude Test (UKCAT) is one such tool and measures mental abilities, attitudes and professional behaviour conducive to being a doctor using constructs likely to be less affected by socio-demographic factors than traditional measures of potential. Universities are free to use UKCAT as they see fit but three broad modalities have been observed: 'borderline', 'factor' and 'threshold'. This paper aims to provide the first longitudinal analyses assessing the impact of the different uses of UKCAT on making offers to applicants with different socio-demographic characteristics.
Methods:
Multilevel regression was used to model the outcome of applications to UK medical schools during the period 2004-2011 (data obtained from UCAS), adjusted for sex, ethnicity, schooling, parental occupation, educational attainment, year of application and UKCAT use (borderline, factor and threshold).
Results:
The three ways of using the UKCAT did not differ in their impact on making the selection process more equitable, other than a marked reversal for female advantage when applied in a 'threshold' manner. Our attempt to model the longitudinal impact of the use of the UKCAT in its threshold format found again the reversal of female advantage, but did not demonstrate similar statistically significant reductions of the advantages associated with White ethnicity, higher social class and selective schooling.
Conclusion:
Our findings demonstrate attenuation of the advantage of being female but no changes in admission rates based on White ethnicity, higher social class and selective schooling. In view of this, the utility of the UKCAT as a means to widen access to medical schools among non-White and less advantaged applicants remains unproven.
ContextStudents from backgrounds of low socio-economic status (SES) or who are first in family to attend university (FiF) are under-represented in medicine. Research has focused on these students' pre-admission perceptions of medicine, rather than on their lived experience as medical students. Such research is necessary to monitor and understand the potential perpetuation of disadvantage within medical schools. Objectives
This study drew on the theory of Bourdieu to explore FiF students' experiences at one Australian medical school, aiming to identify any barriers faced and inform strategies for equity. Methods
Twenty-two FiF students were interviewed about their backgrounds, expectations and experiences of medical school. Interviews were recorded, transcribed and analysed thematically. Findings illustrate the influence and interaction of Bourdieu's principal forms of capital (social, economic and cultural) in FiF students' experiences. ResultsThe absence of health professionals within participants' networks (social capital) was experienced as a barrier to connecting with fellow students and accessing placements. Financial concerns were common among interviewees who juggled paid work with study and worried about expenses associated with the medical programme. Finally, participants' medical student' status provided access to new forms of cultural capital, a transition that was received with some ambivalence by participants themselves and their existing social networks. Conclusions
This study revealed the gaps between the forms of capital valued in medical education and those accessible to FiF students. Admitting more students from diverse backgrounds is only one part of the solution; widening participation strategies need to address challenges for FiF students during medical school and should enable students to retain, rather than subdue, their existing, diverse forms of social and cultural capital. Embracing the diversity sought in admissions is likely to benefit student learning, as well as the communities graduates will serve. Change must ideally go beyond medical programmes to address medical culture itself.
This study focuses on the first year experience of Australian university students from low socio-economic status (SES) backgrounds. Firstly, it examines pre commencement expectations and post commencement experiences from the perspective of six indicators of persistence identified from the literature. It then explores considerations of university drop-out and transfer from the same perspective.
This chapter introduces how the currently under-theorized field of widening access (WA) to medicine could progress by the use of theoretical and conceptual frameworks. It outlines how research could move beyond the existing evidence by the use of theory and conceptual frameworks to inform practice and future research. This is primarily achieved by illustrating how three theoretical lenses are used separately to examine one dataset. The issue of WA is mostly relevant to medicine and hence the authors here focus on medical education. Focusing on power relations across the organizational structures associated with medical education provides opportunities to explore not only the views of stakeholders but also why certain decisions and policies are implemented and, importantly, why some are not. This involves the exploration of possible areas of tension which, when elucidated and better understood, may then be used as potential effective drivers for change.
https://network23.org/freeunisheff/files/2015/07/Mike-Molesworth-Richard-Scullion-Elizabeth-Nixon-The-Marketisation-of-Higher-Education-and-the-Student-as-Consumer-book.pdf
Extending the chance for people from diverse backgrounds to participate in Higher Education (HE) is a priority in the UK and many countries internationally. Previous work on widening participation in HE however has focussed on why people choose to go to university but this vital new research has focussed on looking at why people choose not to go. Moreover, much of the extant literature concentrates on the participation decisions of teenagers and young adults whereas this book foregrounds adult decision-making across the life-course. The book is also distinctive because it focuses on interview data generated from across the membership of inter-generational networks rather than on individuals in isolation, in order to explore how decision-making about educational participation is a socially embedded, rather than an individualised, process. It draws on a recent UK-based empirical study to argue that this network approach to exploring educational decision making is very productive and helps create a comprehensive understanding of the historically dependent, personal and collective aspects of participation decisions.
Selective higher education institutions that take race into account in admissions decisions must be able to demonstrate that their policy is justified by a compelling governmental interest, is narrowly tailored, and is the least restrictive means for achieving that interest. The authors thus investigate whether, among medical students, the association between racial diversity (as distinct from other forms of diversity) and learning from individuals from different backgrounds is unique.
The authors examined six dimensions of diversity, including racial/ethnic diversity, among the 2010, 2011, and 2012 cohorts of fourth-year medical students in the United States. They also examined students' responses to two Medical Student Graduation Questionnaire items pertaining to learning from individuals from different backgrounds. They modeled the association between each of the school-level dimensions of diversity and the student-level responses to having learned from others with different backgrounds, and they assessed whether associations vary across different groups of students.
Racial/ethnic diversity is unique in its very strong association with student perceptions of having learned from others who are different. The association between racial/ethnic diversity and student perceptions of having learned from others who are different is especially strong for members of historically underrepresented minority groups.
Compared with other forms of diversity, racial/ethnic diversity has a unique association with students' perceptions of learning from others who are different. This association is of particular relevance to admissions and diversity policies in an era of strict scrutiny of these policies.
Objectives
This study was designed to elucidate why students from backgrounds of lower socio-economic status (SES) and who may be first in their family (FIF) to enter university continue to be under-represented in medical schools.Methods
Academically able high school students (n = 33) from a range of socio-economic backgrounds participated in focus groups. School careers advisors (n = 5) were interviewed. Students discussed their career and education plans and ideas about a medical career. Careers advisors discussed enablers and barriers to a medical career for their students.ResultsStudents of lower SES and of FIF status attending schools situated in poorer geographic locations had limited access to suitable work experience and, despite their participation in gifted and talented classes, were considered to be at greater risk of not achieving the high level of academic achievement required for admission to medical school.Conclusions
There is utility in exploring intersecting differences and Appardurai's theory of the ‘capacity to aspire’ for the purpose of understanding the causes of the under-representation of disadvantaged students in medical schools. A focused materialist approach to building the aspirations of disadvantaged students, particularly those attending schools located in poorer areas, is required if effective pre-entry equity programmes are to be developed and evaluated. Alternatively, medical schools might rethink their reliance on very high academic attainment in the admission process.
ContextMedical schools in Western societies seek measures to increase the diversity of their student bodies with respect to ethnicity and social background. Currently, little is known about the effects of different selection procedures on student diversity.Objectives
This prospective cohort study aimed to determine performance differences between traditional and non-traditional (i.e. ethnic minority and first-generation university candidates) medical school applicants in academic and non-academic selection criteria.Methods
Applicants in 2013 (n = 703) were assessed on academic and non-academic selection criteria. They also completed a questionnaire on ethnicity and social background. Main outcome measures were ‘not selected’ (i.e. failure on any criteria), ‘failure on academic criteria’ and ‘failure on non-academic criteria’. Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by logistic regression analysis for ethnic subgroups (Surinamese/Antillean, Turkish/Moroccan/African, Asian, Western) compared with Dutch applicants, adjusted for age, gender, additional socio-demographic variables (first-generation immigrant, first-generation university applicant, first language, medical doctor as parent) and pre-university grade point average (pu-GPA). Similar analyses were performed for first-generation university applicants.ResultsCompared with Dutch applicants, Surinamese/Antillean applicants underperformed in the selection procedure (failure rate: 78% versus 57%; adjusted OR 2.52, 95% CI 1.07-5.94), in particular on academic criteria (failure rate: 66% versus 34%; adjusted OR 3.00, 95% CI 1.41-6.41). The higher failure rate of first-generation university applicants on academic criteria (50% versus 37%; unadjusted OR 1.66, 95% CI 1.18-2.33) was partly explained by additional socio-demographic variables and pu-GPA. The outcome measure ‘failure on non-academic criteria’ showed no significant differences among the ethnic or social subgroups.Conclusions
The absence of differences on non-academic criteria was promising with reference to increasing social and ethnic diversity; however, the possibility that self-selection instigated by the selection procedure is stronger in applicants from non-traditional backgrounds cannot be ruled out. Further research should also focus on why cognitive tests might favour traditional applicants.
ContextCalls to increase medical class representativeness to better reflect the diversity of society represent a growing international trend. There is an inherent tension between these calls and competitive student selection processes driven by academic achievement. How is this tension manifested?Methods
Our three-phase interdisciplinary research programme focused on the discourses of excellence, equity and diversity in the medical school selection process, as conveyed by key stakeholders: (i) institutions and regulatory bodies (the websites of 17 medical schools and 15 policy documents from national regulatory bodies); (ii) admissions committee members (ACMs) (according to semi-structured interviews [n = 9]), and (iii) successful applicants (according to semi-structured interviews [n = 14]). The work is theoretically situated within the works of Foucault, Bourdieu and Bakhtin. The conceptual framework is supplemented by critical hermeneutics and the performance theories of Goffman.ResultsAcademic excellence discourses consistently predominate over discourses calling for greater representativeness in medical classes. Policy addressing demographic representativeness in medicine may unwittingly contribute to the reproduction of historical patterns of exclusion of under-represented groups. In ACM selection practices, another discursive tension is exposed as the inherent privilege in the process is marked, challenging the ideal of medicine as a meritocracy. Applicants' representations of self in the ‘performance’ of interviewing demonstrate implicit recognition of the power inherent in the act of selection and are manifested in the use of explicit strategies to ‘fit in’.Conclusions
How can this critical discourse analysis inform improved inclusiveness in student selection? Policymakers addressing diversity and equity issues in medical school admissions should explicitly recognise the power dynamics at play between the profession and marginalised groups. For greater inclusion and to avoid one authoritative definition of excellence, we suggest a transformative model of faculty development aimed at promoting multiple kinds of excellence. Through this multi-pronged approach, we call for the profession to courageously confront the cherished notion of the medical meritocracy in order to avoid unwanted aspects of elitism.
ContextSince the 1970s, the UK medical student body has become increasingly diverse in terms of gender, ethnicity and age, but not in socio-economic background. This variance may be linked to large differences in how individual medical schools interpret and put into practice widening participation (WP) policy. However, attempts to theorise what happens when policy enters practice are neglected in medical education. We aimed to explore the dynamics of policy enactment to give a novel perspective on WP practices across UK medical schools.Methods
We used a qualitative design employing individual telephone interviews to elicit views and concerns around WP from admissions deans and admissions staff within UK medical schools. We carried out interviews with representatives from 24 of 32 UK medical schools. Data coding and analysis were initially inductive, using framework analysis. After the themes emerged, we applied a deductive framework to group themes into four contextual dimensions of ‘situation’, ‘professional’, ‘material’ and ‘external’.ResultsOur participants held different positions in relation to the interpreting and translating of WP policy, which were influenced by a number of contextual factors including: geographical locality and positioning of the medical school; the expectations of the university and other key stakeholders, and resources. The latter were subtle and referred to resources for medical selection processes rather than for WP per se. The data hinted that the political goal of WP and medical education's goal of producing the best doctors may conflict.Conclusions
This is the first study to explicitly explore WP policy enactment in medical education. Our analysis is useful for understanding differences in how WP policy is played out in local contexts, and for planning for future policy enactment and research. The messages identified will resonate internationally with all those engaged in efforts to widen participation in medical education.
In Fisher v University of Texas, the U.S. Supreme Court revisited the constitutionality of race-conscious admissions practices aimed at fostering student diversity in university programs. Although it concluded that student diversity remains the type of compelling state interest that justifies consideration of race in admissions, the court nonetheless raised the bar on the use of such practices by requiring universities to prove that no workable race-neutral methods can produce the same result. Whether this standard of proof is one that can be met-and whether challenges will mount against universities that continue to use the holistic methods sanctioned 10 years ago in Grutter v Bollinger-remains to be seen. In this commentary, the authors review the background and history of the Supreme Court's decisions on race as a factor in university admissions decisions and examine the potential effects of Fisher on medical education specifically.
'Widening participation' and increasing student diversity are currently key concerns across the higher education sector, and particular attention has been drawn to the persistent under-representation of working-class students within British universities. It is thought that widening participation in higher education (HE) can result in a number of social and economic benefits, at a national level, for under-represented social groups and for individual participants. Less is known about the viewpoints and understandings of working-class non-participants, such as whether 'official' perceptions regarding the value of HE are shared or contested. Focus group discussions were conducted with 109 non-participant Londoners, aged between 16 and 30 years, from a range of working-class backgrounds. Findings focus upon non-participants' constructions of risks, costs and benefits during application, participation and graduation. These perceptions of 'value' are discussed with relation to widening participation strategies amongst ethnically diverse 'working class' groups.
The Select Committee Report Access to Higher Education (2001) states that ‘prospects for widened participation will be transformed when schools succeed in persuading students from poor backgrounds to stay on in school beyond the age of 16’. Many schools located in areas with low staying‐on rates are already involved in projects designed to raise students' aspirations towards post‐compulsory education. This paper looks at one such initiative targeting 13 and 14 year olds, encouraging them to ‘aim high’. Drawing on data from a series of semistructured interviews with pupils and staff, it examines the ways in which the process perpetuated inequalities rather than encouraging disadvantaged students. The paper concludes that this project was initiated and imposed from an adult's perspective rather than that of the young people taking part, reflecting the class and habitus of the former. Strategies designed to ‘persuade students’ to stay on post‐16 need, therefore, to recognize how inequality structures both practice and student response and take into account both the student ‘voice’ and their cultural and social background.
The under-representation in medical education of students from lower socio-economic backgrounds is an important social issue. There is currently little evidence about whether changes in admission strategies might increase the diversity of the medical student population. Denmark introduced an 'attribute-based' admission track to make it easier for students who may not be eligible for admission on the 'grade-based' track to be admitted on the basis of attributes other than academic performance. The aim of this research was to examine whether there were significant differences in the social composition of student cohorts admitted via each of the two tracks during the years 2002-2007.
This prospective cohort study included 1074 medical students admitted during 2002-2007 to the University of Southern Denmark medical school. Of these, 454 were admitted by grade-based selection and 620 were selected on attributes other than grades. To explore the social mix of candidates admitted on each of the two tracks, respectively, we obtained information on social indices associated with educational attainment in Denmark (ethnic origin, father's education, mother's education, parenthood, parents living together, parent in receipt of social benefits).
Selection strategy (grade-based or attribute-based) had no statistically significant effect on the social diversity of the medical student population.
The choice of admission criteria may not be very important to widening access and increasing social diversity in medical schools. Attracting a sufficiently diverse applicant pool may represent a better strategy for increasing diversity in the student population.
The Medical University of South Carolina launched a systematic plan to infuse diversity among its students, resident physicians, and faculty in 2002. The dean and stakeholders of the College of Medicine (COM) embraced the concept that a more population-representative physician workforce could contribute to the goals of providing quality medical education and addressing health care disparities in South Carolina. Diversity became a central component of the COM's strategic plan, and all departments developed diversity plans consistent with the overarching plan of the COM. Liaisons from the COM diversity committee facilitated the development of the department's diversity plans. By 2011, the efforts resulted in a doubling of the number of underrepresented-in-medicine (URM, defined as African American, Latino, Native American) students (21% of student body); matriculation of 10 African American males as first-year medical students annually for four consecutive years; more than a threefold increase in URM residents/fellows; expansion of pipeline programs; expansion of mentoring programs; almost twice as many URM faculty; integration of cultural competency throughout the medical school curriculum; advancement of women and URM individuals into leadership positions; and enhanced learning for individuals from all backgrounds. This article reports the implementation of an institutional plan to create a more racially representative workforce across the academic continuum. The authors emphasize the role of the stakeholders in promoting diversity, the value of annual assessment to evaluate outcomes, and the positive benefits for individuals of all backgrounds.
Purpose:
To determine whether underrepresented minority (URM) students and students from disadvantaged backgrounds were more likely to apply to a combined MD-master's degree program designed to train physician leaders in providing care to underserved communities.
Method:
University of California, San Diego (UCSD), School of Medicine applications from the 2008-2010 incoming classes were analyzed. American Medical College Application Service and UCSD secondary application data were used to build a logistic regression model to determine which characteristics were most associated with applying to the MD-master's degree Program in Medical Education-Health Equity (PRIME-HEq).
Results:
Of the total UCSD applications reviewed from disadvantaged students, 61.5% also applied to PRIME-HEq (319/519) compared with 23.5% of nondisadvantaged students (917/3,895, χ = 326.665, P < .001). Of URM student applications, 55.6% also applied to PRIME-HEq (358/644) compared with 23.3% of non-URM students (878/3,770, χ = 284.654, P < .001). Results of a backward stepwise logistic regression analysis showed that disadvantagedstatus was the greatest predictor of applying to PRIME-HEq (odds ratio = 3.15; 95%confidence interval = 2.50-3.966; P< .001).
Conclusions:
URM students and students from disadvantaged backgrounds were more likely to be interested in a curriculum designed to train them to work with underserved communities. These results suggest that PRIME-HEq, or similarly focused programs, may influence URM and disadvantaged students' application decisions.
According to system justification theory, there is a psychological motive to defend and justify the status quo. There are both dispositional antecedents (e.g., need for closure, openness to experience) and situational antecedents (e.g., system threat, mortality salience) of the tendency to embrace system-justifying ideologies. Consequences of system justification sometimes differ for members of advantaged versus disadvantaged groups, with the former experiencing increased and the latter decreased self-esteem, well-being, and in-group favoritism. In accordance with the palliative function of system justification, endorsement of such ideologies is associated with reduced negative affect for everyone, as well as weakened support for social change and redistribution of resources.
In 2006, the United Kingdom Clinical Aptitude Test (UKCAT) was introduced as a new medical school admissions tool. The aim of this cohort study was to determine whether the UKCAT has made any improvements to the way medical students are selected.
Regression analysis was performed in order to study the ability of previous school type and gender to predict UKCAT, personal statement or interview scores in two cohorts of accepted students. The ability of admissions scores and demographic data to predict performance on knowledge and skills examinations was also studied.
Previous school type was not a significant predictor of either interview or UKCAT scores amongst students who had been accepted onto the programme (n = 307). However, it was a significant predictor of personal statement score, with students from independent and grammar schools performing better than students from state-maintained schools. Previous school type, personal statements and interviews were not significant predictors of knowledge examination performance. UKCAT scores were significant predictors of knowledge examination performance for all but one examination administered in the first 2 years of medical school. Admissions data explained very little about performance on skills (objective structured clinical examinations [OSCEs]) assessments.
The use of personal statements as a basis for selection results in a bias towards students from independent and grammar schools. However, no evidence was found to suggest that students accepted from these schools perform any better than students from maintained schools on Year 1 and 2 medical school examinations. Previous school type did not predict interview or UKCAT scores of accepted students. UKCAT scores are predictive of Year 1 and 2 examination performance at this medical school, whereas interview scores are not. The results of this study challenge claims made by other authors that aptitude tests do not have a place in medical school selection in the UK.
This paper makes use of newly linked administrative data to better understand the determinants of higher education participation amongst individuals from socio-economically disadvantaged backgrounds. It is unique in being able to follow two cohorts of students in England - those who took GCSEs in 2001-02 and 2002-03 - from age 11 to age 20. The findings suggest that while there remain large raw gaps in HE participation (and participation at high-status universities) by socio-economic status, these differences are substantially reduced once controls for prior attainment are included. Moreover, these findings hold for both state and private school students. This suggests that poor attainment in secondary schools is more important in explaining lower HE participation rates amongst students from disadvantaged backgrounds than barriers arising at the point of entry into HE. These findings highlight the need for earlier policy intervention to raise HE participation rates amongst disadvantaged youth.